Just last night my ten year old sounded the “MOMMY, MOMMY!!!” alarm in the middle of the night. Almost without opening my eyes I went to his room and calmly walked him to the bathroom where he emptied his bladder with gusto and went right back to bed. Witness: A nightmare with a purpose.

Ever wonder when you, the parent, get to sleep through the night? Now that your child has graduated from the crib, tune into this podcast to learn how to handle situations that sabotage sleep in children: nightmares, night terrors, night wanderings, and bedwetting.

 

 

A common question that many parents ask us in the office is “How can I help my overweight child?”

Our newest podcast provides six simple rules for healthy eating. Listen in to find out the “5-4-3-2-1-0” rules of what to feed your children, how to portion their foods, and how to change their behavior to help them lose excess pounds and maintain a healthy weight.

(If the podcast is not embedded in your RSS reader page,visit the www.TwoPedsInAPod.com home page directly.)

 

Julie Kardos, MD and Naline Lai, MD

©2010 Two Peds in a Pod

 

Three little kittens, they lost their mittens, and they began to cry. 

Oh, mother dear,  we sadly fear That we have lost our mittens. 

What! Lost your mittens, you naughty kittens! 

Then you shall have no Nintendo   DS 

    -the modern version of a traditional poem

 

 

It’s only January and pictured here is a photo of my three kittens’ mittens (gloves) which are already missing mates.

 

Prolonged exposure to cold can lead to injury in body parts with relatively less blood flow such as the ears, fingers and toes. In frostbite, injury occurs secondary to ice crystals which form within or between the cells in your body. Injury can be so severe that the tissue dies and infection sets in.

 

Early signs of frostbite include tingling or achiness. Without treatment, the area will become pale and lose all sensation.

 

If you suspect your child’s hands are starting to become frostbitten, first remove all wet clothing. Rewarm the area by placing immediately in warm water.  Think opposite of a burn- where you use cold water. Do not massage the hand as this may cause further injury, but do encourage your child to move his hands. As very cold hands warm up, they will become blotchy and painful or itchy. Ibuprofen (brand names Motrin and Advil)or acetaminophen (Tylenol) will be helpful.  Warm for at least half an hour even if it is painful.

 

Signs of actual frostbite are blistering, numbness, or color changes. As my sister, an emergency room doctor says, red is good. Black and white are not.

 

Head over to the emergency room if you think your child has frostbite. To avoid the risk of over-heating and to manage the pain of treating frost bite, thawing for frost bite should be medically supervised. Just as you would seek care for a burn, seek medical care for a cold induced injury. To rewarm properly, the frostbitten part of the body should be submerged in warm 37-to-40 C (98 -to-104 F) water.  No higher because then it’s like trying to defrost a chicken. You will end up cooking rather than thawing the tissue, says my sister. Also a big no-no: starting to thaw but then not completing the thaw. Thaw-refreeze-thaw will injure tissue, same as it ruins a defrosting chicken. So again, seek medical attention for your child if you suspect frost bite has set in.

For a recent interesting, but somewhat technical article with photographs on a case of frostbite, check out the New England Journal of Medicine, N Engl J Med 2009;361:2654-62

 

Naline Lai, MD

Two Peds in a Pod © 2010.

 

 

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Ode to the Binkie

Bed time when toddlers start to shout,

It is you, dear binkie, who knocks them out.

Those thumb suckers look so snide,

But haven’t been without you on a long car ride.

None in the diaper bag, none in the crib?

Take one from our infant sib.

If you touch the ground, I’ll give you a quick blow,

Back into the mouth you’ll just go.

But now my child can run and jump with both feet off the ground,

Two to three word sentences she can sound.

If old enough to politely ask for you,

Then old enough to make permanent teeth go askew.

Oh dear binkie, you once had your place,

Now let’s take the cork from the face.

Once you were our beloved binkie,

But right now… you are just stinky.

 

Whether you love or hate the pacifier, at some point, to avoid the possibility of dental and speech articulation impairment, your child needs to wean. Besides, it’s nice to see your child’s entire face. The easiest time to wean is usually around two to three years old. At that point, your child’s dependence on sucking for self-comfort begins to lessen and he begins to want to dissociate himself from being a “baby.”

Now that it’s the New Year, here are some ways to say bye-bye to the binkie, if this is on your child’s (or your) resolution list.

• Throw the pacifier across the room and entice your child to say with you, “Yucky, binkies are for babies.”
• Restrict pacifiers to specific places such as your home, crib, or bed
• Take a  “Binkie finding hunt” with your child and gather all the binkies into a basket. Have the binkie fairy come overnight, take the basket, and leave a present in the morning. Alternatively, one set of parents told me that they told their child that they were gathering binkies for babies who didn’t have any.
• If giving your child a pacifier is part of your bedtime routine, start to introduce something else such as a special blanket or stuffed animal.
• Sometimes as parents, we are the ones who have to be weaned. When your child is upset, do not automatically pop a binkie into your child’s mouth. Seek other ways to help your child calm himself
• Vow to yourself not to buy new pacifiers at the grocery store. Gradually the pacifiers left in the house will disappear or the mold on them will prompt you to throw them away.
• Cut a small hole in the tip of the nipple- the binkie will not “be the same.” Tell your child that the binkie is broken and throw it away.
• Vacations disrupt schedules. Therefor, sometimes in an unfamiliar bed, children wean habits. Conveniently forget the binkie while going on vacation and do not introduce it on return home.
• By age three, most kids appreciate the value of a good bribe. Offer them a reward for going a whole week (or at least 3 days) without the binkie. One night doesn’t count because often the second night is more difficult for the child than the first when he is giving up the binkie. Once you have gone a week, the child will have no desire to go back. Just make sure you have disposed of every last binkie in your home so they will not have reminders of the “good old days.”

Naline Lai, MD with Julie Kardos, MD

Poem by Dr. Lai

©2010 Two Peds in a Pod®

Special note: all of Dr. Lai’s and Dr. Kardos’s children are former binkie users. You could call us “binkie specialists.” Leave a comment about how your child weaned.

 

Acetaminophen, brand name Tylenol, has been in the news recently, and parents are asking me if it is safe.

This medication, used as a pain reliever and as a fever reducer, is safe to give to babies older than two months, but you must be very careful about the dose that you give. Medicine doses are based on the weight, not the age, of a child. So when checking the label on the bottle that tells how much acetaminophen to give, look at the weight recommendations if there is a discrepancy between your child’s weight and age. If you are not sure, then ask your child’s health care provider. I cannot stress proper dosing enough because of how dangerous an overdose can be.

 Here are some facts you need to know in order to avoid over-dosing your child with Tylenol:

1)      Always measure the medicine in the dropper or cup provided by the manufacturer of that particular medicine bottle.

 

2)      Be aware that Tylenol infant drops are more concentrated than the children’s suspension liquid. This means that if you were to pour out equal amounts of infant drops and children’s suspension, the amount of drug is actually HIGHER in the measurement of infant drops than in the same measurement of children’s suspension. For example, one full infant dropper of Infant Tylenol Drops, measured to the 0.8ml line of the dropper, is 80mg of Tylenol. The same 0.8ml of Children’s Tylenol Suspension Liquid is only 25mg.

Another way to look at this medicine math: if you intended to give 80mg = 2.5ml = 1/2 teaspoon of Children’s Tylenol Suspension Liquid   but you actually gave your child 2.5ml = ½ teaspoon of Infant Tylenol instead of Children’s Tylenol, you would be giving them over 240 mg of Tylenol, which is THREE TIMES the amount that you wanted to give. Again, use the dropper provided to give Infant Tylenol drops and use the cup provided when dosing the Children’s Tylenol Suspension Liquid.

 

3)      Note that other medications have acetaminophen (Tylenol) in them. I advise my patients’ parents to avoid combination cold and flu medicines for two reasons. First, there is little evidence that shows that they actually provide symptom relief. Second, from a safety perspective, parents can accidentally overdose their child with acetaminophen because many contain acetaminophen in them. For example, as of this writing, the following medications all contain acetaminophen as stated in the ingredient list:

Benadryl  Allergy and Cold Tablets, Sudafed PE nighttime Cold Maximum Strength Tablets, Theraflu Nighttime Severe Cold and Cough Powder, Tylenol Plus Children’s Cold and Allergy Suspension, Tylenol Sore throat Nighttime liquid, Tylenol Chest Congestion Liquid, and Nyquil.

4)      Be aware that “APAP” in the ingredient list means acetaminophen.

Tylenol overdoses can be fatal by causing liver failure. If your child has a chronic liver disease, it is likely that she should avoid Tylenol altogether.

Because of the risk of overdose, I also avoid advising my patients to “alternate Tylenol (acetaminophen) with Motrin (ibuprofen).” I discourage this practice because I am afraid of parents forgetting which medicine they gave last and possibly over-dosing by mistake. Tylenol is meant to be dosed every 4 to 6 hours unless otherwise specified on the label or by your child’s health care provider. 

If you ever have questions about possible overdose, call the national US Poison Control Center at 1-800-222-1222.

Julie Kardos, MD
©2009 Two Peds in a Pod

Addendum 10/11/2011: The manufacturers of Tylenol (acetaminophen) responded to the hazard of parents and caregivers accidentally giving the wrong dose of infant drops ( see point #2 above) and stopped making the “concentrated infant drops.” Instead, they now manufacture the “infant drops” and “children’s liquid” using the same concentration as each other. Continue to use the measuring dropper or cup provided with the medication for proper measuring.

A friend of mine who has no children commented to me that many people tell him, “You just can’t know happiness until you have children of your own.” However, I know several adults who are very happy people and who have made a conscious decision to not have children. So I would actually amend the above adage to: “You just can’t know WORRY until you have children of your own.”

Especially in winter, many illnesses circulate. All these sick kids make for many worried parents. Some questions that I answer many times a day in the office are: “Okay, Doc, you just told me that my child is handling her illness right now, but how will I know if she is getting worse? When do I need to worry?”

Here is what I tell my patients’ parents:

First and foremost, trust your parent instincts that something is wrong.

Think about these THREE MAIN SYSTEMS: breathing, thinking, and drinking/peeing.

Breathing:

Normally, breathing is easy to do. It is so easy, in fact, that if you take off your child’s shirt and watch her breathe, it can be hard to see that she is breathing. You should try this while your child is healthy. Normal breathing does not involve effort. It does not involve the chest muscles.

If your child has pneumonia, bad asthma, bronchitis, or any other condition that causes respiratory distress, breathing becomes hard. It becomes faster than baseline. It involves chest muscles moving so it looks like ribs are sticking out with every breath. The chest itself moves a lot. Kids’ bellies may also move in and out. Nostrils flare in attempt to get more oxygen. Sometimes kids make a grunting sound at the end of each breath because they are having difficulty pushing the air out of their lungs before taking another breath in. Also, instead of a normal pink color, your child’s lips can have a blue or pale color. Pink is good, blue or pale is bad. Children old enough to talk may actually have difficulty talking because they are short of breath. Any of the above signs tell you that your child needs medical attention.

Thinking:

This refers to mental or emotional state. Normally, children recognize their parents and are comforted by their presence. They are easy to console by being held, rocked, massaged, etc. They know where they are, and they make sense when they talk.

Change in mental state, whether it comes from lack of oxygen/shortness of breath, pain, or severe infection, results in a child who is inconsolable. She may not recognize her parents or know where she is. Instead of calming, she may scream louder when rocked. She may seem disoriented or just too lethargic/difficult to arouse. Being very combative can also be a sign of not getting enough oxygen. In a baby, extreme pain can cause all these signs as well.

Drinking/peeing:

While this varies somewhat depending on the age of the child, most kids urinate every 3-6 hours or so. Young babies may urinate more frequently than this and some older kids urinate perhaps 2-3 times daily. You should know your child’s baseline. Normal urine reflects a normal state of hydration. If you don’t drink enough, you will urinate less.

If your child has fever, coughing, vomiting, or diarrhea, she will use up fluid in her body faster than her baseline. In order to compensate, she needs to drink more than her baseline amount of liquid to urinate normally. A child will refuse to drink because of severe pain, shortness of breath, or change in mental state, and may go for hours without urinating. This is a problem that needs medical attention. Occasionally a child will urinate much more than usual and this can also be a problem (this can be a sign of new diabetes as well as other problems). Basically any change from baseline urine output is a problem.

A note about fever: any infant 8 weeks of age or younger with fever of 100.4 F or higher, measured rectally, requires immediate medical attention, even if all other systems are good. Babies this young can have fever before any other signs of serious illness such as meningitis, pneumonia, blood infections, etc. and they can fool us by initially appearing well.

In older babies and children, fever is defined as 101 F or higher. Some kids can look quite well even at 104 and others can look quite ill at 101. Fever is a sign that your body’s immune system is working to fight off illness. In addition to fever, it is important to look at breathing, thinking, and hydration state because this will help you determine how quickly your child needs medical attention. A child with a mild runny nose and fever of 103 who can play still play a game with you while drinking her apple juice is less ill than a child with a 101 fever who doesn’t recognize her parents.

To summarize, any deviation from normal breathing, thinking, or drinking/urinating (peeing) is a problem that needs medical attention, even if no fever is present. In addition, any change in the wrong direction (getting worse instead of getting better) is a problem that needs medical attention.

Finally, all parents have PARENT INSTINCT. Trust yourself. Ultimately, if you are wondering if you should seek medical advice, just do it. If parents could just worry every problem away, no one would ever be sick.

Julie Kardos, MD with Naline Lai, MD
© 2009 Two Peds in a Pod

I wash my hands about sixty times a day, maybe more.  This in combination with cold Pennsylvania fall air leads to chapped hands.  It’s a sure sign winter is approaching when patients start to show me their raw hands.  Here are the hands of a girl I saw a couple days ago.

To prevent dry hands:
•    Don’t stop washing your hands, but do use a moisturizer afterwards.

•    Whenever possible, use water and soap rather than hand sanitizers.  Hand sanitizers are at minimum 60% alcohol- very drying.

•    Wear gloves as much as possible even if the temperature is above freezing.  Remember chemistry class, cold air holds less moisture than warm air and therefore is unkind to skin.  Gloves will prevent some moisture loss.

•    Before  exposure to any possible irritants such as the chlorine in a swimming  pool,  protect the hands by layering heavy lotion (Eucerin cream) or petroleum based product (i.e. Vaseline or Aquaphor) over the skin.

To rescue dry hands:
•    Prior to bed smother hands in 1% hydrocortisone ointment.  Avoid the cream formulation.  Creams tend to sting if there are any open cracks.  Take old socks, cut out thumb holes  and have your child sleep at night with the sock on his hands.  Repeat nightly for a week or so.  Alternatively, for mildly chapped hands, use a petroleum oil based product such as Vaseline or Aquaphor in place of the hydrocortisone.

•    If your child has underlying eczema, prevent your child from scratching his hands.  An antihistamine such as diphenhydramine (Benadryl) or cetirizine (Zyrtec) will take the edge off the itch.

•    For extremely raw hands, your child’s doctor may prescribe a stronger cream and if there are signs of a bacterial skin infection, your child’s doctor may prescribe an antibiotic.

Happy  moisturizing. Remember how much fun it was to smear glue on your hands and then peel off the dried glue? It’s not so fun when your skin really is peeling.

Naline Lai, MD and Julie Kardos, MD

©2009 Two Peds in a Pod®

Do you ever wonder how vaccines work?

To understand how vaccines work, I will give you a brief lesson on the immune system.

Trust me, it is interesting. Let me give you an example of me. When I was eight, I had chicken pox. It was a miserable week. I started out with fever and headache, then suffered days of intense body itching from blister-like spots, and ultimately, because I “scratched off” some scabs, ended up with scars.

During this time, my immune system cells worked to battle off the chicken pox virus. Immune cells called memory cells also formed. These cells have the unique job of remembering (hence the name “memory cells”) what the chicken pox virus looks like. Then, if ever in my life I was to contact chicken pox again, my memory cells could multiply and fight off the virus WITHOUT MY HAVING TO GET SICK AGAIN WITH CHICKEN POX. So after I was well again, I was able to play with my neighbor even while he suffered with chicken pox.  I even returned to school where other children in my class had chicken pox, but I did not catch chicken pox again. Even now, as a pediatrician, I don’t fear for my own safety when I diagnose a child with chicken pox, because I know I am immune to the disease.

This is an amazing feat, when you think about it.

And now, how vaccines work.

A vaccine contains some material that really closely resembles the actual disease you will protect yourself against. Today’s chicken pox vaccine contains an altered form of chicken pox that is close to but not actually the real thing. However, it is so similar to the real thing that your body’s immune system believes it is, in fact, real chicken pox. Just as in the real disease, your body mounts an immune response, and makes  memory cells that will remember what the disease looks like.  So, if you are exposed to another person with chicken pox, your body will kill off the virus but YOU DON’T GET SICK WITH THE CHICKEN POX. What a beautiful system!

Before chicken pox vaccine, about 100 children per year in the US died from complications of chicken pox disease. Many thousands were hospitalized with secondary pneumonia, skin infections, and even brain damage (encephalitis) from chicken pox disease. Now a shot in the arm can prevent a disease by creating the same kind of immunity that you would have generated from having the disease, only now you have one second of pain from the injection instead of a week of misery and possible permanent disability or death. I call that a Great Deal!

How vaccines are safer than the diseases they prevent.

All vaccines operate by this principle: create a safe environment for your immune system to make memory cells against a potentially deadly disease. Then when you are exposed to someone who actually has the disease, you will not “catch” it. Your body will fight the germs, but you do not become sick. If everyone in the world were vaccinated, then the disease itself would eventually be completely eradicated. This happened with small pox, a disease that killed 50 percent of infected people. There is no longer small pox because nearly everyone on earth received the small pox vaccine. Now we do not need to give small pox vaccine because the disease no longer exists. This is a huge vaccine success story.

Friedrich Nietzsche said “What doesn’t kill us makes us stronger.” We pediatricians feel this is unacceptable risk for children. We would rather see your child vaccinated against a disease in order to become immune rather than risking the actual disease in order to become immune.

Hopefully this blog post answers your questions about how vaccines work. For more details or more in depth explanations, I refer you to the AAP (American Academy of Pediatrics),  the Children’s Hospital of Philadelphia’s Vaccine Education Center, and the book Vaccines: What You Should Know, by pediatricians Dr. Paul Offit and Dr. Louis Bell.

Julie Kardos, MD and Naline Lai, MD

© 2009 Two Peds In a Pod®

updated 1/18/2015