As we are in the middle of Lyme disease season here in the Northeastern United states, I thought I should address Lyme disease. I have diagnosed 8 cases so far this summer, seven in my office and one at a picnic, and what struck me in each case was how relieved the parents were to find out how easy it is to treat the disease when it is diagnosed early. It is important to treat Lyme disease in the early phase because this treatment prevents later manifestations of the illness (arthritis, meningitis, etc.).

 Lyme disease is spread to people by deer ticks. Any one deer tick that you pull off your child has only a 1% chance of transmitting Lyme disease, but the reason so many people get Lyme disease is that there are an awful lot of deer ticks out there.

In areas where Lyme disease is prevalent (New England and Mid-Atlantic states, upper Midwest states, and California), parents should be vigilant about searching their children’s bodies daily for ticks and for the rash of early Lyme disease. Tick bites, and therefore the rash as well, especially like to show up on the head, in belt lines, groins, and axillas (armpits), but can occur anywhere. I shower my kids daily in summer time not just to wash off pool water, sunscreen, and dirt, but also for the opportunity to check them for ticks and rashes.

Most kids do get the classic rash of Lyme disease at the site of a tick bite. The rash most commonly occurs by 1-2 weeks after the tick bite and is round, flat, and typically red. It can have some central clearing. The key is that the rash expands and becomes larger than 5cm. Untreated, it can become quite large as seen in the above photo. The rash does not itch or hurt. This finding is helpful because if you think you are seeing the primary rash of Lyme disease on your child, you can safely wait a day or two before bringing your child to his health care provider because the rash will continue to grow. The Lyme disease rash does not come and then fade in the same day. In fact, the history of a rash that enlarges over a few days is helpful in diagnosing the disease. Some kids have fever, headache, or muscle aches at the same time that the rash appears.

The second phase of Lyme disease occurs if it is not treated in the primary phase. It occurs about one month from the time of tick bite. Children develop a rash that looks like the primary rash but appears in multiple body sites all at once, not just at the site of the tick bite. Each circular lesion of rash looks like the primary rash but typically is smaller. Additional symptoms include fever, body aches, headaches, and fatigue without other viral symptoms such as sore throat, runny nose, and cough. Some kids get the fever but no rash. Some kids get one-sided facial weakness. This stage is called Early Disseminated disease and is treated similarly to the way that Early Lyme disease is treated.

If your child has primary Lyme disease (enlarging red round rash), the diagnosis is made on clinical presentation alone. No blood work is needed because it takes several weeks for a person’s body to make antibodies to the disease, and blood work tests for antibody response. In other words, the test can be negative when a child does have early Lyme disease. Therefore, treatment begins after taking a history and performing a visual diagnosis.

The treatment of early Lyme disease is straightforward. The child takes 2-3 weeks of an antibiotic that is known to treat Lyme disease effectively such as amoxicillin or doxycycline prescribed by your child’s health care provider. This treatment prevents later complications of the disease. While the disease can progress if no treatment is undertaken, in children there is no evidence of “chronic Lyme disease” despite claims to the contrary. Once treatment is started, the rash fades over several days. Sometimes at the beginning of treatment the child experiences chills, aches, or fever for a day or two. This reaction is normal but your child’s health care provider should be contacted if it persists for longer.

If not treated early, then treatment starts when diagnosis is made during later stages of Lyme disease and may include the same oral antibiotic as for early Lyme but for 4 weeks instead of 2-3 weeks. The most common symptom of late stage Lyme disease is arthritis (red, swollen, painful joint) of a large joint such as a knee, hip, shoulder. Some kids just develop joint swelling without pain. The arthritis can come and go. This stage is prevented by early treatment but is also can be treated with antibiotics.

For some manifestations, IV antibiotics are used. The longest course of treatment is 4 weeks for any stage. Again, children do not develop “chronic Lyme” disease. If symptoms persist despite adequate treatment, sometimes one more course of antibiotics is prescribed, but if symptoms continue, the diagnosis should be questioned. No advantage is shown by longer treatments.

Misinformation about this disease abounds, and self proclaimed “Lyme disease experts” play into people’s fears. If you feel that you need another opinion about your child’s Lyme disease, the “expert” that you could consult would be a pediatric infectious disease specialist.

For a more detailed discussion of Lyme disease, I refer you to the Center for Disease Control website: www.cdc.gov.

Julie Kardos, MD with Naline Lai, MD

2009 Two Peds in a Pod, updated 2015

I just went through a stack of mom’s-stuff-stashed-away-when-cleaning-for-a-party-and-forgotten-about and stumbled on a green three inch by three inch curved piece of plastic.  What was it?  A tres modern chair for the Polly Pockets?  A piece to a bicycle seat? Some treasure from a birthday party? My husband also scratched his head at the unidentifiable object.

I was just about to put it in the “mom’s-unidentifiable-but-probably-useful” pile when it occurred to me what it was….the shield to a potty seat.  The shield sits at the front of a potty chair and is supposed to prevent a little boy’s spray from squirting you in the eye while they are sitting.  This reminded me to warn our readers/listeners who didn’t have a chance to listen to our potty training podcast to throw the shields away.  They cause more harm than good when an excited little guy tries to jump quickly on and off the potty.

Why didn’t I throw mine away?  Who knows.  I have a patient’s family who kept the dried out remains of her belly button cord after it fell off.  After keeping them for thirty years, my own mother recently tried to give me back my twenty baby teeth.  I was going to throw the green piece of plastic away.  Maybe I’ll just keep it and give it to my son when he has his first child…boy, will he be surprised.

Naline Lai, MD
©2009 Two Peds in a Pod®

We have an updated version of this post with some recipes as well. Please read it here. 

Link added 8/2019 

“You just don’t appreciate a picky eater until you have one, ” overheard at Dr. Lai’s dinner table.

Picky eaters come in 2 major varieties. One kind is the child who eats the same foods every day and will not vary her diet; for example, cereal, milk, and a banana for breakfast, peanut butter and jelly with milk or juice for lunch, and chicken, rice, and peas for dinner. This diet is nutritionally complete (has fruit, vegetable, protein, dairy, carbohydrate) but is quite “boring” to the parent.

            The other kind of picky eater is the child who either leaves out entire food groups, most commonly vegetables or meat, or leaves out meals, such as always eats breakfast but never eats dinner.

            My own children range from the One Who Tries Anything to the One Who Refuses Everything (these are my twins!). My oldest child lived on cheerios and peanut butter and jelly for about two years and now eats crab legs and bulgur wheat and other various foods. My point: I know where you’re coming from, I feel your frustration, and I will give you advice that works as well as optimism and a new way of thinking about feeding your children.

            Fortunately, from a medical point of view, toddler/child nutrition needs to be complete as you look over several days, not just one meal. For example, if every 3 days your child has eaten some fruit, some vegetables, some protein, some dairy, and some complex carbohydrates, then nutritional needs are met and your child will thrive!

Twelve ways to outwit, outplay, and outlast picky eaters

1)      Never let them know you care about what they eat. If you struggle with your child about eating, she will not eat and you will continue to feel bad about her not eating. Talk about the day, not about the food on the table. You want your child to eat for the simple reason that she feels hungry, not to please you or anyone else, and not because she feels glad or mad or sad or because of what you the parent will feel if she eats or doesn’t eat. Along these lines, NEVER cook a “special meal” for your toddler. I can guarantee that when they know how desperately you want them to eat your cooking, they will refuse it.

2)      Let them help cook. Even young children can wash vegetables and fruit, arrange food on platters, and mix, pour, and sprinkle ingredients. Older kids can read recipes out loud for you and measure ingredients. Kids are more apt to taste what they help create.

3)      Let them dip their food into salad dressing, apple sauce, ketchup etc., which can make their food more appealing or interesting to eat.

4)      Let them pick their own food. Whether you grow your own foods, visit a farm or just let your kids help you in the supermarket, kids often get a kick out of tasting what they pick.

5)      Hide more nutritious food in the foods they already like (without them knowing). For example, carefully mix vegetables into meatballs or meatloaf or into macaroni and cheese. Let me know if you want my recipe for zucchini chocolate chip muffins or Magic Soup.

6)      Offer them foods that you don’t like—THEY might like it. Here’s an example: my children were decorating Easter eggs with Dr. Lai’s children. My kids asked if they could eat their decorated hard boiled eggs. Now, hard boiled eggs are one of the few foods that I do NOT like. I don’t like their smell, their texture, and I really don’t like the way they taste. Yet, all three of my kids, including my pickiest, loved those hard boiled eggs dipped in a little bit of salt. Go figure. Now I have an inexpensive, easy, healthy protein source to offer even though I can’t stand the way my kitchen smells when I cook them… but hey, if my kids actually will EAT them…

7)8)      Hunger is the best sauce. Do not offer junk food as snacks. Pretzels, crackers, cookies, candy, and chips have NO nutritional value yet fill up small bellies quickly. Do not waste precious stomach space with junk because your insightful child will HOLD OUT for the junk and refuse good nutrition if they know they can fill up on snacks later. Along these lines, never bribe food for food. Chances are, if you bribe eating vegetables with dessert, all the focus will be on the dessert and a tantrum will follow. You and your child will have belly aches from stress, not full bellies

9)      It is okay to repeat similar meals day after day as long as they are nutritious. We might like variety as grownups but most toddlers and young kids prefer sameness and predictability.

10)  Turn off the TV. Trust me and trust numerous scientific behavioral studies on this, while it sometimes works in the short term, it never works in the long term. In addition, watching TV during meals is antisocial and promotes obesity.

11)  Do not become a “short order” chef. If you do, your child will take advantage of you. Also see rule #8. When your child says, I don’t want this dinner/lunch/breakfast, I want something else,” you say “The meal is on the table.” One variation of this that works in some families is to have one back up meal that is the same every day and for every meal and must be completely non-cook and nutritious, for example, a very low sugar cereal and milk, peanut butter and jelly sandwich, etc, that you agree to serve if your child does not want to eat what the rest of the family is eating.

12)   You can give your child a pediatric multivitamin. This tactic is not “giving up” nor is it cheating, and it can give the Parent as Provider of Nutrients peace of mind. You can either give a multivitamin every day or just on the days that you are convinced that your child has eaten nothing.

And if all else fails, just remember someday, your child will probably become a parent of a picky eater too, and she will consult ask you how to cope. You’ll be able to tell her what worked for you when she was a picky eater.

Julie Kardos, MD and Naline Lai, MD

                ©2009 Two Peds in a Pod®

                                                       How do you know your child is ready to potty train? A podcast on potty training how-tos.

Julie Kardos, MD and Naline Lai, MD.
©2009 Two Peds in a Pod®