In front of “The Bean” in Chicago

We’re back from the American Academy of Pediatrics National Conference and Exhibition  in Chicago—sharing with you some tidbits from the forefront of pediatrics:

New high blood pressure guidelines are here. Starting at age 3 years, children should have their blood pressure checked annually, more often if they have certain medical conditions such as diabetes or kidney disease. The cutoff for “high blood pressure” has been lowered so more and more, you may notice your pediatrician scrutinizing your child’s blood pressure.

We’ve noticed many more over-use injuries from kids who play the same sport year round. We were reminded that most professional athletes played multiple sports in high school and some even up through college. Specialization in a particular sport leads to more injuries,  burnout, depression, and anxiety.  If you feel that sports rule your child’s life, remember this good rule of thumb: for high school kids, keep training under 16 hours a week. For the younger kids, keep the total number of hours per week playing organized sports under an hour per week for each year of age.  For example, an 8 year old should spend no more than 8 hours per week playing organized sports.

Probiotics are ubiquitous these days, but are they helpful? In viral diarrhea, probiotics can be mildly helpful, and may shorten the duration of diarrhea by about a day.  Probiotic therapy is showing promise for treating colic, but not for treating eczema. For more information see the International Scientific Association of Probiotics and Prebiotics.

If your child scalds himself, put the burn under COLD running tap water for 20 minutes to stop further injury. This treatment is effective for up to 3 hours after a burn.

A cautionary word about herbs: Know that herbs are not regulated by the FDA (Food and Drug Administration). Companies that supply herbs are under no obligation to show that the product works. Additionally, the company that sells the herb does not have to show that the herb is safe or effective, and cannot claim that the product can cure or prevent anything. Additionally there are no manufacturing standards to adhere to, which means you do not know how much herb or for that matter, any other contaminants, are in the herbs that you buy.

Julie Kardos, MD and Naline Lai, MD

©2017 Two Peds in a Pod®

“What? The flu vaccine again? We JUST got it,” our kids groaned when we told them it was time to get their flu vaccines. In fact, they “just got it” a year ago, which we pointed out to them. Read on to see updates on this year’s flu vaccine and why it  should be on your child’s back to school to do list. 

This year’s flu vaccine is slightly different from last year’s– it’s been changed to cover a different strain of circulating H1N1 influenza. Several flu vaccines have been FDA approved for this year’s flu season and all of them will give similar protection for your child. Make sure your child receives a flu shot and NOT the FluMist/spray-in-the-nose kind of vaccine. Unfortunately for those who are needle phobic, the FluMist has not been shown to be effective and therefore, while still licensed, is NOT recommended for use this year.

The flu vaccine is recommended for all kids six months of age and older, with very few exceptions. Even pregnant moms safely can receive the flu vaccine.

Too early for flu vaccine? Nope! Older adults might lose some immunity if vaccinated “too soon” in the season, but this observation is not born out in kids. The threat of incomplete or forgotten vaccine outweighs theoretical risk of delaying flu vaccine (even for older adults), so best to get it now.

In case you forgot, the flu is a week of misery, consisting of high fevers, cough and other respiratory symptoms, body aches, and headaches. Younger kids are prone to some diarrhea or vomiting or both along with these bad cold symptoms. The flu can cause dehydration and pneumonia, and sometimes death, even in previously healthy kids. Simply limiting your child’s exposure to people showing flu symptoms is not an effective way of preventing illness because people are the most contagious right before they show any symptoms.

Booster dose As in previous years, children under nine years of age need a booster dose the first year they receive the vaccine. If your young child should have received a booster dose last year, but missed it, they will receive two doses of this year’s vaccine spaced one month apart (the primary dose plus a booster dose).

This prior post teaches you how to tell if your kid has flu vs “just” a cold. We invite you to read more about this year’s flu vaccine on the Centers for Disease Control website here.

Julie Kardos, MD and Naline Lai MD
©2017 Two Peds in a Pod®

Whether your child is about to start kindergarten or college, we invite you to read Dr. Lai’s letter she wrote to her first born the night before she started kindergarten. Spoiler: You might want to grab a tissue.

My Child,

As we sit, the night before kindergarten, your toes peeking out from under the comforter, I notice that your toes are not so little anymore.

Tomorrow those toes will step up onto to the bus and carry you away from me. Another step towards independence. Another step to a place where I can protect you less. But I do notice that those toes have feet and legs which are getting stronger. You’re not as wobbly as you used to be. Each time you take a step you seem to go farther and farther.

I trust that you will remember what I’ve taught you. Look both ways before you cross the street, chose friends who are nice to you, and whatever happens don’t eat yellow snow. I also trust that there are other eyes and hearts who will watch and guide you.

But that won’t stop me from worrying about each step you take.

Won’t stop me from holding my breath­.

Just like when you first started to walk, I’ll always worry when you falter.

I smile because I know you’ll hop up onto the bus tomorrow, proud as punch, laughing and disappearing in a sea of waving hands. I just hope that at some point, those independent feet will proudly walk back and stand beside me. Maybe it will be when you first gaze into your newborn’s eyes, or maybe it will be when your child climbs onto the bus for the first time.

Until then, I hold my breath each time you take a step.

Love,
Mommy

Naline Lai, MD

©2017 Two Peds in a Pod®, reposted from original 2009

one way to beat allergies

The stereotype of the runny nosed preschooler is not so far fetched. But is it allergies or a cold?  The difference between allergies caused by environmental irritants and colds caused by viruses can be tough to sort out in this age group. After all, germs spread like wildfire through the preschool crowd who tends to touch everything and everyone. The little ones are still sucking thumbs and rubbing eyes but aren’t so skilled at hand washing. At the same time, environmental allergies affect this age group just as much as in our older kids.

Your pediatrician can help sort out if your child suffers from back-to-back cold viruses or from allergies, although it isn’t always straightforward. One hint is in genetics. After all, the apple does not fall far from the tree. If one biological parent has allergies, a child has about a forty to fifty percent chance of having allergies. If both parents do, then the kid is doomed to about an eighty percent chance of allergies. Also, if one parent complains loudly that their nose is runny from allergies and your child’s nose starts to run,  then it’s allergies. If your child has other signs such as a seasonal itchy face, a perpetual runny nose, or a dry sounding cough, your child’s doctor might recommend a trial of allergy medicine.

There are a few reasons that pediatricians often choose trial of allergy medicine without allergy testing.

1. Allergy testing involves either a blood draw or “skin testing” which is basically “skin pricking.” As you are likely well aware, kids this age are almost uniformly needle-phobic. Also, specifically testing for  potential allergic triggers in the environment can be tricky. After all, we can’t test for every flower or tree.

Testing may be useful when there is something specific that can be eliminated in order to control symptoms. For example, if the new family cat is the trigger, then the cat can be kept out of the child’s bedroom, or in extreme cases parents may need to find a new home for the pet. In general, we caution about testing for sensitivity to family members such as dogs or cats.

2. If we decide that a child is allergic to trees, grass, pollen, or dust, things that kids cannot easily avoid, then, the mainstay of treatment is to periodically treat allergy symptoms with medicine. So if the end result is that the child will take allergy medicine, then one approach is to try the medicine, and if the child’s symptoms resolve, we have confirmed allergies.

So which allergy medicine to start? Here are some options:

Diphenhydramine (brand name eg. Benadryl, Banofen): This safe allergy medicine has been around for many years, and for this age, comes as a liquid, chewable tablet, and a melt-on-your-tongue form. The dose for kids younger than 6 years is based on your child’s weight, so you can check the correct dose with your pediatrician. The main side effect is sleepiness, so if symptoms are worse overnight, this medicine is good for bedtime dosing. This medicine lasts 6-8 hours, so your child may need 2 or 3 doses in a 24 hour period to adequately control symptoms. A small percentage of children can become hyper, rather than sleepy, when they take diphenhydramine. If this happens, you will know NOT to give a dose at bedtime.

Cetirizine (brand name eg. Zyrtec, Aller-tec): This safe allergy medicine has been approved for kids this age for many years. The advantage is that it can be dosed once daily. It does not cause as much drowsiness as diphenhydramine. Just in case their kids feel a little sleepy on it, many parents will give the dose at bedtime. For children aged 2-5 years, the commonly recommended dose is between 2.5 and 5mg, but may change depending on other medical problems your child might have, so check with your child’s pediatrician for proper dosing. For this age, the medicine comes as a liquid and as a chewable tablet.

Loratadine (brand name eg. Claritin, Alavert): Similar to cetirizine, loratadine is less sedating than diphenhydramine and also less likely to sedate than cetirizine. The dose commonly recommended for this age group is 5mg once daily, but check the dose with your child’s pediatrician because the dose may change with certain health conditions, such as kidney or liver problems. Kids usually take the liquid or dissolve-on-the-tongue form. The tablet form techinically can be cut in half and chewed, but tastes like cardboard.

While allergy nasal sprays and allergy eye drops work very well for allergies (see our prior post on the best allergy medicine for kids),  Parents often end up wresting their kids in order to administer the drops.

Of course, you can also try to  “wash the outside off” once your allergic kid comes inside. This means washing hands and face with soap and water, and perhaps even changing shirts. Or you can do what our photographer did with her little one — a dunk in the sink.

Julie Kardos, MD and Naline Lai, MD
©2017 Two Peds in a Pod®

photo by Lexi Logan www.LexiLogan.com

Dr. Lai was shocked when she saw her first child, at age 2 ½ years, pour water out of a small pitcher into her own cup at daycare.  At home it never occurred to Dr. Lai to let her try.

When can you start letting your kids do things for themselves? While there is not a lot of hard data on this, developmentally your kids may be more capable than you think.

Eating/self feeding:
-with hands: 9 months
-with spoon/fork: 18 months
–with chopsticks: 4 years

Pour own cereal and milk: 5 years but expect some spills

Cook a meal or at least start to cook a meal on their own: around age 12 +/- 2.5 years per 2007 survey of American pediatricians. In fact, kids are allowed to participate in the TV show Chopped Junior at age nine.

Brush teeth:
Toddlers: kids take a turn, then parents take turn.
Preschool/early school aged kids: parents continue to inspect and may continue to take a turn
Again, according to the 2007 pediatrician survey, around age 8 years is when kids can do complete oral care on their own.

Pee/Poop:
5 years-Kindergarteners should be able to independently go to the bathroom. That includes undressing, using toilet/wiping, redressing, and washing hands. Unfortunately, they may still not be great at wiping- this is one reason for daily baths/showers at this age.

Completely dress/undress including zippers and buttons: 5 years. But don’t necessarily expect matching colors – some adults never even learn this skill!

Tie shoes: 4-6 years.

Medical and emergency care

Self-injectable epinephrine (brand names Epi-pen, AuviQ): 12-14 years – per survey of 88 allergists.

Diabetes self care: kids around age 7 have the fine motor coordination needed to inject insulin and check blood sugar under supervision of an adult.

Come home to an empty house:
According to the American Academy of Pediatrics, 11-12 year olds can come home to an empty house after school if:
-Daytime
-Not alone for longer than 2-3 hours
-Depends on safety of neighborhood
-Depends on other neighbors nearby who could help in an emergency
-Child should know how to answer phone, what to do in the event of fire, knows how to access the home’s water shut-off, can handle a medical emergency, knows where first aid kit is, and knows the name of pediatrician, preferred hospital, insurance, and how to contact parent

Babysit:
Recommendations vary and while there are no specific laws, there are plenty of state guidelines and recommendations. Ultimately, parents are responsible for who cares for their kids when the parents are not present. The American Red Cross offers an on-line babysitting course for kids starting at age 11 years.

So teach your children how to take care of themselves well, for their own sake and for yours. Remember, they will be the ones caring for you in your old age.

Naline Lai, MD and Julie Kardos, MD
Ⓒ2017 Two Peds in a PodⓇ

Teach your child to recognize poison ivy: “leaves of three, let’em be!”

Recently we’ve had a parade of itchy children troop through our office.  The culprit: poison ivy.

Myth buster: Fortunately, poison ivy is NOT contagious. You can catch poison ivy ONLY from the plant, not from another person.

Another myth buster: You can not spread poison ivy on yourself through scratching.  However, where  the poison (oil) has touched  your skin, your skin can show a delayed reaction- sometimes up to two weeks later.  Different  areas of skin can react at different times, thus giving the illusion of a spreading rash.

Some home remedies for the itch:

Hopping into the shower and rinsing off within fifteen minutes of exposure can curtail the reaction.  Warning, a bath immediately after exposure may cause the oils to simply swirl around the bathtub and touch new places on your child.

Hydrocortisone 1%-  This is a mild topical steroid which decreases inflammation.  We suggest the ointment- more staying power and unlike the cream will not sting on open areas, use up to four times a day

Calamine lotion – a.k.a. the pink stuff- This is an active ingredient in many of the combination creams.  Apply as many times as you like.

Diphenhydramine (brand name Benadryl)- take orally up to every six hours. If this makes your child too sleepy, once a day Cetirizine (brand name Zyrtec) also has very good anti-itch properties.

Oatmeal baths – Crush oatmeal, place in old hosiery, tie it off and float in the bathtub- this will prevent oat meal from clogging up your bath tub. Alternatively buy the commercial ones (e.g. Aveeno)

Do not use alcohol or bleach– these items will irritate the rash more than help

The biggest worry with poison ivy rashes is the chance of infection.  Just like with an itchy insect bite, with each scratch, your child is possibly introducing  infection into an open wound.  Unfortunately, it is sometimes difficult to tell the difference between an allergic reaction to poison ivy and an infection.  Both are red, both can be warm, both can be swollen.

However, infections cause pain – if there is pain associated with a poison ivy rash, think infection.  Allergic reactions cause itchiness- if there is itchiness associated with a rash, think allergic reaction.  Because it usually takes time for an infection to “settle in,” an infection will not occur immediately after an exposure to poison ivy.  Infection usually occurs on the 2nd or 3rd day of scratching.  If you have any concerns take your child to her doctor.

Generally, any poison ivy rash which is in the area of the eye or genitals (difficult to apply topical remedies), appears infected, or is just plain making your child miserable needs medical attention.

When all else fails, comfort yourself with this statistic: up to 85% of people are allergic to poison ivy.  If misery loves company, your child certainly has company.

Naline Lai, MD and Julie Kardos, MD
©2017, 2016, 2015 Two Peds in a Pod®, updated from 2012

NOTE: Recommendations about rear facing car seats have been updated since the publication of this post. Please link here.

This photo above is a horrific yet terrific reminder of why we strap our kids into car seats. This child was buckled into a car seat when the unthinkable happened— a potentially lethal car accident. As you can see, the child’s bruises directly line up with properly-applied car seat restraints. Thankfully, the injuries to this child are only skin-deep. On the other hand, the photo below shows what happened to the car.

Please remember always to travel with your children properly restrained.

For maximum safety in cars:

• Keep children in rear facing car seats until age two years. Usually they will outgrow the baby car seat that you brought them home in and you will need to install a new rear facing car seat before they reach two years. Check the weight/height limits for the seat.
• Keep them in the car seat until age five years, or until they outgrow the weight or height limits set forth by the car seat manufacturer.
• Use a booster until your children are 4 feet 9 inches or until the car’s shoulder seatbelt falls naturally across the chest (not the neck) and the lap belt lies low across their hip bones (some kids are in boosters to age 10 years and beyond).
• Keep infants and children in the back seat until at least age 13 years.
• Don’t drive while distracted or sleep deprived. Children learn from watching their parents. Emulate now the way you want your 16-year- old to drive.

Your can read more details on car seats and seat belts on the CDC (Centers for Disease Control) website here.

Read about guidelines for child safety restraints on airplanes here.

Julie Kardos, MD and Naline Lai, MD

© 2017 Two Peds in a Pod®, photos used with permission

These lucky fish don’t have to worry about swimmer’s ear… they don’t have any ears! –Photo by Dirk Peterson, MD

It’s the type of ear pain that usually creeps up on a school-aged summer camper. One night he may notice discomfort when his ear is against his  pillow. The next night, the pain gets worse. Eventually, even touching the ear is painful. The ear is probably infected, but infected with “the other kind” of ear infection—swimmer’s ear.

Ear infections are divided into two main types: swimmer’s ear (otitis externa) and middle ear infections (otitis media). An understanding of the anatomy of the ear is important to understanding the differences between the two types of infection.  Imagine you are walking into someone’s ear. When you first enter, you will be in a long tunnel. Keep walking and you will be faced with a closed door. The tunnel is called the external ear canal and the door is called the ear drum.

Swimmer’s ear occurs in the ear canal. Dampness from water, and it can be water from any source- not just the pool, sits in the ear canal and promotes bacterial infection.  

Next, open the door. You will find yourself in a room with a set of three bones. Another closed door lies at the far end.  Look down.  In the floor of the room there is an opening to a drainage pipe. This room is called the middle ear. This is where middle ear infections occur.

During a middle ear infection, fluid, such as during a cold, can collect in the room and promote bacterial infection.  Think of the sensation of clogged ears when you have a cold. Usually the drainage pipe, called the eustachian tube,  drains the fluid.  But, if the drain is not working well, or is overwhelmed, fluid gets stuck in the middle ear and become infected. 

Because a swimmer’s ear infection occurs in the external canal, the hallmark symptom of swimmer’s ear is pain produced by pulling the outside of the ear.  Since middle ear infections occur farther down in the ear, pain is not reproduced by pulling on the outer ear.

Doctors treat swimmer’s ear topically with prescription antibiotic drops.  To avoid dizziness and discomfort when putting drops in, first bring the ear drop medicine up to body temp by holding the bottle in your hand.

Home remedies to prevent swimmer’s ear:

• After immersion in the water, tilt your child’s head to the side and towel dry what leaks out.
• Mix rubbing alcohol and vinegar in equal parts. After swimming, place a couple drops in the ear.  Do not put these drops in if there is a hole in your child’s eardrum. 
• Prior to swimming put a drop of mineral oil or olive oil in each ear. This serves as a barrier protection against the water as well an ear wax softener. Do not put in if there is a hole in your child’s eardrum.

Although it’s tough to remind children to dry their ears well, take heart.  Dr. Lai once spent two hours trying to get a cockroach out of a child’s ear canal.   We  suspect those parents would have been happier if instead, water had gotten into their child’s ear.

Naline Lai, MD and Julie Kardos, MD

©2017 Two Peds in a Pod® 
updated from 2016

A few years ago, we asked our dad readers to help us write our Father’s Day post.  We thought you would enjoy hearing from them again. The dads completed this thought: “Before I became a dad, I never thought I’d…”

…Learn to curl hair for cheerleading competitions

…BE RESPONSIBLE

…Become a stay at home dad AND love it so much after everything I’ve been through!!

…Learn all of the names of Thomas The Tank Engine’s friends and the many songs associated with them.

…Have a toys r us in my house.

…Go food shopping at midnight.

…Make so many pancakes on Sunday mornings.

…Volunteer in a dunk tank and have pie thrown at me.

One of our readers summed up his thoughts on becoming a dad:

Since I’ve become a father, nearly seven years and two beautiful daughters later, my life has become a series of jobs that I never thought I would have to tackle. These include:

Beautician: I never thought in a million years that I would be learning how to do pony tails, side pony’s, braids (not that I can braid yet), and painting little finger and toe nails.

Disney Princess Aficionado: At one point in my life I thought I was cool because I knew a lot about beer, how it was made, where it was from, where the best IPA’s were being poured. Now I am “cool” because I know where Mulan lived, and because I know the story about Ariel falling in love with Prince Eric.

Doctor: I am well versed here and can cover almost everything from the simple band-aid application and boo-boo kissing, to the complex answering of why daddy is different and why he gets to go to the bathroom standing up.

Cheerleader: Both of my daughters enjoy participating in sports. It’s been such a great experience to cheer them both on from the side line. I enjoy watching them grow with the sport and gain confidence game after game.

Becoming a father was one of the best choices I have made with my life. I love being a dad, and I look forward to the future dad challenges, good and bad, and being the best mentor I can be.

Thank you to our readers for contributing to this post.

Happy Father’s Day!

Julie Kardos, MD and Naline Lai, MD

©2014, 2017 Two Peds in a Pod®

“Hi, it’s me, Hannah.  Hannah Baker.” So begins the first episode of 13 Reasons Why, a thirteen installment Netflix series that focuses on the aftermath of the suicide of a 17-year-old high school student.  Based on the novel by Jay Asher, the series has sparked quite a bit of debate and concern among parents and mental health professionals.  At its best, the series has served as a conversation starter; at its worst, it has glamorized suicide and the fantasy of revenge.  At the end of the day, however, an important question remains:  How do we talk with our kids about suicide?  While many difficult topics have become increasingly safer to discuss, suicide is one that is still shrouded in secrecy and shame. In fact, it is so difficult to talk about that I had a hard time writing this post.  Finding the right words about something that often remains unspoken is not an easy task.  So if circumstances require it, how are we to explain suicide to our children?

According to the American Foundation for Suicide Prevention, research has shown that over 90% of people who died by suicide had a diagnosable, though not always identified, brain illness at the time of their death.  Most often this illness was depression, bipolar disorder, or schizophrenia, and was complicated by substance use and abuse.  Just as people die from physical illnesses, they can die as the result of emotional ones.  If we can change the narrative about suicide from talking about it as a weakness or character flaw to the unfortunate outcome of a serious, diagnosable, and treatable illness, then it will become easier for us to speak with honesty and compassion.

Telling the truth about any death is important. While it is natural for us adults to want to protect our children from pain, shielding them from the truth or outright lying will undermine their trust and can create a culture of secrecy and shame that can transcend generations.  We can protect our children best by offering comfort, reassurance, and simple, honest answers to their questions. It is important to recognize that we adults typically offer more information than our children require.  We should start by offering basic information, then let them take the lead on how much they actually want to know.

For young children, your statements may look something like this: “You have seen me crying, that is because I am sad because Uncle Joe has died.”  They may not even ask how the death occurred, but if they do, you can say “He died by suicide. That means he killed himself.”  The rest of the conversation will depend on the child’s response.  With older children, the narrative can follow a similar theme yet use more sophisticated language.  The older the child, the more likely they are to ask direct questions.  Some examples of honest answers are “Do you know how people have illness in their bodies, like when Grandma had a heart attack and our neighbor had cancer?  People can get illness in their brains too, and when that happens, they feel confused, hopeless, and make bad decisions. Uncle Joe didn’t know how to get himself help to stop the pain.”  If they ask how the suicide occurred, you can say “With a gun” or “She cut herself.”  Sometimes you will have to say “I don’t know. I wish I knew the answer.”  Whatever the age of your child, do your best to use simple, truthful language.

Regardless of age, children converse about and process death differently than adults.  If you tell your child about a suicide, it is likely that he/she will want to talk about multiple times over the course of days, weeks, or even years.  Keep the dialogue open, and check in with them periodically if they have questions.  If you find that you or your family is in need of the support of a professional, you might want to consider a bereavement group or a trained professional who specializes in grief.  These resources are available through online directories, local hospitals, and the Psychology Today therapist finder.  Overall, be aware that providing truthful information, encouraging questions, and offering loving reassurance to your children can allow your family to find the strength to cope with terrible loss.

(Excerpts taken from The American Foundation for Suicide Prevention’s “Talking to Children about Suicide”, www.afsp.org.)

Links:

Sesame Sreet Workshop’s When Families Grieve
The Dougy Center for Grieving Children and Families
The American Foundation for Suicide Prevention
Hands Holding Hearts (Bucks County, PA)
The Jed Foundation

Dina Ricciardi, LSW, ACSW

©2017 Two Peds in a Pod®

Guest blogger Dina Ricciardi is a psychotherapist in private practice treating children, adolescents, and adults in Doylestown, PA. She specializes in disordered eating and pediatric and adult anxiety, and is also trained in Sandtray Therapy. Ricciardi is a Licensed Social Worker and a member of the Academy of Certified Social Workers. She can be reached at dina@nourishcounseling.com.