Medical mystery: What is that lump?
Hint: Your basketball star now is taller than you and works out daily.
Hint: He talks about pain at this spot.
Answer: Your kid’s tibial tuberosity when affected by Osgood Schlatter disease

First, some knee anatomy. The knee cap (patella) is anchored into place by tendons and ligaments. One called the patellar tendon attaches to the shin bone (tibia) below the knee at a point called the tibial tuberosity .

Repetitive bending movements of the knee, such as running and jumping, cause the patella tendon to pull on the bone where it attaches at the tibial tuberosity. Strain can result in a large tender lump which forms as the body tries to repair this area. This condition called Osgood Schlatter disease is associated with puberty, so most kids eventually “grow out of it.”

Ice, rest, and ibuprofen will alleviate pain. Your child’s health care provider may recommend gentle stretching of the quadriceps muscles or a knee brace. Beware of increased pain because rarely the muscle tears away from the bone and causes stress fractures.

Never know when you will “kneed” this information.

Naline Lai, MD and Julie Kardos, MD
© 2011 Two Peds in a Pod®

Emmy award winning journalist Janet Zappala, author, nutritionist, chef, and  mom, blogs for us today!

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Summertime is in full swing and the snacking is easy. This is the season to grab all of the fresh fruits and vegetables you can. Berries, for example, are brimming over in your local supermarket. Blackberries, blueberries, raspberries and strawberries: not only are they delicious, they’re also chock full of antioxidants that fend off free radicals to keep our cells healthy, and they’re an excellent source of dietary fiber so they don’t spike your blood sugar and cause a lull in energy. Eating berries will keep your energy up all day, so you can enjoy all of the fun activities that summer has to offer. Keep them refrigerated so they’re nice and cold on a hot summer day. They’ll also last a bit longer than if you leave them out. The same goes for vegetables: what’s more refreshing than chilled cucumber, carrot, celery and bell pepper slices? Want to dip? Check out my spinach dip and/or my hummus recipe at www.janetzappala.com.

Snacking is a great way to avoid overeating as well. By keeping nutritious snacks handy you can snack throughout the day and stay satisfied and energized. The key is knowing which snacks provide the most nutrients, and one of your best bets is whole grains. Whole grain crackers and chips are just sitting on your supermarket shelves, “ripe” for the picking. Vegetable chips are another tasty option. A personal favorite is Terra’s Sweets and Beets, chips made from sweet potatoes and beets. What could be more satisfying? You’re still getting a crunchy treat, but one that’s made from ingredients that will do your body good. Worry-free eating, that’s what it’s all about. One of life’s greatest pleasures is eating, why should we give up the things we love? We don’t, we just have to find healthier options, a much easier task these days as manufacturers are tuning into the consumer’s demand for healthier options.

If you and your kids are sandwich lovers, go for whole grain bread, a couple slices of fresh roasted turkey (not processed), lettuce and tomato, and top if off with a slice or two of Jarlsberg Lite cheese. It’s my favorite for its great taste, and it’s relatively low in fat and calories. Drizzle a little extra virgin olive oil, a splash of red wine vinegar, and a sprinkle of salt and pepper on top, and you have a mouthwatering and nutritious lunchtime treat that will pack the punch you and your family need to keep you going throughout your day.

Finally, a little more food for thought, seeds! Don’t forget to have plenty on hand, everything from sunflower seeds, to sesame seeds, to pumpkin seeds, to flaxseeds. All will provide you with countless nutrients and energy, not to mention a good amount of fiber in every delectable bite. Grab a handful during the day and you’ll be providing your body with everything from protein and iron, to potassium, and magnesium. Flaxseed alone provides heart-healthy omega 3 fatty acids. Go nuts for nuts too! Heart-healthy almonds and omega 3 rich walnuts are especially good for you.

All this said, opt for the raw, unsalted variety if you can. If that’s too big a step at first then try to stay away from salted nuts. As you go along your palate will change gradually and you’ll be able to enjoy raw unsalted seeds and nuts the way mother nature intended.

Enjoy the summer and all of the great foods and fun it has to offer!

– Janet

Janet Zappala is a certified nutritional consultant and author of My Italian Kitchen — Home-Style Recipes Made Lighter & Healthier. She is also a six-time emmy award winning television journalist and the host of Wealth of Health at www.janetzappala.tv. Janet is a busy mom as well and is always creating ways to offer up delicious, nutritious foods that are quick and easy to make. 

Recently, we lost the air conditioning in our home. My family welcomed the sympathy as we fried in an early summer heat wave. My neighbors and co-workers all offered us time in their homes as a respite from the heat. Actually, it wasn’t too bad at home. If anything it showed my family how much energy we in fact waste. With the help of two fans and by pulling down window shades, the homework still got done, meals were eaten, and the kids, although sweaty, still played.

Our weeks in our hot home made me think about a disturbing trend I tend to see over the summer. Often, overweight kids at the end of summer come back to my office heavier than they were in the spring. I’ve always thought of summer as a time for constant outdoor play and physical activity, but for some, the hot summer is as tough as the cold winter when it comes to healthy weight maintenance. As I saw my kids function as they normally do despite the heat, I wonder if we use high temperatures in summer just as we use low temperatures in the winter as an excuse not to send our kids outside. 

Of course we need to be respectful of the dangers of over-heating. As the air conditioner fix it company works in my home, I’ve read at least four articles that came across my computer about the signs of heat stroke. We too have written posts about dehydration in Two Peds in a Pod. Yet I wonder if our own inability to tolerate heat may be curtailing our kids’ activities. As one mom said to me, “I don’t want to send my kids outside, because I don’t want to go out with them.” 

Summer also makes me think “Ice Cream.” I am a great fan of the ice cream truck. In fact, I am friends with the ice cream man and pictured here is a photo of a beautiful gift he gave me before he left last summer. But I wonder if we use the heat as an excuse to give more ice cream and more sugar filled drinks such as lemonade than we do during the school year.  As much as we complain about school systems institutionalizing junk food as part of classroom celebrations and lunches, private camps are not necessarily better regulated.  And for the kids at home, parents often feel obligated to feed play dates “something fun.”

An American Journal of Public Health article in 2007 supports my observations. The study lead by Paul T. Von Hippel found a more rapid rate of weight gain (using body mass index) during kindergarten and first grade summers than during the school year. Unfortunately the study was not structured to shed light on the reasons behind the rate increase, but I’m thinking it’s us… the perfectly-coiffured-not-smelly parents who somehow on the way to adulthood forgot how to turn on the hose and play in the summer heat.

Naline Lai, MD with Julie Kardos, MD

©2011 Two Peds in a Pod®

What is it ? Pictured here are the toes of one of my best friend’s toddler. She is happy, has no fever, and plays nearly everyday in the neighborhood pool. The round shiny pink bumps and dots on her toes appeared yesterday morning and haven’t changed much in a day. They don’t seem to bother her very much… answer below.

Dozens of kids are pouring into our offices or calling from the shore because of swimmers ear. Time to bring up from the archives info about swimmer’s ear and ways you can prevent reoccurrence.

No set of blog posts about summer time plagues would be complete without a discussion on swimmer’s ear (Otitis Externa). 

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.

Swimmer’s ear is treated topically by your doctor with 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. 

WE HAVE UPDATED THIS POST and added photos- please read it here. 

We’re seeing a lot of this stuff around the office. It’s hand-foot-mouth disease, a common, self-limited illness caused by the Coxsackie virus most often in the spring and summer. Named for rashes which can affect the hands, feet or mouth, this illness can cause fever for the first few days as well as some loose stools.

If you look carefully at the photos above, you will see faint red bumps on this child’s feet. The rash may also look like tiny blisters and will always blanch (if you press on it and lift up your finger, the redness will briefly disappear- just as if you pressed on a sunburn). The same rash may appear on the hands and is not itchy. The child’s throat above is red in the back and has several ulcers, or canker sores. The hands, feet and mouth are not always simultaneously affected, and although we don’t call the illness Hand-foot-mouth-tush disease,  sometimes kids also get a red bumpy rash on their buttocks.

The throat ulcers can be quite painful and the rash on the feet may be slightly tender.  Usually the rash on the hands is not felt by the child. You can alleviate your child’s throat pain with acetaminophen (brand name Tylenol) or ibuprofen (brand names Advil or Motrin). For toddlers and older, Magic mouthwash, a mix of 1/4 tsp diphenhydramine (plain liquid Benadryl) and 1/4 tsp Maalox (the regular adult stuff) squirted over mouth ulcers prior to eating a meal (three times a day)  is an age old way to sooth sores.

Because this virus is contagious through saliva, prevent kids from sharing cups, eating utensils, and tooth brushes and clean up toddler drool. This vigilance can prevent the virus from spreading to family members and friends. Children with this virus can still attend daycare as long as they are not feeling ill. Typically after the first few days of illness, fever and pain subside. Most commonly the rash and mouth ulcers last about a week or two.

Unfortunately there is no treatment for hand-foot-mouth disease, but fortunately your child’s body is fully capable of fighting off the virus. Your role is to help soothe pain. Otherwise, kids may refuse to drink and end up dehydrated. When my son had this illness at age two, he liked sucking on a washcloth soaked in very cold water. I also gave him lots of sherbet, ice cream, milk shakes, and noodles.  These foods were easier for him to swallow while his throat was sore.

Kids can get this virus more than once, and many strains of this virus circulate. Even parents are not always immune. So now add Coxsackie virus, or hand-foot-mouth disease, to your Dr. Mom and Dr. Dad list of manageable diseases. Knowledge is power. However, if your child’s fever lasts more than three days, he does not drink enough to urinate his baseline amount, he is unconsolable or seems disoriented or if your parent gut-instinct tells you something more might be wrong, do get your child to medical attention.

Julie Kardos, MD and Naline Lai, MD
©2011 Two Peds in a Pod®

After we complete a Two Peds in a Pod planning or edit session, our conversation inevitably turns to the question, “What are you cooking for dinner tonight?”

We know parents are always searching for simple ways to move beyond macaroni and cheese suppers. Here are two chicken dishes Dr. Kardos’s kids love and one tofu dish Dr. Lai’s children enjoy. For picky eaters, please note each item is well demarcated- no food has to “run into” or “touch” the other items. All can be eaten with a fork or with fingers for younger toddlers.  They have flavors that adults like but are not too strongly flavored to turn a kid off.  Best of all, they are easy to prepare.  

Gram mom’s Chicken-in-a-Pot

Need: One 5-8 lb oven stuffer roaster chicken, carrots, onions, spices, cast-iron pot/dutch oven

Rinse off chicken and discard innards/gizzards. Pat dry. Sprinkle with spices that are kid friendly (no hot pepper unless your child really likes it). I use garlic powder, onion powder, salt, and tarragon. Place chicken into a cast-iron pot/Dutch oven. Add cut up carrots or “baby” carrots and either frozen pearl onions or a fresh onion chopped up. Other vegetables that will not fall apart/become mush would work as well. DO NOT ADD WATER.

Cover the pot, place on stove on low heat, and cook for 2-3 hours, until chicken is tender.  It makes its own juices as it cooks so you never need to add water. When done, the chicken falls off the bones with minimal prompting. Carefully discard bones.

Result: easy to chew, pleasantly but not strongly flavored chicken, and cooked carrots. Dr. Kardos’s kids love to eat this with applesauce (two like to dip the chicken), raw carrots (only one of her kids likes cooked carrots), rice or noodles (juices from chicken taste great on either one) and fresh strawberries or other kid-pleasing fruit.

A ma’s (Taiwanese for gram mom) easy Tofu

Need: extra firm or firm tofu, rice, soy sauce, sesame oil, dried basil (Mrs. Dash has a tomato-basil-garlic spice mixture which is great, but tough to find)

Cut a block of  tofu into one-third inch thick square pieces (approximately one and one half inch by one and one half inch). Liberally coat the bottom of a frying pan with sesame oil, add tofu and soy sauce, sprinkle dried dried basil over pieces. Cover and cook on high heat until starting to brown, then flip pieces over and cook on medium heat until other side starts to brown. For the picky kid, mush with a fork into rice and serve in a big bowl with fruit and vegetables on a separate plate. For everyone else, consider adding pepper and serve over steamed white or brown rice. 

Mom mom’s baked chicken

Need: Boneless/skinless thicker cut chicken breasts, herb or Italian flavored breadcrumbs, grated parmesan cheese, butter (or Smart Balance).

Melt butter in one bowl. In another bowl, mix equal parts breadcrumbs and parmesan cheese.

Rinse chicken, pat dry. Dip the chicken first into the melted butter, then into the breadcrumb mixture until well coated, then place onto baking pan. Drizzle any remaining melted butter onto the chicken. Bake at 350° for 25-30 minutes (until chicken is cooked through).

Serve with rice, noodles, couscous, or bulgur wheat, salad or frozen mixed vegetables that steam right in the bag, and fresh pineapple or other kid-pleasing fruit.

Bon Appetite,

Julie Kardos, MD and Naline Lai, MD
©2011 Two Peds in a Pod®

Picture the Mission Impossible theme song in your head… da da da DUM DUM da da da DUM DUM dadada…dadada…dadada…DA DA! Keep this background music playing as you read.

Recently, Two Peds in a Pod went undercover as two unsuspecting moms surveying the scene on the shelves of a local chain pharmacy, seeking to uncover what medicines, ointments, and therapies avail themselves to the unsuspecting consumer. Today we break open the case.

All medication labels have an “active ingredient” list. This list contains the actual medicine that acts on your child’s body to hide symptoms or cure a condition.  Read this list carefully so that you know what you are actually giving your child. For example, Flu-Be-Gone claims it “cures the aches and cough of flu and helps your child sleep better.” In order to know just what is actually in Flu-Be-Gone, you need to read the active ingredients. Included might be acetaminophen (brand name Tylenol), a fever reducer and pain reliever, and diphenhydramine (brand name Benadryl), allergy medicine that has the common side effect of causing drowsiness and has some mild anti-cough properties. Notice neither active ingredient actually kills the flu germ. Additionally, you may already have these two medications in your medicine cabinet, or you might have already given your child diphenhydramine recently and giving Flu-Be-Gone would overdose your child. 

Also note, diphenhydramine is everywhere. If you see the word “sleep” or “PM” in the name of a product, you will usually find diphenhydramine in the active ingredient list. 

Now, let’s hone in on your choices for the anti-itch therapy, hydrocortisone. When your child’s health care provider advises treating an itchy bug bite, poison ivy, or allergic rash with hydrocortisone, make sure that the ACTIVE INGREDIENT in the product is “hydrocortisone 1%.” Hydrocortisone comes as a cream, ointment, spray, or stick (looks like a glue stick) and can have aloe, menthol, or other ingredients thrown in as well. Don’t bother with anything less than maximum strength. Regular strength is 0.5% and is generally ineffective.  Also, keep in mind that while ointment is absorbed a bit better, it is more greasy/messy than cream.

Don’t be fooled into thinking products with the same brand name contain similar active ingredients. Also, do not depend on your doctor to necessarily know the difference between the all the formulations.We noticed that the same brand name pain reliever, such as Midol, can have different active ingredients depending on which one you choose. Midol Teen contains acetaminophen, Midol liquid gels contains ibuprofen,  and Midol PM contains acetaminophen and diphenhydramine.

Let’s talk bellyache. Did you know that kids should not take adult pepto bismol because it has a form of aspirin in it? Aspirin may cause Reye’s syndrome, a fatal liver disorder. However, we did see a product called Children’s Pepto Bismol and guess what the active ingredient is? It is calcium carbonate, which is the SAME active ingredient as in Tums, and is safe to give kids. However, watch your wallet: the children’s pepto bismol that we found cost $6.00 for a box of 24 tablets. The TUMS that we found cost $4.50 for a bottle of 150 tablets of the same stuff, just in slightly higher dose. Check with your child’s doctor but in most cases, the kids can take the adult dose.

Also, be aware that cold and cough medicine have not been shown to treat colds successfully or even to actually relieve symptoms in most kids. In fact these medicines have potential for harmful side effects, accidental overdose, or accidental ingestion and are just not worth giving your children. However, we found tons of cold and cough medicines marketed for children. Here are the three most commonly used active ingredients:

• If you see “suppressant” you will likely find “dextromethoraphan” in the active ingredient list.
  
• If you see “expectorant” you will likely find “guaifenesin” in the active ingredient list.
  
• If you see “decongestant” you will likely find “phenylephrine” in the active ingredient list.

Many products combine two or all three of the above. We ask, even if these ingredients did work well in kids and were not potentially dangerous, what is the POINT of combining a cough suppressant with an expectorant? Can you really have it both ways?

( Remember, that Mission Impossible theme is still playing in the background.)

A few other tidbits. “Dramamine,” used for motion sickness, gets broken down in the body to diphenhydramine, that allergy medicine that we already talked about. So look at cost differences when choosing a motion sickness medicine. Both have the same side effect: sleepiness.

Many cough drops contain corn syrup and sugar. This is the same stuff lollipops are made of, so just call a candy a candy and keep your child’s throat wet with the cheaper choice, if you choose to do so.

Finally, we found one “natural children’s cough medicine” which claimed that it is superior because of its “all natural ingredients.” The first active ingredient listed? Belladonna. Sure it’s natural because it comes from a plant. So does marijuana. Just because it’s “natural” doesn’t mean it’s safe. Belladonna can cause delirium, hallucinations, and death and in fact has been used in high doses as a poison! Leave the cough medicine on the store shelf, and read our post about other ways to soothe a cough.

Bottom line:  remember always to check the “active ingredient” list when buying any over-the-counter medication for your children.

As we were wrapping up our mission, one of the pharmacy employees came over to us, raised an eyebrow at our clipboard, and asked, “Can I help you ladies with anything?” We were tempted to answer “YES, can you help us take notes?”  but we just smiled and said “No, we’re fine, thanks. Just checking out what’s available.”

So now, we will don our stethoscopes and come out of hiding, go back into our offices and onto our website. Thanks for tuning in to this episode of Two Peds in a Pod…. Da da da, DUM DUM da da da, DUM DUM dadada…dadada…dadada…DA DA!!!

Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®

In today’s podcast we discuss how to spot the rash of lyme disease, what to do about poison ivy, and  how to avoid sunburns. Pictured below is a creative way one child found to block the sun effectively. Notice there’s  no burn underneath the areas of skin which were once covered by temporary tattoos.

Naline Lai, MD and Julie Kardos, MD

©Two Peds in a Pod®

“I see green stuff all over my car and I park  in the garage,” a mom said to me today.

The pollen count is high on the east coast and with it comes green cars and  itchy eyes. Eighty  percent of the older kids I saw today, including those seen for routine check-ups, had red irritated eyes.

So what to do?  Pollen directly irritates eyes, so start with washing the pollen off. One parent told me he applied cool compresses to his child’s eyes. This is not enough- get the pollen off. Plain tap water works as well as a saline rinse. Filter the pollen out of your house by running the air conditioning. Some people will leave shoes outside the house and wipe the paws of their dogs in order to keep the green stuff from tracking into the house.

Oral medications do not help the eyes as much as topical eye drops. Over-the-counter antihistamine drops include ketotifen fumarate (eg. Zatidor and Alaway). Prescription drops such as Pataday or Optivar add a second ingredient called a  mast cell stabilizer. Avoid use of a product which contains a vasoconstictor (look on the label or ask the pharmacist) for more than two to three  days to avoid rebound redness. Contacts can be worn with some eye drops– first check the package insert. Place drops in a few minutes before putting in contacts and avoid wearing contacts when the eyes are red.

Hopefully allergy season  will blow through soon. After all, as a couple teens pointed out-prom is around the corner and allergies can make even the young look haggard. One teen male told his mom that he shaved today  because having a beard and blood shot eyes made him look THIRTY years old.

Miserable allergies!

Naline Lai, MD with Julie Kardos, MD

©2011 Two Peds in a Pod® , rev 5/8/2013, rev 2015