Early childhood educators wear many hats. Not only do they teach, but also they are often called on to give medical attention to their students. Last week we shared with early childhood teachers at the Delaware Valley Association for the Education of Young Children’s 2012 Early Childhood Conference the signs a child is in respiratory trouble. Although we focused on asthma, these signs of respiratory difficulty may be present in a variety of illnesses such as pneumonia.

My youngest child clambered off the bus Friday afternoon with a fixed grin across his face.

 “What are you doing here?” he asked curiously. Usually, I am not home in time to greet the afternoon bus.

“I came to walk you home from the bus stop and then go for a run,” I said beaming, and kissed him on the forehead.

As my son stiffly kissed me back, the strange fixed grin remained on his face.  Then I noticed his hands were behind his back. With a sly glance, I saw he clutched a crinkled brown paper bag. I smiled. Hidden crumpled paper bags close to Mother’s Day mean only one thing — a “surprise” gift.

“Don’t you want to go running now?” my son asked as we walked up our driveway, carefully rotating his body so that he continued to face me.

“Yes, good idea” I said, and resisted the temptation to look back.

As I jogged through the neighborhood, I mused over the upcoming holiday and what it meant to be a “happy” mother on mother’s day. Last week I had gained some insights after participating on a panel at Brown University’s Women’s Leadership Conference. The topic of the discussion was “Happy Kids/Happy Parents: What’s the Secret Sauce?” The talk was lively, and since it was a women’s conference, discussion focused on motherhood. Ultimately the conclusion made by moderator Clare Hare was “There is not one right way to parent,” but, perhaps, some good guidelines. Here are some ideas to think about:

On the dilemma of working outside the house vs. working full time as a mom at home: As a mom it is easy to give, give, and give so much of yourself to others that you can lose a little (or a lot) of your own self-identity. By maintaining a self-identity you become a more confident mother. Some women draw confidence from forging a career outside the home. Others draw from organizing local community-based activities. A mom ultimately needs to feel at the end of the day that she raised her own child, no matter how she does it. Stop comparing yourself to others and do what is right for your own family. In an economy where it is often not financially feasible for one partner to stay at home, working outside the home may be less of a choice and more of an obligation; however, the crucial point remains— if you are not the person you want your child to see, then become the person you want her to see.

On helicopter parenting: Worried that you are too much of a helicopter parent? Know where to draw the line. Use the “cry now or cry later” philosophy. If you know your child will be crying in 30 years when he is obese and diabetic because you didn’t insist on a healthy diet with limited “junk”, stand your ground and let him cry now and you refuse him a second helping of cake. If you know your child will NOT be crying in 30 years because you didn’t insist that he continue piano lessons, let it go.

On keeping you and your child sane during the college admission process: Yes, statistically it’s tougher than ever to get into colleges- this is a matter of demographics. There are more college-bound seniors because of population growth, and hence more applicants per spot. But the pressure for students to overextend themselves in multiple activities is imposed by parents and the kids themselves, not by the admission offices. In the years preceding applying to college, encourage your child to concentrate on excelling in specific areas—think quality not quantity. Do what comes from the heart. When your child seems overwhelmed, as Dr. Kardos and I always say, insure basic needs are met — eat, sleep, drink, pee and poop. And don’t forget to leave time for play and relaxation.

On ignoring hype:  Be willing to change your opinion in light of data. Use evidence, not hype, to drive your actions. Despite data showing teens naturally awaken later in the morning than younger children, one audience member recounted how she still encountered many difficulties when she advocated for later high school start times in her school district. 

All thoughts to nosh on.

You never realize the soaring magnitude of your own mother’s love until you meet your child. No matter your approach to raising children, we wish you “happy” as you remember how you felt when you were the child who brought home a brown crinkled paper bag to surprise your own mom. And again “happy” as you feel gratitude and awe for the privilege of now receiving the surprise.

Dr. Kardos and I wish you a Happy Mother’s Day.

Naline Lai, MD

Special thanks to my fellow panelists: Clare Hare, Principle of Clare Hare Design; Jill Hereford Caskey, Director, Alumni College Advising Program, Office of Alumni Relations, Brown University; Judith Owens , Director of Sleep Medicine, Children’s National Medical Center; Peg Tyre, Director of National Advocacy, Edwin Gould Foundation, author of The Trouble With Boys and The Good School.

© 2012 Two Peds in a Pod®

We’re pleased to bring to the Greater Phildaelphia Area our “Scoop on Poop” post which was published in the Healthy Kids blog for Philadelphia Inquirer’s philly.com.

Although many can not talk about the topic without snickering, face it. “Poop” is an essential of life. If pooping gets thrown off, everything gets thrown off. The kid who won’t poop in the potty sets everyone else in the household off kilter, and leads to bribes, threats and chaos. A constipated kid is a grumpy kid.  Constipation can lead to tantrums, refusal to eat, and even an inability to fall asleep. If you still have have infant and toddler poop questions, check out our podcast on potty training and our post “When potty training gets hard: constipation.”  On a related topic, please also visit our post “It’s a Gas, your young infant’s burps and farts.”

Until you are a parent, you can never fully appreciate the fierce desire for “everything to come out okay in the end.”

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

Our fantastic Two Peds in a Pod photographer Lexi Logan recently put in a request for a post on bloody noses. I cringed, thinking any photo would not be pretty. “No problem,” she replied,” I’m thinking just a tissue and a top-of-nose shot… pinch angle.”

I was aghast. “Looks like you fell for the number one myth associated with bloody noses,” I said.”That’s the wrong spot to pinch.”

“See,” she told me,”that’s why I need the post.”

So, how does one squelch the fountain of red which spews from a bloody nose? Apply pressure to the SIDE of the nostrils—not up near the bridge of the nose. More blood vessels lay near the bottom of the septum, the divider which separates the nostrils, than near the top. Pinch the nose firmly. Since kids never seem to apply enough pressure on their own, go ahead and pinch for them.  You’ll find it easier to pinch both nostrils simultaneously even if the blood is dripping from only one side.

Now hold. Hold. Hold. Hold in the middle of the night until you nearly fall back to sleep. Hold until the pot of spaghetti boils over. Hold for at least ten minutes before peeking in order to allow the blood to clot. If the nose is still oozing, pinch for another ten minutes. Have your kid sit up straight or lean slightly forward. Otherwise, blood will drip down the back of her throat and cause nausea and vomiting.

Do not be surprised after an episode if the next couple of nights bring more bloody noses.  At night during sleep kids tend to rub their noses. Any scab that formed from a recent nose bleed gets sloughed off.

To prevent reoccurrence, protect those fragile blood vessels by keeping the inside walls of the nose moist. Once or twice a day, spritz saline into the nose, then apply a thin layer of petroleum jelly. Try running a cool mist humidifier in your child’s bedroom.

Prevent nasal irritation by decreasing environmental irritations such as cigarette smoke or dust. Teach your child to dab at his nose or blow gently when he has a cold. Ironically, some steroid nasal sprays, which treat runny noses caused by allergies, can irritate nasal passages.

Your kid is having too many bloody noses when you start to carry around tissues or your child sleeps with a box of tissues next to his pillow “just in case.” Go to your child’s doctor if this occurs.  Also, go if there are signs of a clotting problem such as easy bruising, bleeding gums, or heavy periods. Likewise, if bloody noses take more than twenty minutes to clot, or if the nose bleed requires an emergency room visit or packing in the nose, make an appointment. Other reasons for more evaluation include if your family has a history of clotting disorders, your child gets speckled flat rashes that look like broken blood vessels (petechiae) which do not blanch (lose color for a second when you press on it) or if a nosebleed is caused by trauma.

Your child’s doctor may recommend sealing vessels with cauterization or investigating for possible blood clotting problems. Depending on your child’s age, she may also recommend a short course of oxymetazoline (eg Afrin). Be sure to use oxymetaxzoline according to directions- overuse can cause rebound symptoms.

Ultimately, you may find that your kid’s bloody noses are just the result of the perfect storm: dry air and a kid who picks his nose. In the meantime save that thirty percent-off Kohl’s coupon. You might be buying a lot of pillow cases.

Naline Lai, MD and Julie Kardos, MD
©2012 Two Peds in a Pod®

You wake up in the middle of the night to the sound of a seal barking inside your house. More specifically, from inside the crib or toddler bed. Unless you actually have a pet seal, that bark is the sound of your child with croup. 

The news is filled with stories about boys wearing pink nail polish, a baby whose gender will be kept a secret by his/her parents, and Chaz Bono’s new book and identity as a man.  What’s the deal with gender, and why have the media waves exploded in the past few years?  Is gender variance becoming more common, or just more recognized?  And what should you do if your son wants to wear pink or your daughter cuts her hair short?

First, some definitions. 

–Gender is one’s internal sense of self as male, female, or neither, while sex is assigned at birth based on external appearance.  As one astute child told me, “sex is what’s between your legs, while gender is what’s between your ears.” 

–Gender expression is how one chooses to portray his or her sex or gender—for example a male child (sex assigned at birth) who feels he is a girl (gender) might still wear boys’ clothing and hairstyles to fit in with peers (gender expression).  Or, a female child (sex) feels she is a girl (gender) but prefers to wear boys’ clothing (gender expression) and chooses a gender-neutral name. Her gender expression is masculine. 

–Gender variant, gender diverse, and gender nonconforming refer to a child who expresses gender identity or expression that is different than what one expects based on sex.  These terms refer to a wide range of children—from the little boy who likes to play with Polly Pocket dolls to the male child who insists he is a girl and wears dresses to school.  Some gender variant children will be transgender, which refers to a child who persistently feels the sex assigned at birth is incorrect.

When gender variant children reach puberty, they may become aware of their sexual orientation, or who they are sexually attracted to.  They may find that they are attracted to the “opposite gender” and have a straight (heterosexual) orientation, or they may be attracted to the same or any gender, and identify as gay, lesbian, or bisexual.  Of course, these labels become especially confusing when discussing gender variant teenagers. For example, is a female-bodied teen who identifies as a man (transgender) and attracted to women heterosexual or homosexual?  For this reason, many young people choose to identify as queer, an umbrella term with a positive connotation that conveys many ways of loving people with different bodies and gender expressions. 

How common is gender variance?

International epidemiologic studies estimate the prevalence of transgender adults to be anywhere from 1 in 1,000 to 1 in 30,000.  That’s a huge range.  When you include children who are gender variant but not transgender, the numbers are much higher.  For example, Gender Spectrum, an organization that I work with in California, conducts trainings at schools that have identified a gender variant child who is facing bullying or discrimination.   To date, they have been invited to nearly every elementary and middle school in their geographic area.  Most schools in this area have approximately 100-500 students, so my best estimate of gender variance in my geographic area is 1 in 500.

How do you know if a child is gender variant? 

The child tells you.  Many of the gender variant children I know recall telling their parents at an early age that they felt different.  For example, some transgender boys (i.e. born in a female body, identify as male) I know corrected the adults who tried to call them girls as children, insisting they were boys.  One parent recalls her transgender son telling adults “I am a boy now, but when I grow up I will be a mommy.”

Most kids exhibit some sort of gender exploration in their early childhood, and this is a normal part of development.  However, a child who is shows gender variance generally makes claims that are early and persistent, and then develops distress when corrected by adults.  The “test” becomes when a child is given the freedom to express his/her internal sense of gender.  In gender variant children, this distress will be alleviated. 

What do you do if this describes your child? 

The emerging consensus among experts is to let your child guide you, and to aid your child in his or her gender exploration by working with local resources to create a supporting and accepting environment.  In the past, some experts recommended a sort of reparative therapy, for instance removing all “girlish” toys from a boy-bodied child’s home and insisting that he wear only “masculine” clothing.  While this may have worked for a short time, the child’s distress often emerged later on, often in puberty, with depression and suicide.  In fact, a survey of transgender adults showed that one-third of them had attempted suicide in their life, some as young as age seven or eight.  These are good reasons to pay attention to your young child.   Research shows that children raised in supportive families have more positive outcomes.

Parents raising gender variant children worry about their safety and acceptance in their schools, neighborhoods, and extended families—and for good reason.  Gender variant children are bullied and face discrimination, abuse, and violence at rates much higher than their peers.  Often, parents do not agree with each other—as one parent may allow more gender exploration than the other.  The child’s gender presentation may not be accepted in churches or within the family’s religious belief.  It is imperative that families obtain professional help, especially when there is disagreement between parents on how to support the child.  In addition, there are many parents groups and conferences where families can meet each other for mutual support.

If you are concerned about a child in your own life, there are wonderful organizations that can help you. 

Resources:

Resources: Gender Spectrum www.genderspectrum.org

Family Acceptance Project http://familyproject.sfsu.edu/

Trans Youth Family Allies http://www.imatyfa.org/

My favorite blogs, articles, and videos about raising Gender Variant Children

Sarah Hoffman’s Parent Blog http://www.sarahhoffmanwriter.com/

A Boy’s Life from the Atlantic http://www.theatlantic.com/magazine/archive/2008/11/a-boy-apos-s-life/7059/

Two Families Grapple with Son’s Gender Identity from NPR http://www.npr.org/2008/05/07/90247842/two-families-grapple-with-sons-gender-preferences

Transgender Kids recent CNN segment http://www.cnn.com/2011/09/27/health/transgender-kids/index.html

Ilana Sherer, MD

Returning guest blogger Dr. Ilana Sherer is the Director of General Pediatrics of the Child and Adolescent Gender Center at UCSF. She is a recipient of the Chancellors Award for LGBT leadership at UCSF and also of the American Academy of Pediatrics Dyson Child Advocacy Award.

©2012 Two Peds in a Pod®

As a call to service in honor of Martin Luther King Day, we bring you an eye opening child advocacy post from guest blogger Dr. Heidi Román, who works with underserved children and their families in California .

Early in my pediatric residency training I entered the exam room to see a one-year old patient. Her mom blurted out excitedly, “We finally have a place to live.” It turned out that they had been living in motels or with relatives for most of the child’s life. I paused for a moment as I realized that it had never really registered. She had been seen in our clinic for multiple visits, but no one had noticed the changing addresses. No one had asked the questions in a way that allowed her to tell us. They were homeless. This was my wake up call. Since then, I have met many families affected by homelessness. Many hard working families are pushed into poverty and homelessness by loss of a paycheck, foreclosure, or divorce. They are reluctant to talk about it. Children and families are the “hidden” homeless.

While the mainstream media consistently covers the recession, quoting jobs numbers and the like, there is a disturbing new set of data out that doesn’t seem to be getting much press. Last month the The National Center on Family Homelessness released their report on child homelessness entitled “America’s Youngest Outcasts 2010“, and the news is not good. During the time period of the recession (2007-2010) there was a 38% spike in the number of homeless children. Currently, there are 1.6 million homeless children in the United States. Children now make up almost 40% of the homeless population and families with children are the most rapidly growing segment of the homeless population.

That’s a lot of kids and families. And, as children are often not included in homeless statistics, the number is probably higher. Why don’t we hear about it more? Well, homeless families tend to be the invisible segment of the homeless population. They fly under the radar. They move from place to place. They “double up” with friends or relatives for a few months, and then stay in a shelter or motel for a while. They sleep in their car. Parents may not even report that they are homeless to teachers or health care providers for fear of losing their children. There are various reasons that families become homeless. Certainly worsening poverty, due to job loss or changes in welfare programs, is a major cause of housing loss for families. But, domestic violence or parental separation is also very often to blame.

Once families become homeless, it is very difficult to escape. Even if the parents are lucky enough to find a job, it will likely pay only minimum wage. Adequate housing is still out of reach for these families. This is true regardless of the state, city, or town the family lives in; and the gap between income and housing costs is even greater in areas with a high cost of living. 

Experiencing homelessness profoundly affects a child’s physical, psychological, and educational health. Homeless children have higher incidence of trauma-related injuries, poorly controlled asthma, developmental delays, growth problems, and anemia, among other health problems. Homeless children are far less likely to have a medical home or adequate health insurance. They are far more likely to utilize the ER for care at a later stage of illness. Homeless adolescents have much higher risk of being victims of violence or sexual abuse and have higher rates of substance use, HIV, and teen pregnancy.

Homeless children, regardless of cognitive ability, do far worse in school. They are more likely to change schools during the year or miss more school days, greatly affecting their ability to do well academically and flourish socially. Even simple things, like being asked by a teacher to draw their room or describe their house, become awkward and painful.

What’s being done about this? Sadly, not much. Per the State Report Card on Child Homelessness, only seven states have extensive plans relating to services for homeless families. In the current economic and political climate, the number of homeless children and families continues to increase and the services provided to them are shrinking.

What can we do?

• If you or someone you know is at risk of homelessness:
  • Talk to someone you trust- a physician, teacher, church staff, or social worker. Learn about emergency assistance programs in your area.
  • If you will be homeless in a few days or weeks, The National Coalition for the Homeless has a list of things to do. It includes making sure you have a current and available ID, packing a bag of essentials for each family member, and applying for public and transitional housing. Search the Coalition’s directory of homeless advocacy organizations and shelters.

• If you are a person who cares about these kids and families:
  • Learn about the “hidden homeless” and start talking to friends and colleagues. Work to change misperceptions about homelessness. Find out how your state is doing in terms of providing services to homeless families.
  • Consider volunteering with or donating to an organization that fights to end homelessness. National organizations include The National Coalition for the Homeless, The National Law Center on Homelessness and Poverty, and The National Center on Family Homelessness. Find a local organization to work with here or via internet search.
  • The National Coalition for the Homeless has a great list of other creative ways to get involved.
  • Finally, contact your congressperson and tell them you support H.R. 32 The Homeless Children and Youth Act of 2011. This bi-partisan bill changes the definition of “homeless person” to include certain adolescents and youth that are currently excluded for technical reasons. Their inclusion would allow them to access much needed services. If I can’t convince you, perhaps these kids can. They testified about their experience being homeless at the H.R. 32 hearing on child and youth homelessness, held by the U.S. House of Representatives’ Financial Services Subcommittee on Insurance, Housing, and Community Opportunity last December.

Heidi Román, MD

Heidi Román MD, FAAP is a mother and pediatrician who practices in San Jose, California. She has special interest and experience working with under-served families from diverse racial and socio-economic backgrounds. Dr. Román is a passionate child health advocate who works towards improved health for all kids, both in and out of the clinic. She writes about everything from parenting to policy at mytwohats.wordpress.com.

©2012 Two Peds in a Pod®

When your baby turns one, you’ll realize he has a much stronger will. My oldest threw his first tantrum the day he turned one. At first, we puzzled: why was he suddenly lying face down on the kitchen floor? The indignant crying that followed clued us to his anger. “Oh, it’s a tantrum,” my husband and I laughed, relieved.

Parenting one-year-olds requires the recognition that your child innately desires to become independent of you. Eat, drink, sleep, pee, poop: eventually your child will learn to control these basics of life by himself. We want our children to feed themselves, go to sleep when they feel tired, and pee and poop on the potty. Of course, there’s more to life such as playing, forming relationships, succeeding in school, etc, but we all need the basics. The challenge comes in recognizing when to allow your child more independence and when to reinforce your authority.

Here’s the mantra: Parents provide unconditional love while they simultaneously make rules, enforce rules, and decide when rules need to be changed. Parents are the safety officers  and provide food, clothing, and a safe place to sleep. Parents are teachers. Children are the sponges and the experimenters. Here are concrete examples of how to provide loving guidance:

Eating: The rules for parents are to provide healthy food choices, calm mealtimes, and to enforce sitting during meals. The child must sit to eat. Walking while eating poses a choking hazard. Children decide how much, if any, food they will eat. They choose if they eat only the chicken or only the peas and strawberries. They decide how much of their water or milk they drink. By age one, they should be feeding themselves part or ideally all of their meal. By 18 months they should be able to use a spoon or fork for part of their meal.

If, however, parents continue to completely spoon feed their children, cajole their children into eating “just one more bite,” insist that their child can’t have strawberries until they eat  their chicken, or bribe their children by dangling a cookie as a reward for eating dinner, then the child gets the message that independence is undesirable. They will learn to ignore their internal sensations of hunger and fullness.

For perspective, remember that newborns eat frequently and enthusiastically because they gain an ounce per day on average, or one pound every 2-3 weeks. A typical one-year-old gains about 5 pounds during his entire second year, or one pound every 2-3 months. Normal, healthy toddlers do not always eat every meal of every day, nor do they finish all meals. Just provide the healthy food, sit back, and enjoy meal time with your toddler and the rest of the family.  

A one-year-old child will throw food off of his high chair tray to see how you react. Do you laugh? Do you shout? Do you do a funny dance to try to get him to eat his food? Then he will continue to refuse to eat and throw the food instead. If you say blandly,” I see you are full. Here, let’s get you down so you can play,” then he will do one of two things:

1)      He will go play. He was not hungry in the first place.

2)      He will think twice about throwing food in the future because whenever he throws food, you put him down to play. He will learn to eat the food when he feels hungry instead of throwing it.

Sleep: The rule is that parents decide on reasonable bedtimes and naptimes. The toddler decides when he actually falls asleep. Singing to oneself or playing in the crib is fine. Even cries of protest are fine. Check to make sure he hasn’t pooped or knocked his binky out of the crib. After you change the poopy diaper/hand back the binky, LEAVE THE ROOM! Many parents tell me that “he just seems like he wants to play at 2:00am or he seems hungry.” Well, this assessment may be correct, but remember who is boss. Unless your family tradition is to play a game and have a snack every morning at 2:00am, then just say “No, time for sleep now,” and ignore his protests.

Pee/poop: The rule is that parents keep bowel movements soft by offering a healthy diet. The toddler who feels pain when he poops will do his best not to have a bowel movement. Going into potty training a year or two from now with a constipated child can lead to many battles. 

Even if your child does not show interest in potty training for another year or two, talk up the advantages of putting pee and poop in the potty as early as age one. Remember, repetition is how kids learn.

Your one-year-old will test your resolve. He is now able to think to himself, “Is this STILL the rule?” or “What will happen if I do this?” That’s why he goes repeatedly to forbidden territory such as the TV or a standing lamp or plug outlet, stops when you say “No no!”, smiles, and proceeds to reach for the forbidden object.

When you feel exasperated by the number of times you need to redirect your toddler, remember that if toddlers learned everything the first time around, they wouldn’t need parenting. Permit your growing child to develop her emerging independence whenever safely possible. Encourage her to feed herself even if that is messier and slower. Allow her to fall asleep in her crib and resist rocking her to sleep. Everyone deserves to learn how to fall asleep independently. You don’t want to train a future insomniac adult.

And if you are baffled by your child’s running away from you one minute and clinging to you the next, just think how confused your child must feel: she’s driven towards independence on the one hand and on the other hand she knows she’s wholly dependent upon you for basic needs. Above all else, remember the goal of parenthood is to help your child grow into a confident, independent adult… who remembers to call his parents every day to say good night… ok, at least once a week to check in…. ok, keep in touch with those who got him there!

Julie Kardos, MD with Naline Lai, MD
©2012 Two Peds in a Pod®