I often pass a parent on her way out of my office carrying an infant in an infant car seat. As I stop to elicit a goodbye smile from the baby, I check to see that the car seat straps are buckled properly. I say to the parent, please make sure that the cross strap is across his chest, not down at his lap. And please tighten the shoulder straps; I should not be able to pinch the strap above his shoulders. These are too loose.

Car seats save many lives every year. After immunizations, they are the most effective way to prevent death in children, but car seats need to be used properly. Many families travel this time of year and that means it’s time to update your car seat safety knowledge.

Until recently, experts recommended that babies in car seats need to weigh at least 20 pounds AND be at least one year old until they could face forward. Newer recommendations say babies should stay rear facing in a car seat until two years old, or until they no longer fit facing backward. The reason for this change is that in a crash, children suffer fewer injuries when they face backward. Different car seat brands have different weight and height specifications so be sure to read the literature that comes with your car seat. If the seat fits well, the middle of the back seat is the best spot to install a car seat. Rear facing infant seats are the most difficult to install correctly. Luckily, many police stations and gas stations offer programs to check if car seats are installed properly. Check with your local police.

Children should remain in car seats as long as they correctly fit. For some kids this is age four years and for smaller kids this may be five or even six years. If your child is particularly tall or obese he may require a high-backed booster soon after age three. My friend had a tall child that unfortunately ended up in a car accident recently. Again, read the literature that comes with your car seat for the height and weight limit; this is more important than the age of your child. The more restraints, the safer the seat. Five point harnesses are safer than three point. After five years a car seat should be replaced. Usually the third born ends up with a new seat. Because of the risk of hairline cracks, also replace a car seat if it was in an accident.

When your child outgrows the car seat, he graduates to a booster. Again, remember the more restraints, the safer the seat. A high backed booster is preferable until your child outgrows it. Keep your child in his booster seat until he is tall enough for the chest strap of a car’s seatbelt to lie diagonally across his chest without hitting his neck and for the lap strap to lie straight across the bony parts of his hips, not his stomach. To provide neck support and minimize whip lash, his ears should not jut up past the top of the back of the booster or car headrest. Keep children 12 years old and younger in the back seat. The force of an air bag can harm a young child. 

Parents can call 1-800-CARBELT to access the American Academy of Pediatrics car safety seat hot line for their more specific car seat questions.

To ingrain good car safety habits in your children, remember to be a role model and buckle up yourself 100 percent of the time, even if you are driving only next door. Your children are watching you.

Julie Kardos, MD with Naline Lai, MD
©2010 Two Peds in a Pod?

Addendum: Please note that the official updated car restraint policy of the American Academy of Pediatrics as of March 2011 include the above recommendations of staying rearfacing until age two years and avoiding riding in the front seat until at least age thirteen years. In addition, more specific guidelines about boosters were added: children should stay in a booster seat until the car’s seat belt fits properly, at the minimum height of 4’9″ and between 8-12 years of age.

Graco was founded nearly 70 years ago, and Evenflo and Child Craft have been around even longer. In fact, most of the prominent baby supply manufacturers have been in the baby business for decades, so I am always appalled when their products are recalled. Haven’t they perfected the art of manufacturing safe baby products yet? Drop-down side cribs are the latest example in faulty designs. In the past year, manufacturers announced the recall of many drop side cribs. Ultimately, last week, the Consumer Product Safety Commission completely banned drop-down side cribs  because they have been implicated in the deaths of at least 32 infants since 2001. 

Recalls occur slowly. Here’s an example. My husband and I discovered some of the plastic pieces which held up the mattress support for our firstborn’s crib had cracked in half when we tried to set up the crib for our second born. Thinking we had used too much force to snap the pieces into place, we simply ordered more parts and put the crib together. Not until after my third child was born, five years after my first, did a recall on this crib go out. Other families experienced some of the pieces snapping while babies were in the cribs and the mattresses fell to the ground.

Through the years, I’ve noticed most recalls are only for a handful of reasons. Look at your children’s toys and equipment for these potential dangers before the recall occurs:

• Head entrapment – The most common story is that the baby slides through a leg hole of a stroller or baby carrier and his neck gets stuck. A baby also may strangle when his neck is wedged between parts of a piece of equipment. This problem occurred with drop-down side cribs. The recommended width between crib rails is 2 3/8 inches (the width of a soda can) because a child is more likely to trap his head in any larger of an opening.  Make sure there are no openings or potential openings larger than 2 3/8 inches.

• Choking – Any part that can be pulled off and fit into a toilet paper tube is a choking hazard.

• Restraint failure – Equipment is often recalled for inadequately restraining a baby, e.g. loose swing straps.

• Lead ingestion – Lead needs to be consumed to cause poisoning so anything your baby chews on, including railings, are suspect. Lead check kits are readily available; the one I use is leadcheck.com.

If your child is injured because of faulty equipment, even with an injury which seems inconsequential, remember to report the problem to the consumer product safety commission and to the manufacturers.  

Forget waiting for the recall. It could be years. Don’t buy something that makes you suspicious in the first place.

For more baby proofing hints, please see our post The In’s and Out’s of Baby proofing.

© 2010 Two Peds in a Pod℠

Dashing through the mall, having traded your one-horse open sleigh for a minivan, you have secured gifts for all creatures, including the mouse. Now you are ready to  leave on a plane tomorrow to spend the holidays with forty of your closest relatives.

How will you avoid illness this holiday season? How best to travel with children? We take you to a couple posts to help you out: Traveling with Children, and A happy, healthy holiday part 2: more holiday sanity hints .

We wish you all good health this season.

Julie Kardos, MD and Naline Lai, MD

©2010 Two Peds in a Pod℠

Our pediatric offices are getting busier as the winter germs start to circulate!  We have a great way to demonstrate to your children good hand washing techniques during this cold and flu season. Lightly cover your children’s hands with petroleum jelly and sprinkle “germs” in the form of glitter over their hands. Use different colors for each child. Then have them high-five each other. Observe how the “germs” spread from hand to hand. Then wash under water for a few seconds and observe how much comes off.  Share with your kids that 10-15 seconds (the time it takes to sing the “ABC song”) of hand washing is most effective at decreasing germs. Another fun way is to use a substance called Glo Germ . The pretend invisible germ is rubbed on the hands. Only a black light reveals the Glo Germ. Have your children wash their hands, then use a black light again to see if they successfully washed off the Glo Germs.

Enjoy the glitter but not the germs of the winter holiday season.

Naline Lai, MD with Julie Kardos, MD

©2010 Two Peds in a Pod℠

A mom wrinkles her brow and  hands me a bulging bag of inhalers. “Which medicine is the ‘quick fix’ inhaler? And which medicine is the ‘controller’ inhaler?” she asks.

Perfecting a treatment regimen for a child with asthma initially can be tricky and confusing for parents. But don’t panic. There are simple medication schedules and environmental changes which not only thwart asthma flare ups, but also keep lungs calm between episodes. The goal is to abolish all symptoms of asthma. Here are some commonly used measures used in non-hospitalized patients:

For asthma flares

Albuterol (brand  names Proair, Proventil, Ventolin). When inhaled, this medicine works directly on the lungs by opening up the millions of tiny airways constricted during an attack. Albuterol is given via nebulizer or inhaler. A nebulizer machine areosolizes albuterol  and pipes a mist of medicine into a child’s lungs through a mask or mouth piece.

For kids who use inhalers, we provide a spacer, a clear plastic tube about the size of a toilet paper tube which suspends the medication and gives the child time to slowly breathe in the medication. Without a spacer, the administration technique can be tricky and even adults use inhalers incorrectly. Albuterol in a drinkable form does exist but is less effective and has more side effects.

Prednisone (brand names include Prelone, Prednisolone, Orapred): Given orally in the form of pills or liquid, this steroid medicine acts to decrease inflammation inside the lungs. The kind of steroid given is not the same kind used illegally in athletics. While steroids in the short term can cause side effects such as belly pain and behavior changes, if needed, the advantages of improving breathing greatly outweigh these temporary and reversable side effects. However, if your child has received a couple rounds of steroids in the past year, talk to your pediatrician about preventative measures to avoid the long term side effects of continual steroid use. 

Quick environmental changes One winter a few years ago, a new live Christmas tree triggered an asthma attack in my patient. The only way he felt comfortable breathing in his own home was for the family to get rid of the dusty tree. Smoke and perfume can also spasm lungs. If you know Aunt Mildred smells like a flower factory, run away from her suffocating hug. Kids should avoid smoking and avoid being around others who smoke.

For asthma prevention

Taking preventative, or controller medicines for asthma is like taking a vitamin. They are not “quick fixes” but they can calm lungs and prevent asthma symptoms when used over time.

Inhaled steroids (brand names Flovent or Pulmicort, for example) work directly on lungs and do not cause the side effects of oral steroids because they are not absorbed into the rest of the body. These medicines work over time to stop mucus buildup inside the lungs so that the lungs are not as sensitive to triggers such as cold viruses. 

Monteleukoclast (brand name Singulair)  also used to treat nasal allergies, limits the number and severity of asthma attacks as well by decreasing inflammation at a different point than steroids. It comes as a tiny pill kids chew or swallow daily.

Avoid allergy triggers  (see our allergy post ) and respiratory irritants such as smoke. Even if you smoke a cigarette outside, smoke clings to clothing and your child can be affected.

Treat acid reflux appropriately. Sometimes asthma is triggered by reflux, or heartburn. If stomach acid refluxes back up into the food pipe (esophagus), that acid could tickle your child’s airways which lie next to the esophagus.

Avoid Respiratory Viruses and the flu. Teach your child good hand washing techniques and get yearly flu shots. Parents should schedule their children’s flu vaccines as soon as the vaccines are availiable.

Use Peak flow meters. Peak flow meters are small, hand-held devices that measure how well your child’s lungs are functioning and can detect an impending asthma flair before the cough or symptoms are obvious. The child blows as hard as he can into the small plastic air chamber and gets a number score. Baseline scores depend mostly on a child’s height, and the meters come with charts to guide what your child’s best score on a good day should be. The child tracks his scores daily until his baseline is well established. Then, if the child starts with a runny nose, he begins using his peak flow meter. If the number drops from baseline, treatment medicine (albuterol) is started. An asthma attack may be prevented because the attack is treated before symptoms get bad. 

Some parents are familiar with asthma because they grew up with the condition themselves, but these parents should know that health care providers treat asthma in kids differently than in adults. For example, asthma is one of the few examples where medicine such as albuterol can be dosed higher in young children than in adults. Also some treatment guidelines have been improved upon recently and may differ from how parents recall their own asthma was managed as children.  A doctor friend now in his 50’s said his parent used to give him a substance to induce vomiting. After vomiting, the adrenaline rush would open up his airways.

Don’t do that. We can do better so that both you and your child can breathe easy about asthma.

Julie Kardos, MD with Naline Lai, MD
©2010 Two Peds in a Pod℠

Today our dear friend, pediatrician, and mom, Wendy Lee shares insights and personal experience on how to tell your child he is adopted.

My husband and I had waited three long years for “the phone call” letting us know who would become our baby.  Only three short weeks prior to boarding a plane to China, we got the news we would not be bringing just one beautiful girl home from China, but TWO. Twins. We should have known right at that moment we would begin living a life of improvisation.

As with all parenting, there are endless numbers of issues to tackle.  One unique to families formed by adoption is how and when to tell your child he is adopted.  There are many differing opinions on how to do this right, but all agree children should be told.  It wasn’t so long ago that “the experts” deemed it to be psychologically damaging for a child to know about his adoption, and recommended not revealing this information.  Thankfully, things have evolved, and we are faced not with if, but how, to best share the news about adoption.

Just as with many aspects of child rearing, it is often best to take cues from your child.  If your child is younger, as were our girls (thirteen months old at the time we first met them), it is a good time to discuss adoption openly so it takes on a normalcy.  We read a full library of children’s books to them about adoption, and show the girls pictures and videos of our trip over and again.  We speak with them about our “Gotcha Day” (the day we got them and they got us).  And we celebrate this day each year with some of the families who traveled to China and got their daughters on the same day.  We talk about their birth parents in China and celebrate their heritage which, although similar to ours, is not exactly the same (I am Korean, and my husband is Cambodian). 

We gave ourselves a little pat on the back one day when we told our children one of our friends was going to have a baby, and they in turn asked which plane the parents were going to ride to get the baby.  They certainly thought adoption was a normal way to have a baby, but now we were faced with telling them other ways this could happen!  

As children grow, they enter new stages which may require improvisation.  A child’s age and temperament will guide you in your discussions regarding her birth and adoption.  Some children will never have any questions and will be satisfied with the here and now.  Others will have lifelong struggles to try and understand their history.  At certain stages, children will want nothing else but to fit in.  Being adopted, at that point, may set them apart from others and become something they will not want to advertise.  While “Gotcha Day” right now is another opportunity for our girls to have cupcakes, presents, and company, at some point it may be a day that reminds them of what they have lost and how they are different from their friends. They may choose not to celebrate this day any longer.  For some children, curiosity about their birth parents will be all-consuming and for others, it may just bring fleeting thoughts. 

Regardless of the age, stage or temperament of your child, my advice is to be truthful, open, supportive and positive. As your child grows, you will share more information. At some point, probably during his/her adolescence, your child should be given all the information that is known regarding his or her history, even if it may be difficult to share.   Discussions will move from simple explanations to potentially heart-wrenching, tear-ridden sessions where answers aren’t available.  I think whatever reaction your child will have to this part of her past, the longer she has to process it, and the longer you have to deal with your child’s emotions in this regard, the better it will be for all.

Wendy C. Lee, MD, FAAP
General Pediatrician

Presently full-time mama to two beautiful twin girls adopted from China

Anxiously awaiting a third child from Korea

© 2010 Two Peds in a Pod℠

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Last week a nurse in my office rushed a one year old girl back to one of my exam rooms. She was sitting in her mom’s lap, anxious and breathing hard. Her nostrils flared with every breath she took, and when I had her mom pull up the child’s shirt, I could see her ribs every time she inhaled because she was using extra muscles in her chest to breathe.  Her belly was moving in and out as well. Her breathing had just become labored an hour before the office visit.  The child had similar experiences in the past and now carries the diagnosis of asthma.

Asthma. Parents initially cringe at the diagnosis. But what is it? Most children with asthma never show up in the office with an attack as severe as the child I described above.

Asthma is a condition where the millions of airway tubes (called bronchioles) throughout the lungs get clogged with mucus (inflammation) and also get narrower (constrict) and thus become harder to breathe through. Medicine reverses the effects of asthma. Think of asthma as sensitive airways.  A nasty cold virus or the billowing dust cloud from cleaning the garage makes everyone’s airway spasm. In kids with asthma, the spasm may be more severe, resulting in more cough or airway tightening.

Asthma is the most common on-going illness in children. Many babies and toddlers who have asthma have a good likelihood of outgrowing it by age three. Another subset of children, again especially below age three, have ONE episode that looks for all the world like asthma, but then they never have another episode.  Other kids have asthma that stays and these kids and their families must proactively manage their asthma long term.

Asthma symptoms can start at any point, from infancy through the teen years. Adults can be diagnosed with asthma for the first time at age fifty.  Dr. Lai has had symptoms of asthma since childhood but Dr. Kardos first had symptoms of asthma when she turned thirty.

The tendency to develop asthma is genetic, but there are environmental triggers in kids who carry the asthma gene. The most common triggers of asthma flares are cold viruses, cigarette smoke, and environmental allergies (animals, pollen, etc). Also, air pollution, exercise, and very strong scents (new house paint or perfume, for example) can trigger an asthma attack. It is also common for someone with asthma to have allergies and/or eczema (excessively dry, irritated skin).

How do you know your child has asthma? No one test can definitively identify asthma.  Chest x-rays cannot show asthma. Sometimes Pulmonary Function Testing  in older children helps doctors diagnose asthma, but younger kids often have a hard time performing the test.

Pediatricians diagnose asthma by studying the past experiences of the child.  Not every child is out of breath like the patient I saw in the office. The most common symptom of asthma is cough.  Watch for the following symptoms:

1. Night time cough most nights of the week, usually starting somewhere after midnight. The child may or may not wake up because of the cough.
2. Cough that shows up with exercise, usually after several minutes of running, swimming, jumping, even laughing.
3. Cough with a common cold virus that lasts much longer than what is typical—longer than two weeks after the onset of a cold when most other kids or siblings with the same cold are better.
4. Cough that is accompanied by increased work of breathing. Your child’s nostrils may flare in and out with each breath, or her ribs might stick out with each breath, or her breathing rate is much higher than baseline as if she were just running hard even when she is just resting. She might not be able to talk in complete sentences, drink, or eat because she is too short of breath.
5. A wheeze— a high pitched sound heard during exhalation. The sound is not the strange, hoarse sound heard during inhalation (e.g. in a child with croup) nor is it the mucus/rumble you hear from the back of the throat of most kids with a cold.
6. Cough triggered by cold: eating an ice pop or breathing cold, winter air, for example.

Don’t worry about labeling your child with the diagnosis of asthma.  Gone is the stereotype of a child with asthma as a sickly kid who sits in the corner and is told not to participate in sports.  A large percentage of Olympic athletes have asthma.  The diagnosis of asthma will open up a world of medication and lifestyles which can soothe your child’s irritated airways.

Stay tuned for Understanding Asthma, part 2: the treatment of asthma.

Julie Kardos, MD and Naline Lai, MD
©2010 Two Peds in a Pod℠

Panic.

Off to the mall today with my children. Everyone was strapped in the minivan ready to go.  But where were the gift certificates the kids just got for Christmas from the relatives? I was perplexed and scuttled back into the house. Inside, I recreated in my head the scene at grandma and grandpa’s where I had last seen the gift certificates. At their house, after the children had properly said their thank yous, I remembered carefully folding the certificates in tissue paper and tucking them into the sparkly blue gift bag which was to go to my parents on behalf of my in-laws.  As an added guarantee that they would not be forgotten, I deliberately placed the blue bag with the other presents we had received. Where could they be? After all, they were safely in the big black trash bag with all of the other presents.

The trash bag? Oh dear.

Suddenly I remembered arriving home from my in-laws to a family room cluttered with gifts from Santa. I told the kids to clear everything out. When the dust settled I saw a big black trash bag in the center of the room. I grabbed it and threw it in the garage. Then a Christmas miracle happened.  In the midst of holiday hub-bub, my husband remembered that it was trash pickup day and took out the trash.

Gone were the gift certificates. Gone were my in-law’s presents to my parents. Gone was the plug in Star Wars game module. Gone was the “last copy” of a book of Chinese folk tales lovingly picked out for my daughter. And gone was the silly Bop- it game, a crazy game of Simon Says where one of the commands is to “bop” the toy against your tummy.

For a brief moment I contemplated running down to the dump and trolling through the garbage. After all, there were probably only a couple thousand black garbage bags. If I started now, I could be done by next Christmas.

Laughing (what else could I do?), I made my way back to the car where I broke the news to my kids. I too was disappointed, but I couldn’t go back and undo the event.  I had no choice but to laugh.

Together, between the tears, we stepped through lessons learned.

Lesson #1 Be more careful with our things

Lesson #2  Forgiveness is hard but essential for moving forward

Lesson #3 We were happy two days ago and that was before the presents arrived

Lesson #4  Let your kids play with their new toys the moment they get them- you never know when they will disappear

And the most important lesson #5 Use clear trash bags

My oldest smiled slowly and pointed out that I had declared to the kids, “Any presents not cleared out of the family room and put away in your own rooms will be thrown out.” I had unknowingly carried out my threat. Gradually, murmurs of disappointment gave way to laughter as we all imagined a scruffy bearded hobo going through the garbage picking up gift certificates from the girly stores Justice and Abercrombie.  Somewhere there is a stylin’ hobo with a scruffy beard in a fur trimmed hooded puffy coat and tank top, hopping up and down, playing Bop-it.

The minivan shook with laughter.”Oh, mommy, I’m laughing so hard my stomach hurts,” my daughter said. “Mine too,” my other two moaned between giggles.

The cost of “the stuff”:

A lot.

Making kids laugh so hard that their stomachs hurt:

Priceless.

Naline Lai, MD
©Two Peds in a Pod℠

Kids are noisy. A noisy child is usually a healthy child, so we pediatricians welcome noise. Today we give you Top Ten Sounds we are grateful for this Thanksgiving:

10. The sound of a six-month-old baby’s belly laugh.

 9. The sound of a two year old trying to say “gobble, gobble, gobble.”

 8. The sound of a three year old saying “why?” about 100 times a day.

 7. The sound of a chatty first grader who tells you about her favorite part of her day in one gigantic run-on sentence.

 6. The sound of a grade school orchestra concert (as heard through ear plugs).

 5. The sound of a high school orchestra concert played by the same students you remember playing in their grade school concert.

 4. The sound of a teenager confiding something very important during a check up and then answering “yes” to the question “Do your parents know about this?”

 3. The sound of a high school senior saying he got into his first choice college.

 2. The sound of children (and their pets) breathing as they sleep.

 1. The sound of a child’s small voice at Thanksgiving dinner leading her family in thanks.  

Wishing you all a noisy Thanksgiving.

Julie Kardos, MD and Naline Lai, MD

©2010 Two Peds in a Pod℠

Your child wakes up hot with fever but no other symptoms. She seems hungry, eats a great breakfast, and after a dose of Tylenol, she is no longer feverish and is now jumping off the couch. Are you a mean mommy or an unethical daddy if you send her off to school? Maybe not. Last month we had the privilege to address an audience of early childhood educators at the Bucks County Association for the Education of Young Children’s annual conference about when a child should leave school for medical reasons. In our podcast, When to keep your child home from school, we share some of the medical scenarios we discussed with the teachers: fever, vomiting, diarrhea, head lice, and pink eye.

Guidelines are based on Managing Infectious Diseases in Child Care and Schools, 2^nd edition, Editors: Susan S. Aronson, MD, FAAP and Timothy R. Shope, MD, MPH, FAAP published by tThe American Academy of Pediatrics. 

 Happy listening. Some of the answers may surprise you…

Julie Kardos, MD and Naline Lai, MD

©2010 Two Peds in a Pod℠