“Mom, can we do screen?”

My kids ask me this question when they are bored.  Never mind the basement full of toys and games, the outdoor sports equipment, or the numerous books on our shelves. They’d watch any screen whether television, hand-held video game, or computer for hours if I let them. But I notice that on days I give in, my children bicker more and engage in less creative play than on days that I don’t allow some screen time.

Babies who watch television develop language slower than their screen-free counterparts (despite what the makers of “educational videos” claim) and children who log in more screen time are prone to obesity, insomnia, and behavior difficulties.  The American Academy of Pediatrics recommends no more than two hours of television watching a day for kids over the age of two years, and NO television for those younger than two.

Over the years, parents have given me tips on how they limit screen time. Here are some ideas for cutting back:

• Have children who play a musical instrument earn screen time by practicing music. Have children who play a sport earn screen time by practicing their sport.
• Turn off the screen during the week. Limit screen to weekends or one day per week.
• Set a predetermined time limit on screen time, such as 30 minutes or one hour per day. If your child chooses, she can skip a day to accumulate and “save” for a longer movie or longer video game.
• Take the TV, personal computer, and video games out of your children’s bedrooms. Be a good role model by taking them out of your own bedroom as well.
• Turn off the TV during meals.
• Turn off the TV as background noise. Turn on music instead.
• Have books available to read in relaxing places in the house (near couches, beds, etc.). When kids flop on the couch they will pick up a book to relax instead of reaching for the remote control.
• Give kids a weekly “TV/screen allowance” with parameters such as no screen before homework is done, no screen right before bed, etc. Let the kids decide how to “spend” their allowance.

Not that I am averse to “family movie night,” and I understand the value of plunking an ill child in front of a video in order to take his mind off his ailment. In fact, Dr. Lai lives in a house with three iPod Touches, two iPhones, a Nintendo DS and three computers. But I do find it frightening to watch my otherwise very animated children lose all facial expression as they tune in to a television show.

For more information about how screen time affects children, see the American Academy of Pediatrics web site (www.aap.org) and put in “television” in the search box.

Let us know how you dissuade your children from the allure of the screen.

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

Here is a photo of a lovely plant nestled along side the bicycle path my family rode on over the weekend. Recognize it? “Leaves of three, let them be!”- That’s right, it’s either poison oak or poison ivy. In this case my iphone captured poison ivy in its late spring glory. As we rode along I barked at my family to avoid the poison ivy, reminded them about Lyme ticks, rubbed in sunscreen, fitted bike helmets and fretted over everyone’s hydration status.  Nothing is more jovial and carefree than a bike ride with your pediatrician mom!

One parental job you probably did not anticipate is the upkeep of rapidly growing finger and toe nails.  Questions first time parents often ask me include:  Should I use clippers or scissors? How do I avoid accidently nicking the skin? How often should I trim?  The only question I haven’t heard so far is: Should the tips be rounded or squared?

When your newborn fingers her face, even her soft finger nails can cause scratches. Yes, newborns need their first “manicure” within days of birth. Although the nails are long enough to scratch, most of the nail is adherent to the underlying skin. I recommend using an emery board or nail file for the first weeks of nail trimming. This method is unlikely to go awry and is effective. File from the bottom up, not just across the nail, in order to shorten and dull the nail.

Babies gain weight rapidly in the first 3 months at a rate of about one ounce per day and they grow in length at a rate of about an inch per month. Their finger nails grow as rapidly as the rest of the body and therefore need trims as often as twice a week. Toe nails grow quickly as well but because they do not cause self-injury, infants tend to be okay with less frequent trimming.

Once the nails are easy to “grab,” advance to using scissors or clippers. I honestly don’t believe either method is superior to the other. The method I used was to hold my baby on my lap facing out and then gently press the skin down from his nails and clip or cut carefully.

Unfortunately, no matter how careful you are, it is possible to hurt your child while cutting his nails. I remember injuring one of my twins when he was a few months old. Picture a benign tiny paper cut that seems to cause a disproportionate amount of bleeding. He wasn’t even all that upset, but…oh, the guilt I felt!  If you accidentally nick your child, wash the cut with soap and running water and apply pressure for a few minutes with a clean washcloth to stop the bleeding. Once the bleeding stops, band aids are not necessary and can actually be a choking hazard in babies who spend most of their waking moments with their fingers in their mouths. Thankfully, rapidly growing kids heal wounds rapidly.

I think it is a good idea to trim nails while babies are awake so that they get used to the feeling of a “home manicure.” This practice can prevent the later toddler meltdowns over nail trimming. However, some kids are just adverse to nail trimming, or have sensitive, ticklish feet and balk at trims. Yet trim we must! Try clipping an uncooperative toddler’s nails while she is sleeping. If your toddler sleeps lightly, then you may have to time your manicure/pedicure for when another adult caregiver is home with you. One adult holds the hand/foot or distracts the toddler with singing, book reading, or watching a soothing video together (Elmo to the rescue once again!). The other trims the nails.

So, now with the birth of your child you have added a new title – “Master Manicurist” of your home.  This job does become more glamorous when your child is old enough to ask for nail polish. Until then, happy nail trimming!

Julie Kardos, MD
©2010 Two Peds in a Pod

I heaved a sigh of relief. My children and their friend greeted my husband and me at the door. The children had just baby-sat themselves. I thought everyone was unscathed until I saw one of my children covered in band aids. Apparently, although I had admonished them not to ride anything with wheels and not to climb on anything above the ground, the child with the band aids had tripped over her own feet during a benign game of four square.

“Did you wash the scrapes?” I asked.

“Yes,” the kids said, proudly nodding. They knew the first line of defense against infection is to wash out a wound. But as it turns out, they had only dabbed the cuts with wet paper towels. Aghast, I propelled the injured child off to the bathroom and hosed down the cuts. Too many times I have seen a minor scrape turn into a major skin infection.

When a wound is not thoroughly cleansed, the bacteria which normally live on skin (Staphylococcus or Streptococcus) find an opportunity to enter the body. Even a mosquito bite can turn into a raging puss filled mess if scratched often and not cleansed enough. These days, some children carry on their skin a type of Staphylococcus called MRSA (Methicillin resistant Staphylococcus aureus), since this germ can be tough to treat, a deep cleansing is more important than ever.
While infection is rarely introduced from whatever cuts the child, exceptions include cuts caused by animal or human bites (the human mouth is particularly filthy) or cuts caused by old, dirty or rusty metal.  Tetanus lives in non-oxygenated places such as soil. So for deep or very dirty wounds, make sure your child’s tetanus vaccine is up to date.

Despite what many believe, wiping the surface of a cut with a wipe is not adequate to cleanse a wound. “Irrigate, irrigate, irrigate,” a wise Emergency Department physician explained to me when I was a resident in training. “I have never had someone return with a wound infection,” she said proudly. In the emergency room, saline is usually used, but at home soap and running water are effective. Stay away from hydrogen peroxide because it can irritate rather than help the skin. Stay away from rubbing alcohol because it hurts and is not necessary if soap and water are used.

So, even if your child just took a shower, wash him again if he scrapes himself. The sooner you irrigate even the tiniest of wounds, the better.  An ounce of prevention is worth a pound of antibiotics.

Naline Lai, MD and Julie Kardos, MD

© 2010 Two Peds in a Pod®

As Mother’s Day approaches, we give you our first Two Peds in a Pod “Top Ten List.” 

Top Ten Skills You Acquire as a Mother

     10)  Not being completely grossed out by another person’s poop.

 9)  Ability to sense the “moment before the vomit” and to hustle your child to the nearest garbage can or toilet before it’s too late.

 8)  Ability to lick your own finger and then use it to clean a smudge completely off your child’s face.

 7)  Ability to get through a day (after day after day) after one (or many) completely interrupted night’s sleep.

 6)  Willingness to show up at work or just go out in public with dried spit-up on your shoulder.

 5)  Ability to use your “momometer” by touching or kissing your child’s forehead to tell if he has a fever (with fair degree of accuracy!).

 4)  Ability to see through walls in order to tell that your child did not wash his hands after using the bathroom.

 3)  Ability to see directly behind you to know that your child is getting into trouble.

 2)  Ability to wield the Magic Kiss that can make any and all boo-boos better.

 1)  Ability to love more than you ever thought possible, and the ability (finally) to understand just how much your mother loves you.

Rejoice in your abilities!

Happy Mother’s Day from Two Peds in a Pod.

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

This truth we know for certain: teething causes teeth. 

We all can picture our babies chewing on their fingers and toys and drooling before getting their first tooth. But what other symptoms do incoming primary teeth cause?

Nearly everything in the past has been blamed on teething, including seizures, meningitis, and tetanus. According to an article in Pediatrics in Review (April 2009), teething was listed as the official cause of death in about five thousand infants in England in the early 1800s. In France from 1600 to 1900, fifty percent of all infant deaths were blamed on teething!

Numerous studies have tried to identify which symptoms coincide with tooth eruption. Two such studies: http://pediatrics.aappublications.org/cgi/content/abstract/106/6/1374 and http://pediatrics.aappublications.org/cgi/content/abstract/105/4/747 involved parents and/or daycare teachers. They kept daily checklists of symptoms such as runny nose, diaper rash, crankiness, diarrhea, and fever. Every day caretakers checked for new teeth. Guess what those researchers found? They found little correlation between any single illness symptom and a new tooth.

Despite scientific evidence to the contrary, people still blame teething for numerous maladies.

Here are symptoms which are NOT caused by teething that parents should be aware of:

· Teething does not cause fever over 101 degrees F. Fever of this height or higher indicates infection somewhere. Maybe a simple viral infection such as a cold, or a more severe infection such as pneumonia, but parents should NOT assume that their baby’s fever over 101 F is caused by teething. These babies could be contagious. Parents should not expose them to others with the false sense of security that they are not spreading germs.

· Teething does not cause diarrhea severe enough to cause dehydration. If a child has severe diarrhea, then he most likely has a severe stomach virus or another medical issue.

· Teething does not cause a cough severe enough to cause increased work of breathing. Babies make more saliva around four months of age and this increased production does result in an occasional cough. But babies never have breathing problems or a severe cough as a result of teething. Instead, suspect a cough virus or other causes of cough such as asthma.

· Teething does not cause pain severe enough to cause a change in mental state.

Some children get crankier as their teeth erupt and cause their gums to swell and redden. But, if parents cannot console their crying/screaming child, the child likely has another, perhaps more serious, cause of pain and needs an evaluation by his or her health care provider.

Just from a logic standpoint, if teething causes symptoms as babies get their primary teeth, shouldn’t incoming permanent teeth cause the same symptoms? Yet I’ve never heard a parent blame teething for a runny nose, rash, cough, fever, or general bad mood in an eight, nine, or ten year old child who is growing permanent teeth. 

Maybe these parents are too busy bemoaning the cost of early orthodontal work.

Julie Kardos, MD
©2010 Two Peds in a Pod

It’s only 3 p.m. on a Saturday and one of my children is in the shower for the second time today washing off the pollen which has turned her face into a puffy, slimy raspberry. It’s that beautiful time of year when the blooming flowers trigger allergic symptoms such as runny noses and red itchy eyes.

In addition to washing pollen off your child’s body, you can make some changes in your child’s environment to help decrease allergic reactions to the “great” outdoors. For one, turn on the air conditioner and close the windows to limit the outdoors from entering your child’s bedroom. Also, have your child wash her hands as soon as she comes in from playing outside to decrease the chances of her rubbing allergens into her eyes and nose.

Many kinds of medications can help allergy symptoms. The most commonly used oral medications are the antihistamines. These medicines work by limiting the “histamines” your body makes in response to allergies. Histamine causes itchy skin, red eyes, and runny noses. Examples of antihistamines are diphenhydramine (brand name Benedryl), loratadine (brand name Claritin), cetirizine (brand name Zyrtec) and fexofenadine (brand name Allegra). The most common side effect of antihistamines is drowsiness, especially with older antihistamines such as diphenhydramine.  Most antihistimines are now available over the counter.

Allergy eye drops and nose sprays act topically on the eyes or nose to combat allergy symptoms. Some prescription nose sprays contain topical steroids or antihistamines. Eye drops may contain antihistamines or mast cell stabilizers (more cells which cause allergy symptoms!).

Another allergy medicine heavily advertised is Singulair. This medicine is a leukotriene inhibitor which prevents the body from releasing another type of substance (leukotrienes) that causes allergy symptoms.

Decongestants such as phenylephrine or pseudoephedrine can help decrease nasal stuffiness. This is the “D” in “Claritin D” or “Allegra D.” However, they are discouraged in young children because of potential side effects such as rapid heart rate, increased blood pressure, and sleep disturbances.

Some of the above mentioned medicines can be taken together and SOME CAN NOT. Parents may inadvertently give more than one oral antihistamine simultaneously. Read the labels carefully for the active ingredients and do NOT give more than one oral antihistamine at a time. In contrast, most antihistamine eye drops and nose sprays can be given together with oral antihistamines.

Please consult your child’s health care provider to determine which allergy medications will best help your child this allergy season.  A carefully thought out allergy plan can go a long way to helping your child’s allergy symptoms.

Sure beats taking five showers a day or having your nose removed for allergy season!

Naline Lai MD and Julie Kardos, MD

© 2010 Two Peds in a Pod

“Help, help, my EAR HURTS!!!”

I admit to having no statistics on this observation, but as a pediatrician and a mom, I have observed that ear infections strike disproportionately on Friday nights. Have you observed this as well?

I wish children had some kind of external ear indicator that would flash “infection” or “not an ear infection” when they have middle of the night attacks of pain. Unfortunately, most people can not diagnose their child in the middle of the night. Even I can’t diagnose my own children at home because my portable otoscope, the instrument used to examine ears, died from overuse a year ago.  However, there are ways to treat ear pain no matter what the cause.

Of course we all want to know the cause of our children’s pain. However, there is no danger in treating pain while we investigate the cause, or until daytime comes and pediatricians open their offices.  Good pain relievers such as acetaminophen (brand name Tylenol) or ibuprofen (brand names Advil and Motrin), given at correct doses, will treat pain from any source. Treating pain does not “mask” any physical exam findings so go ahead and ease your child’s misery before going to your child’s health care provider. I feel bad for my young patients whose parents tell me, “We didn’t give him any pain medicine because we wanted you to see how much his ear is hurting him.”

Heat in the form of warm wet compresses or a heating pad will also help. Prop your child upright. If the pain is from an ear infection, the position will relieve pressure. Distraction such as a 2:00 am Elmo episode will also blunt pain.

blog post) is treated differently than a middle ear “inside” infection. Nearby body parts can also produce pain. Throat infections (pharyngitis), from strep throat (see strep throat posts) or viruses, often cause pain in the ears. Even pain from jaw joint strain and dental issues can show up as ear pain. Over the years I have sent several children straight from my office to the dentist’s office for treatment of tooth ailments masquerading as ear pain.

No article on ear pain would be complete without addressing“ear tugging.” Many babies by nine months of age discover their ears and then play with them simply because they stick out (I will leave to your imagination what boy babies tug on). Babies often tug on ears when they are tired. Therefore, tugging on ears alone may not indicate an ear infection, especially if not coupled with other symptoms.

Although ear infections are one of the most common ailments of childhood and most children have at least one ear infection by age three,  remember that not all ear pain is caused by ear infections. In the middle of the night, and even in the middle of the day, it IS okay to give some pain relief before seeing your child’s health care provider.

Why ear pain always seems to awaken a child in the middle of the night, I’ll never know.  All I know is that I have to remember to buy a new otoscope for home.

Julie Kardos, MD
©2010 Two Peds in a Pod

As I pack for an upcoming family vacation, I am reminded of the numerous questions over the years that parents have asked me about traveling with children. Often they ask, what is the best way to travel that will allow everyone to enjoy the vacation?

Ha,ha, I think to myself. The real answer is to hire a sitter or enlist grandparents to babysit and leave the kids at home. My husband and I always refer to family vacations as “family displacements.” 

No, really, family vacations are wonderful experiences as long as you hold realistic expectations. First you have to get there.

Easier said than done.

When traveling by air, parents wonder if they should bring a car seat for the plane. Young children who sit in a car seat in the car should sit in a car seat in an airplane. Unfortunately, not all car seats fit into the airplane seat properly. The best advice I can give is to bring your car seat and make an attempt to fit it properly. If it doesn’t fit properly, you will still need it for the car ride from the airport after you arrive at your destination. Not all car rental facilities provide car seats.

Another question I am frequently asked about long plane rides is “Should I give my child Benadryl (diphenhydramine) so he/she will sleep through the flight?” Unfortunately, Benadryl’s reliability as a sleep aid is spotty at best. Most kids get sleepy, but the excitement of an airplane ride mixed in with a “drugged” feeling can result in an ornery, irritable child who is difficult to console. I advise against this practice. On the other hand, Benadryl can help motion sickness and is shorter acting than other motion sickness medications.

Ear pain during an airplane’s descent is also a common worry. Yes, it is true that ears tend to “pop” during the landing as the air pressure changes with altitude. Some young children (and their parents) find this sensation very unpleasant. However, most babies are lulled to sleep by the noise and vibration of an airplane and are unaffected. If your child is safely in a car seat, I do not advise taking him out of it to breastfeed during landing. Offer a pacifier if you feel he needs to suck/swallow during the landing, and offer an older child a snack so she can swallow and equalize ear pressure if she seems uncomfortable during the landing.

Speaking of food, try to carry healthy snacks rather than junk food when traveling. Staying away from excessively salty or sweet food will cut down on thirst. Also, keep feeding times similar to home schedules in order to prevent toddler meltdowns.

Remember that young children hate to wait for ANYTHING and that includes getting to your destination. Bring along distractions that are simple and can be used in multiple ways. For example, paper and crayons or pencils can be used for: coloring, drawing, word games, origami, tic-tac-toe, math games, etc.

When traveling internationally, check the Center for Disease Control website www.cdc.gov for the latest health advisories for your travel destination. Do your research several weeks in advance because some recommended vaccines are available only through travel clinics. Also, some forms of malaria prevention medicine need to be started a week prior to travel.

Please refer to our “Happy, Healthy Holiday” blog post from 12/10/2009 for further information about keeping kids on more even keel during vacations. In general, attempt to keep eating and sleeping routines as similar to home as possible. Also remember to wash hands often to prevent illness during travel. Finally, locate a pediatrician or child friendly hospital ahead of time in case illness does strike. Unfortunately, most illnesses cannot be diagnosed by your child’s health care provider over the phone.

While traveling with young children can seem daunting, the memories you create for them are well worth the effort. And it DOES get easier as the kids get older. Now I can laugh at the image of my husband with two car seats slung over his back lugging a large diaper bag and a carry-on, leading my preschooler struggling with his own backpack filled with snacks and air plane distractions, while I am balancing two non-walking twin babies, one in each arm, as we all take our shoes off for the airplane security checkpoint.

We’ve come a long way, and so can you. Happy Travels!

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

Do vaccines cause autism?

Concerned parents ask me this question, and I am relieved to be able to tell them “NO.”

Amazingly, most of the autism/vaccine hoopla can be traced to one very small report.

In 1998 a doctor named Andrew Wakefield published a paper in a well respected British medical journal called The Lancet. He said that in his study of twelve children who were patients in a GI (Gastroenterology) clinic, eight of them had evidence of abnormal intestines and abnormal behavior that began after they received the MMR vaccine.  He wondered if the combined MMR vaccine may have triggered abnormalities in the gut, allowing unspecified toxins to leak out from the gut, causing brain damage.

Unfortunately, this one small paper involving 12 children caused huge controversy about the safety of vaccines. Many parents lost confidence in the very vaccines that were so successful at protecting the lives of their children.  They stopped vaccinating and caused the measles rate to increase. For evidence of this please see:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5733al.htm

http://www.parliament.uk/commons/lib/research/briefings/snsg-02581.pdf.

On February 6, 2010, The Lancet published a retraction of this paper because the study design was flawed and thus any conclusions cannot be reliable. Specifically, the UK General Medical Council’s Fitness to Practise Panel, after investigations, concluded that the children in the study were not “consecutively referred,” meaning that they were not “random samples” as stated in the paper.

In addition, the panel discovered that Dr. Wakefield did not have permission from any institutional review board (panels that review the ethics of research done on people) to perform the lumbar punctures, MRIs, EEGs, endoscopies, and intestinal biopsies that he conducted on the children whom he studied.

Despite the original study being flawed, a question about a connection between MMR and autism had been raised. In the years since 1998, scientists performed subsequent studies to see if the MMR vaccine might have a link to autism. No association was found. These studies involved thousands of children and showed that the rate of autism in vaccinated children is THE SAME as the rate of autism in unvaccinated children. To read these articles as well as the original article that caused the controversy, you can go to www.TheLancet.com and register to view the articles for free.

I urge all parents reading this blog post to speak with your child’s health care provider if you have ANY doubts about vaccinating your children. In addition, if you are going to conduct your own research on this subject on the Internet, I urge you to consult the following credible sites:

www.aap.org, www.cdc.gov, www.vaccine.chop.edu, www.webmd.com,  www.mayoclinic.com

Vaccines save lives. Unfortunately, for those too young to be vaccinated, those who have immune system diseases, and those who do not receive immunizations, vaccine preventable diseases still can potentially cause severe  illness and death.

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

January 10, 2011: The above links to the CDC and UK parliament are down. For more information on trends in measles rate, please see http://news.bbc.co.uk/2/hi/health/7872541.stm.