Join us as we talk with moms from Building the Family, part of Child, Home and Community, a Pennsylvania based organization dedicated to empowering young parents.  We share with you a few tidbits on milk, daycare and thumb sucking – topics gathered from a podcast recording party held this summer. Here we are pictured with the fabulous moms and some of their children (listen carefully and you will hear the pitter-patter of little feet in the background).

Play the podcast here!

Naline Lai, MD and Julie Kardos, MD

©2010 Two Peds in a Pod℠

Unfortunately, constipation and potty training go together.

This should come as no surprise. Let’s consider the two favorite words of two and three-year-olds:
“Mine,” and “No.”

Now think of how these words apply to a toddler who is starting to understand the purpose of the potty. The well meaning parent says, “Honey, we want you to put your poop to the potty.”

For many toddlers, the answer is… “NO! MINE!”

The problem begins when the toddler is determined NOT to give up her own poop. The longer your child holds in the poop, the harder and more difficult it will be to pass the poop. Thus, a vicious cycle begins. Your child finds pooping painful and scary. This cycle must be interrupted. Here are some tips:

Stop potty training and go back to diapers.

Before you groan at this suggestion, hear this story:  The parents of one 2 ½-year-old were pleased that all “pee pee” was making it into the potty, but dismayed that she demanded a Pull-Up for poop. I suggested that she should wear diapers full time, and when pee AND poop go in the potty, then the princess underwear would come back. The child responded to me, “That isn’t very nice!” But guess what? That night, she pooped in the potty. Of course, her baby sibling is due in a few weeks, so we’ll see if success continues…  but regression with new babies is a topic for another blog post.

Make the poop easy to pass.
Use natural interventions: increase water throughout the day and give undiluted juice such as prune, pear, apple, or pineapple (the other juices don’t hurt but do not actually help the cause) once a day. Offer fresh fruits, fresh vegetables, and high fiber cereals (just read the labels, try for more than 3 grams per serving).  Encourage exercise.

Practice regular potty/toilet sitting.

Catch the poop when it’s naturally likely to come.  The most likely time a toddler will poop is just after eating because of the gastrocolic reflex, a reflex which causes the bowels to move after eating. After every meal, have your potty trainer sit for 2-5 minutes. Treat this as a house rule. Read a book on the potty or tell stories to help pass the time.

Teach your child to prioritize pooping over playing.
If kids “really have to go” but they are busy playing, they will hold in the poop to avoid interruption. Watch for signs of a need to defecate such as squirming (better known as the potty dance) or hiding. To avoid a power struggle, say something like, “The poop wants to come out, let’s go,” rather than, “Do you want to go to the potty now?” and reward the child for sitting, not for producing.

Some over-the-counter products can help. You should discuss dosing, timing, risks, and benefits of each with your child’s health care provider before choosing. Medicines include:

• Mineral oil: mix with something that tastes good such as juice or chocolate milk.  The brand Kondremul tastes sweet and is hidden easily in milk because it’s white. Mineral Oil makes poop so slippery that even a determined toddler will not “hold it.”
• Polyethyleneglycol (PEG) 3350 (Miralax):  with a prescribed amount of liquid, it has no taste and pulls extra water into the bowels so that the poop stays soft.
• Glycerin suppositories:  can be the “quick fix” step before you have to resort to enemas, which are more traumatic.
• Children’s laxatives such as Milk of Magnesia.
• Senna-containing products – in the past there were concerns of bowel dependency with long-term use. This concern has been questioned by specialists. Ask your doctor about the products.

At one potty training child’s three year birthday party, the poor birthday boy spent half his party trying to pass a large hard poop, the result of several days of withholding. After one small glycerin suppository and a large amount of anxiety, he rejoined his friends; leaving his parents feeling guilty that they had not paid attention to his pooping frequency prior to the party. While the goal is for our children to be completely independent potty users, we have to help our potty trainers by keeping track of the frequency and consistency of their poop in order to prevent a withholding/painful pooping/constipation cycle from starting.

Be alert to potential medical causes of constipation (as opposed to behavioral or situational) and consult your child’s health care provider if you can’t seem to remedy the problem.

In the world of young potty trainers, try to avoid power struggles, “keep things moving,” make things soft and easy, and remember that this too shall pass.

Julie Kardos, MD with Naline Lai, MD
© 2010 Two Peds in a Pod®
updated 2017

Our guest blogger today is Dr. Jason Komasz. Practicing pediatrics in Pennsylvania for nearly a decade, he is the father of two and a respected colleague.

“Can’t you just call in an antibiotic for me?”
As doctors we hear this question a lot.  Parents are often disappointed and upset when we answer that question with a “No.”  Your child is sick, you missed the Saturday office hours, and now you can’t schedule an appointment until Monday morning.  There are reasons why doctors usually do, and should, answer “no” to this question.

1. Not every illness requires an antibiotic. Only bacterial illnesses respond to antibiotics and many illnesses are viral. In fact, misuse of antibiotics can lead to antibiotic resistance in our population.

2. The physical exam is very important in the evaluation of a patient.  The exam helps doctors determine if a patient needs antibiotics, and if so, what type.  If we do not see a patient, we are “flying blind.”  This puts the patient as risk for misdiagnosis and incorrect treatment.

3. Antibiotic use before a patient is evaluated can affect laboratory results. For example, after starting antibiotics, Strep Throat and urinary tract infection tests may be inaccurate and therefore obligate the patient to an unnecessary course of antibiotics.

4. All but the most severely ill patients can usually be managed at home with pain/fever control and symptomatic care (fluids, etc) until they can be evaluated by a doctor.

5. If your child is ill enough to require an antibiotic, he is sick enough to need an evaluation by a physician.  It is better to wait in an ER and receive proper care than to just treat without proper evaluation.

As always, your physician is trying to do what is best for your child.  Your doctor should always be able to offer an explanation for why he or she is choosing a particular course of action for your child’s illness.  We do not want them to suffer, just as you don’t.  Just remember, the antibiotic is not always the answer.

Jason M. Komasz, M.D., F.A.A.P.
© 2010 Two Peds in a Pod®

In honor of Father’s Day, we bring you our second “Top Ten” list.

Top ten skills you acquire as a father:

10. The ability to attract swarms of women if you walk in the park or the grocery store with your infant.

9. Tolerance of temperature extremes at the skating rink or on the ball field.

8. Not being completely grossed out by spit up on your nicely pressed shirt.

7. The ability to sit patiently through a 3 hour ballet recital, school music concert or graduation.

6. The ability to sit patiently through an endless one hour television show featuring some sort of dancing and singing animal and then to stand in an hour long line to buy the stuffed toy version of the animal.

5. The skill to coach teams for which you last played the sport twenty years ago.

            4. The ability to swing a child, “again!”, “again!”,  and “again!”

3. The ability not only to get through a day after one (or many) completely interrupted night’s sleep, but to wake up in the morning having forgotten about the interruptions.

2. An ability to seize the moment and create great memories for your child: you ignore the dishes, the garbage, and the dirty bathrooms in lieu of an impromptu wrestling match.

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

Happy Father’s Day from Two Peds in a Pod!

Julie Kardos, MD and Naline Lai, MD

© 2010 Two Peds in a Pod℠

“I need a nap!”—recognize this tired parent?

OKAY, let’s take a quick survey: how many of you have ever put your over-tired young child into the car, then driven on a bumpy road on a route known for its paucity of traffic lights, looking in the rearview mirror hoping to see a sleeping child?

How many of you have ever rocked your young child until you BOTH have fallen asleep in the chair?

How many of you have purposefully keep your child AWAKE in the car in order to get home before nap time, doing anything to keep her awake? Otherwise, you predict, if  your child falls asleep on the five minute car ride home, she will wake up when you try to transfer her to the crib. If that occurs you will lose the nap for the rest of the day and she will be MISERABLE (and, hence, so will you).

How precious is nap time? All parents know the answer to this question: VERY VERY PRECIOUS! Parents spend the time during a baby or toddler’s nap to pay bills, do laundry, prepare a meal, clean the house, spend time with an older sibling, and perhaps most importantly, TO TAKE A NAP OURSELVES.

Yet all children outgrow their need to nap sooner or later (at least, until they become parents themselves). The exact time this dreaded day comes can vary. The range is typically between two and five years of age. And children do not always give up their naps all at once. One day they do not nap, then they nap the rest of the week, then they don’t nap for a few days, then they nap one day, and so forth. Sometimes they fall asleep only if they happen to be in the car. Eventually your child will sleep only overnight and not at all during the day.

Naps are very important for young children. Not only do naps foster better cheer, better learning, and better behavior, but also good naps actually help improve night time sleep. Any parent can attest that an overtired toddler has a WORSE night sleep than a toddler who goes into bedtime well-rested. This is one of the great paradoxes of childhood. I like to explain to my patients: “Good sleep begets good sleep.”

Just as you invest your time and effort in taking good care of baby teeth only to have them all fall out later, you should invest your time and effort in establishing good nap habits for your young child, even though your child eventually gives up her nap. Start by making sure she can fall asleep on her own during her NIGHT bedtime routine (see our podcast on this subject) . If she can fall asleep on her own at night, she will be more apt to fall asleep in the day.  Darken the room and give her other signals associated with sleep such as her favorite stuffed animal or lullaby. Have a short “nap time routine” just as you have a night time routine. Save the serious sleep training for night time- you do not have the luxury of hours to train in the day.  If she does not fall asleep within half an hour, get her up and struggle through the rest of the day, or try again later.

If she still will not nap after several days of trying, go ahead and do whatever it takes to have a happy kid by dinner. Take that car ride, rock her to sleep… understand that the “fix” is temporary. Either she will give up the “nap rebellion” or she will give up the nap entirely. Continue to put your non-napper in bed at night earlier to make up for her lack of daytime sleep.  When your child is mostly cheerful, not throwing an unusual number of toddler tantrums, and is at least two years old, then likely she has truly outgrown her need to nap.

In the meantime, go grab some Zzzzzs. I know some of you only have time to read this post because your child is napping. So go follow suit!!

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

Ten years ago I watched a very sick, feverish toddler arch his back on my exam table while a high pitched screech weakly escaped his mouth as I tried to examine him. Attempts by his mother to cradle him in her arms only resulted in more pain.

The diagnosis –– bacterial meningitis, puss in the spinal cord and around the brain.

The culprit ––a potentially deadly germ called Streptococcus pneumonia.

A few months after I saw that toddler with meningitis, a vaccine against Strep pneumonia, under the brand name Prevnar-7, entered the market. I often wonder how outcomes would have differed for that toddler if the vaccine had been released earlier.

In addition to causing bacterial meningitis in children, this pneumococcal germ is also responsible for other forms of invasive disease such as pneumonia and overwhelming infection in the blood (sepsis). After Prevnar-7 entered the market in 2000, the number of children contracting invasive pneumococcal disease dropped by 76 percent. This decrease was seen in children under age five years, the most common age group for contracting pneumococcal disease. Vaccines at work!

The original Prevnar-7 offered protection against 7 types of the pneumococcal germ. But other types which weren’t targeted by Prevnar continued to cause infections. A new vaccine called Prevnar-13 offers protection against six additional types.

How does the release of the new Prevnar-13 affect your child? Recently, the American Academy of Pediatrics released its immunization recommendations:

–If your child has never been immunized against Pneumococcus, he will receive Prevnar-13 instead of Prevnar-7 on the same schedule as in the past. The series of four doses total are given at two months of age, four months, six months, and lastly a booster dose at 12-15 months of age. 
–If your child is under five years old but has completed the full Prevnar-7 schedule, he will need at least one dose of Prevnar-13 to be fully protected.
–If your child is in the middle of the Prevnar series, he will likely complete the series with Prevnar-13. 
–Children from 6 years to 18 years of age who are at very high risk for complications (e.g., children with sickle cell anemia and cochlear implants) may consider at least one dose of Prevnar-13 along with their usual “high risk” pneumovax 23 vaccine. 

At this point there aren’t any recommendations to immunize non-high-risk children after five years of age because for most children, the risk of contracting life-threatening illness from this germ dramatically decreases after age five.

There’s more protection out there against more streptococcal pneumonia. Go get it!

For the full AAP recommendations see the online version of the AAP Policy Statement May 24, 1010 at www.pediatrics.org.

See also: Center for Disease Control March 12, 2010 Mobidity and Mortality Weekly Report for information about the impact of Prevnar on invasive pneumococcal disease.

Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod℠

Sand and specks of dried seaweed fly into the air. Your kids are on the beach shoveling their way to China.  “Watch out!” you yell. “Watch those shovels! The ocean is big. The beach is big. You don’t need to be right on top of each other.  There is plenty of sand for everyone.”

You sigh and go back to counting snacks and unearthing buried flip-flops.  You look back at the kids. Aw, you think to your self, they look so cute. Just as you reach for the camera, the idyllic moment is shattered. Your youngest is holding his eye and everyone, even the kid who threw sand into the injured child’s face, is crying.

Quickly you grab a water bottle and flush the irritating granules out of his eye.  Satisfied nothing is left, you ask, “Does that feel better?”  Your child ruefully nods, and resumes holding his eye.  An hour later his eye is still watering. What next?

With any eye injury, pain, watery eyes or visual changes are all reasons to seek medical care. In this case, the sand or a little wood chip probably caused a scratch on the outer layer of the eye.  This layer, called the cornea, heals very quickly. But like a scratch on any part of the body, the major potential complication is infection.

The most common way for health care providers to find a scratch on the cornea is to place a dye (fluorescine) into the injured eye. This dye glows under black light. The dye pools wherever there is a depression or scratch on the eye. Pictured here is a photo of a child I saw in the office the other day. The scratch is marked with an arrow. If an abrasion is found, your child’s doctor will prescribe antibiotic eye drops to prevent infection.  Placing a patch over the eye has not been shown to hasten healing. However, for comfort, some children prefer putting on an eye patch for a day.

It’s a good thing our eyes are set back in our skulls, otherwise, we’d constantly have scratches on our eyes. Despite any precautions you may take, accidents still happen. Years ago a nurse I knew accidentally rolled over in bed and scratched her spouse’s eye with her diamond engagement ring.  Imagine explaining that to the in-laws.

Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod℠

“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