Pediatricians associate Back to School with “Time to get your flu vaccine.” At least this pediatrician mom does. As I try to figure out when I can get my own three children over to my office to get their flu vaccines, we want to give you a flu vaccine update.

Good News.

Last year we responded to your concerns about arsenic in food, particularly rice, and shared with you the FDA’s recommendation at that time.

We are relieved that after considerable research which included analyzing over 1300 samples of rice products, the FDA scientists determined that “… the levels of inorganic arsenic found in the samples are too low to cause immediate health damage.” Please see this link for the details of the investigation and recommendations.

Bottom line: continue to offer a well-balanced diet to your children and vary the types of grains that you serve to your families.

Julie Kardos, MD and Naline Lai, MD
©2013 Two Peds in a Pod®

Some kids simply don’t like team sports. Today, childhood obesity specialist Dr. Patricia Cantrell and Youth Fitness Expert Anna Renderer, share a piece from their fitness site on activities which encourage kids to move without signing them up on a roster. Enjoy—and join in!
Drs. Lai and Kardos

KFIT Health, LLC

Why does that big pimple always appear the first week of school, the night before prom, picture day, her sweet sixteenth birthday party, or any other important event in your teen’s life?

A rite of passage, acne is caused by a combination of genetics and bad luck. The perception of acne as a problem depends on the eye of the beholder. When I see a teenaged patient in my office for acne, the first question I ask is, “Who is more concerned about the acne? The parent or the patient?” Some kids have very mild acne, yet those kids perceive their pimples are the size of golf balls. Other kids are oblivious, and the parents are more upset than the teen. When you’re a teenager, everything to you seems bigger than it actually is.

Even if your teen starts to break out with what she perceives are huge blemishes but are really the size of pin pricks, do take her seriously. For anyone dealing with acne, to them one spot can seem like many. 

Many effective, safe products can diminish mild acne and thus greatly help self-esteem in a self-conscious teen. Also, make sure to probe to see if a negative perception of her appearance extends to an overall poor body image. Sometimes distress over minimal acne can be an early sign of body image disorders such as anorexia nervosa or bulimia.

The categories of acne medicines are:

-Topical antibiotics such as benzoyl peroxide or clindamycin, applied directly to skin- works to kill the bacteria that lead to acne

-Topical medications called retenoids such as tretinoin (Retin A) and adapalene (Differin) stop acne formation mainly by penetrating into the deep layers of the skin to loosen acne causing pores

-Topical creams which combine both a retenoid and an antibiotic also exist such as the adapalene and benzoyl peroxide product called Epiduo.

-Oral antibiotics, such as minocin, clindamycin, or erythromycin also kill the bacteria that lead to acne formation

-Accutane, an oral medical reserved for severe, scarring acne. Can cause significant birth defects and so girls who take it must also take birth control pills and have periodic pregnancy tests. Chemical imbalances may occur, so blood work is required for both sexes.

-Hormonal therapy (birth control pills)- works best for females who break out near their periods, smooths out the hormonal fluctuations which fire up acne.

I always remind my patients that most treatments take six weeks to work. For kids who experience dry skin from the topical medications, use noncomedogenic (non acne forming) moisturizer liberally. Pediatricians usually schedule follow up visits for acne at 4-6 week intervals. If your teen has mild acne but truly doesn’t want to bother with treatment, just encourage washing with a mild cleanser (for example Dove or Cetaphil soap) once or twice a day. No scrubbing, and stay away from alcohol containing astringents. You don’t want him irritating already irritated skin. Also ask him not to use the same smelly germy cloth after every wash. Instead dry off with a clean washcloth or soft paper towel . Applaud his self-confidence and lack of obsession with a skin condition which almost always improves with time.

Myth buster: eating chocolate does not cause acne. The chocoholic in me is greatly relieved by this knowledge.

Truth: arranging hair to hide the face tends to make acne worse. Avoid oily hair gels and sprays. In addition, touching and picking at the skin also causes irritation in an already irritated area.

Finally, what to do on prom night? Cosmetics work wonders, and parental reassurance, even if your teen waves it aside, can take care of the rest.

Julie Kardos, MD with Naline Lai, MD
©2013 Two Peds in a Pod®
Updated from the original post of July 22, 2010

“You just don’t appreciate a picky eater until you have one. ”
—Overheard at Dr. Lai’s dinner table.

Picky eaters come in two major varieties. One kind is the child who eats the same foods every day and will not vary her diet; for example, cereal, milk, and a banana for breakfast, peanut butter and jelly with milk or juice for lunch, and chicken, rice, and peas for dinner. This diet is nutritionally complete (has fruit, vegetable, protein, dairy, carbohydrate) but is quite “boring” to the parent.

The other kind of picky eater is the child who either leaves out entire food groups, most commonly vegetables or meat, or leaves out meals, such as always eats breakfast but never eats dinner.

My own children range from the One Who Tries Anything to the One Who Refuses Everything (these are my twins!). My oldest child lived on cheerios and peanut butter and jelly for about two years and now eats crab legs and bulgur wheat and other various foods. My point: I know where you’re coming from, I feel your frustration, and I will give you advice that works as well as optimism and a new way of thinking about feeding your children.

Fortunately, from a medical point of view, toddler/child nutrition needs to be complete as you look over several days, not just one meal. For example, if every 3 days your child has eaten some fruit, some vegetables, some protein, some dairy, and some complex carbohydrates, then nutritional needs are met and your child will thrive! 

Twelve ways to outwit, outplay, and outlast picky eaters

1) Never let them know you care about what they eat. If you struggle with your child about eating, she will not eat and you will continue to feel bad about her not eating. Talk about the day, not about the food on the table. You want your child to eat for the simple reason that she feels hungry, not to please you or anyone else, and not because she feels glad or mad or sad or because of what you the parent will feel if she eats or doesn’t eat. Along these lines, NEVER cook a “special meal” for your toddler. I can guarantee that when she knows how desperately you want her to eat your cooking, she will refuse it.

2) Let them help cook. Even young children can wash vegetables and fruit, arrange food on platters, and mix, pour, and sprinkle ingredients. Older kids can read recipes out loud for you and measure ingredients. Kids are more apt to taste what they help create.

3) Let them dip their food into salad dressing, apple sauce, ketchup etc., which can make their food more appealing or interesting to eat.

4) Let them pick their own food. Whether you grow your own foods, visit a farm or just let your kids help you in the supermarket, kids often get a kick out of tasting what they pick.

5) Hide more nutritious food in the foods they already like (without them knowing). For example, carefully mix vegetables into meatballs or meatloaf or into macaroni and cheese. Let me know if you want my recipe for zucchini chocolate chip muffins or Magic Soup.

6) Offer them foods that you don’t like—THEY might like it. Here’s an example: a few years ago, my children were decorating Easter eggs with Dr. Lai’s children. My kids asked if they could eat their decorated hard boiled eggs. Now, hard boiled eggs are one of the few foods that I do NOT like. I don’t like their smell, their texture, and I really don’t like the way they taste. Yet, all three of my kids, including my pickiest, loved those hard boiled eggs dipped in a little bit of salt. Go figure. Now I have an inexpensive, easy, healthy protein source to offer even though I can’t stand the way my kitchen smells when I cook them… but hey, if my kids actually will EAT them…

7) Continue to offer foods even if they are refused. Don’t force feed; just have them on the table. It could take 20 -30 exposures before your kids might try them so don’t despair. It took eight years of exposure to brocoli until two of my three kids decided they loved it.

8) Hunger is the best sauce. Do not offer junk food as snacks. Pretzels, crackers, cookies, candy, and chips have NO nutritional value yet fill up small bellies quickly. Do not waste precious stomach space with junk because your insightful child will HOLD OUT for the junk and refuse good nutrition if they know they can fill up on snacks later. Along these lines, never bribe food for food. Chances are, if you bribe eating vegetables with dessert, all the focus will be on the dessert and a tantrum will follow. You and your child will have belly aches from stress, not full bellies.

9) It is okay to repeat similar meals day after day as long as they are nutritious. We might like variety as grownups but most toddlers and young kids prefer sameness and predictability.

10) Turn off the TV. Trust me and trust numerous scientific behavioral studies on this, while it sometimes works in the short term, it never works in the long term. In addition, watching TV during meals is antisocial and promotes obesity.

11) Do not become a “short order” chef. If you do, your child will take advantage of you and likely will not end up eating anyway. When your child says, I don’t want this dinner/lunch/breakfast, I want something else,” you say “The meal is on the table.”
One variation of this that works in some families is to have one back-up meal that is the same every day and for every meal and must be completely non-cook and nutritious, for example, a very low sugar cereal and milk, peanut butter and jelly sandwich, or yogurt with nuts or fruit mixed in it, etc, that you agree to serve if your child does not want to eat what the rest of the family is eating.

12) You can give your child a pediatric multivitamin. This tactic is not “giving up,” nor is it cheating, and it can give the Parent as Provider of Nutrients peace of mind. You can either give a multivitamin every day or just on the days that you are convinced that your child has eaten nothing.

If all else fails, your consolation is that your child will likely become a parent of a picky eater too, and she will ask you how to cope. You’ll be able to tell her what worked for you when she was a picky eater.

Julie Kardos, MD with Naline Lai, MD
©2013 Two Peds in a Pod®
Originally posted on July 24, 2009, with modifications

As you stand watching your budding baseball star at his five o’clock practice, the rest of your kids start to whine. “Please, please, please,” they say. “Can we go to the snack stand? We can’t wait for dinner.” Feeling faint from hunger yourself, you begrudgingly acquiesce and later cringe as you see them trouping back from the snack stand with fluorescent nacho cheese covered chips and candy. Sound familiar? Today we bring you thoughts from a mom who did the unthinkable… she revamped her kids’ sports snack stand menu. Now she brings you ideas to overhaul yours. We are impressed. –Drs. Kardos and Lai

Skittles, hot dogs, nachos, soda, and ice cream.  If you have been to your child’s sporting event recently, then this should sound like a typical snack stand menu.  Somehow, sports and junk food are synonymous.  But doesn’t that contradict itself?  Aren’t we having our children participate in sports to keep them healthy?  Well, then, why are we feeding our children junk food at the very moment that they need fuel to help them perform better?  These foods are laden with sugar, trans fat, and sodium, foods which will adversely affect the health of your family.

As parents, we need to take back control of what we are feeding our children. Statistics show that type 1 and type 2 diabetes are on the increase among children.  According to the SEARCH for Diabetes in Youth study, the prevalence of type 2 diabetes increased 21 percent among American youth from 2001-2009, while type 1 diabetes rose 23 percent.  The effects of diabetes are staggering:  heart disease, blindness, kidney disease, nervous system disease, and poor circulation leading to amputation.  And diabetes is only one of the many negative results of eating processed junk food.  

You may be thinking, what’s the harm in eating a little junk food at snack stands?  Well, it wouldn’t be overly harmful if snack stands were the only place that our children occasionally purchase junk food.  Think about all of the other locations that our children consume unhealthy food:  school lunches, fast food restaurants, vending machines, and convenience stores.  All of these poor food choices add up and will eventually lead to serious health consequences.

Over the past few weeks, I revamped the menu of the snack stand for my daughters’ summer swim team.  I was apprehensive about making these changes because I was concerned about how the parents and children would react.  Would my own children be subjected to teasing because I took away the M&M’s?  I was able to transform the menu from items riddled with sugar and trans fat to whole foods fresh from our grocery store.  Here’s a sample of items that we offered:

Old Menu                                                       New Menu

Skittles                                                             Fresh Fruit Salad

Cupcakes                                                         Smoothies made from fruit

Brownies                                                         Chocolate Covered Frozen Bananas

Cow Tails                                                         Trail Mix

Soft Pretzels                                                    Air Popped Popcorn

Hoagies on White Bread                                 Subway Hoagies on Whole Wheat Bread

Snapple (with more sugar than soda!)           Water

Gatorade                                                         100% Fruit Juice

Of the hundreds of families that we served, I only had one person who complained.  One!  Instead, I had an outpouring of support and many families who appreciated having fresh, healthy food choices for their family.  One dad went as far as emailing the president of our board to compliment us on our healthy snack stand. 

So, what can you do if your snack stand does not yet offer healthy choices?   Here’s a bit of food for thought:

• Pack your own snacks!  You can control what your family is eating by giving them healthy choices.*  Here are my favorite items to pack in our cooler:
  • Water
  • Peanut Butter and Banana Sandwiches on whole wheat (cut them into quarters for little snacks to share)
  • Make your own trail mix with a variety of nuts, plain cheerios, and toss in a few mini chocolate chips to make this feel like a sweet treat!
  • Nature Valley Honey Oat Snack Bars
  • Fruit Kabobs
  • Applesauce cups (natural, no sugar)
  • Fruit cups (packed in fruit juice)
  • Cheese sticks
  • Air popped popcorn – pop enough in an air popper to store in a new trash bag.  Add a little melted butter and salt and shake.  Bring solo cups and scoop out for your child to share with their friends. 
• If you must purchase an unhealthy choice from a snack stand, then try splitting it into two portions.  Ask your child to eat half of it now, and save the other half.  Cutting the portion size down is an important step towards getting healthy. 
• Try feeding your family before you leave for an event.  You will have more control and choices about what your child eats. 
• Talk to the board of your child’s team and ask them to revisit the food that is served in your snack stand.
• If you are visiting another team, then find the name and email address of the board members and email about making a change.

Together, let’s make steps towards changing the way that we think about the food that we feed our children.  The next generation’s life depends upon it.  If that is not enough incentive, then think about how much money you will be saving.  Maybe you can save enough to treat yourself to a little something nice.  Now, we’re talking!

*NOTE:  If you child is resistant towards making these changes, focus on one area (i.e. drinks, sandwiches, or snacks) and make that your focus.  Do not try to make too many changes all at one.  You may find that your chances of success increase when you only focus on one food area at a time.

Mary McDonald, MA

© 2013 Two Peds in a Pod®

Mary McDonald holds a Masters of Education from Arcadia University and a health coach certification from Institute of Integrative Nutrition.  She is a high school teacher, a mom of four daughters, and an advocate for healthy food choices.  For more information on her health coaching services, please contact her at nutrition101withmary@gmail.com or visit her website at nutrition101withmary.com.

We had such a great response to our Two Peds in a Pod® visual diagnosis post that we are posting another summertime picture puzzle:

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

It’s Swimming pool pulpitis- a fancy word for a reaction of the pulp (the meaty tip) of fingers or toes. Mostly seen on the finger tips, the pulpitis is usually caused by irritation of the fingers by the rough side of the swimming pool as kids pull themselves in and out. Kids are sometimes annoyed by the dots, but they go away on their own as soon as the kids decide to use the ladder. In this case, this little swimmer irritated her toes, not her fingers, while “monkey walking” along the side of the swimming pool in the water.

Naline Lai, MD with Julie Kardos, MD

We interrupt your summertime to present another Two Peds in a Pod® visual diagnosis learning session. Do you recognize this rash? Hint: it is mildly itchy and painful and can result from scratching bug bites or a skinned knee. Read on for the answer.

The rash on this child’s arm is impetigo. Impetigo is just a fancy name for a crusty skin infection on the surface of the skin. The infection is caused by the common germs that often lurk on our skin, Staphylococcus and Streptococcus. (You may recognize the germ Streptococcus from our sore throat post because it can also cause Strep throat). The germs wait for a break in our skin, from a tiny cut, pimple or a scrape, then invade the skin and spread. Impetigo is often seen next to the nose because the germs love to lurk in the nasal passages and kids often pick at the skin under the nose when it gets irritated from a cold virus.

Doctors tend to describe infections with appetizing food analogies (yes, we know- eew). In this case, impetigo is often described as having honey-colored-crusted lesions. The areas are tender and red, and often itchy. Kids often spread this infection on themselves when they scratch at the infection and then touch other areas of their skin.

Pediatricians treat impetigo with either a topical antibiotic or oral antibiotic for anywhere from 7 to 10 days. The choice of how to treat depends in part how much of the skin is affected and which body surfaces are involved. The infection is contagious until 24 hours after starting treatment.

Prevent this infection: Hand washing is a great way to prevent spread of impetigo. Washing all skin wounds well with soap and water is another way to prevent the emergence of this infection. See our prior post on wound care.

Ok, now back to the pool and barbeques for all our summertime readers. Just remember your bug spray and remind your children not to scratch and pick at their skin.

Naline Lai, MD and Julie Kardos, MD

©2013 Two Peds in a Pod®

A favorite pediatrician party game is to guess the age of a child by observing his skills and body habitus. Most people are stumped when it comes to differentiating between preschoolers. Here’s a hint: while three-year-olds look a bit pot-bellied because of weak abdominal muscles, four-year-olds look lankier because their muscles are stronger.  

Here are other ways to recognize and understand four-year-olds.

They start recognizing letters and numbers. Do NOT run out and buy flash cards! Teach them simple words that are useful in everyday life. For example, point out STOP or EXIT signs. Point out key words while you read to them.  Teach them simple math: “I am giving you and your sister four stickers to share—how many would each of you get to make it fair?”

Their speech is more fluent and expressive than three-year-olds’, and if you listen to them play, you will hear elaborate make-believe stories and scenarios. Make sure you limit TV/screen time so your kids have a chance to “act out” their favorite story lines.

Watch out! Four-year-olds often try potty talk for the first time, especially at the dinner table. Try not to laugh or to shush them angrily, as it only encourages them. Better to ignore and change the subject. If you respond emotionally, you give their words much more power, and they will persist to see if you continue to give an “entertaining” reaction to their words.

They are better rule followers. At preschool they absorb the rules of the classroom. At home you can encourage them to follow house rules such as hand washing before meals, no shoes on the couch, food stays in the kitchen, etc. In the context of house rules, you can introduce “no potty talk at the dinner table.” Four-year-olds  will tattle on siblings who fail to follow the rules. This same rule-following skill will now allow your child to play board games that are a bit more complex.

They are hero worshippers. Four-year-olds admire their parents, older siblings, teachers, and fictional heroes who are stronger, more powerful, and larger than themselves. Feed their egos by allowing them to beat you at games or races some of the time.

In their eyes, the world still revolves around them. If you need to occupy a four-year-old, tell her a story where she is the main character. If you feel that you are not up to the creative challenge, just tell her a known fairy tale but give your four-year-old the starring role. Tell the story of “Goldilocks” but rename it “Elizabeth and the Three Bears.”

They tell riddles and understand simple jokes. Amusingly, they tell the same joke over and over again, with peals of laughter.  For those of you who remember, “Riddle cups” were very popular with four-year-olds.

Kids this age like rituals. Four-year-olds more actively participate in family prayers. They often latch onto a favorite shirt or dress and insist on wearing it every day of the week. Choose your battles over this, or just buy duplicate favorites so you have time to launder the favorite outfit.

Physically they are more coordinated. They can now hop on one foot, run, climb, skip, throw and catch balls much more accurately. Kids appreciate outdoor play and playgrounds for longer time periods at this age.

Most have given up naps by now: make sure bedtime is early enough so they are not too exhausted to enjoy your bedtime ritual and that they get enough sleep. Most four-year-olds are still “early birds” and wake up with the sunrise.

Enjoy your four-year-old; elementary school is just around the corner!

Julie Kardos, MD and Naline Lai, MD

©2013 Two Peds in a Pod®