In the office it’s raining school forms. At this time of year, I see many of my patients embarking on their next stage of schooling. Kids I remember starting kindergarten are off to high school. Babies are starting daycare and  teens are starting college. For all the parents who have a child entering a new school, whether it’s preschool or college, this letter is for you:

My kids and I cheered as we watched the Olympic swim races together on TV. Having just finished their first summer swim team season, they were especially interested in these events. While we joked about how much faster Olympian swim times were than their own, we also noted that “just like on swim team” at the end of the races, the Olympians shook hands with the swimmers in the adjacent lanes. It got me thinking about sportsmanship.

The adage says, “It’s not whether you win or lose, it’s how you play the game.” But our society puts such heavy emphasis on winning, coming in first, being the best (and thus beating out others) that kids can feel extreme pressure to win. Parents should resist adding to that pressure.

We, as parents, have to accept that our kids can’t always come in first, get the perfect score, or win everything they do. From an early stage, we need to praise our children’s effort, and also teach them to appreciate other kids’ efforts, skills, and accomplishments. We can say to our kids, “Wow, Bobby sure is a fast runner. I bet if you practiced running (or hitting, or catching, or kicking) you could get better too. I’ll help you if you want.” Teach your child that if she wants to improve a skill or test grade, she will have to work at it. Friendly competition that inspires us is a good thing. Kids cheat when they feel too much pressure to win, and fail to understand that there are no “quick fixes.”

When parents (and coaches) fail to model good sportsmanship, kids blame their pitcher when the other team hits, blame their goalie for letting up scores, blame their parents for not buying the most expensive equipment that would have enhanced their performance. At one of my kid’s games, I saw a young athlete punch a child on the winning team during the end-of-game “high five/good game” ritual because he was so angry that his own team lost the game.

Unfortunately, some teen athletes convince themselves that “because everyone does it,” it’s okay to cheat by taking steroids to enhance their performance. Students without a diagnosis of attention deficit hyperactivity disorder cheat by taking their friends’ ADHD medications so they can concentrate longer when studying for exams or completing homework. Even Olympic athletes cheat. Discuss with your children why eight badminton players were disqualified when they attempted to throw their games in order to get a “better” placement in the tournament. Because they cheated, they were given NO place in the tournament.

The 2012 Olympics is a perfect opportunity for parents to point out examples of good sportsmanship to their children. Even the Olympic athletes who cry from disappointment express support for their teammates and gratitude at the opportunity to compete at such a high level. So as we cheer for our own country or for our favorite athletes, let’s also teach our kids to cheer the athletes’ sportsmanship and performance.

Kids should learn to work hard, study hard, do their best all of the time. We hope that as adults they will value themselves and others for having good work ethics and improving their skills. Of course we should teach our kids to “go for the gold.” But we also need to be clear that we still love them even if they never claim a medal.

For tips on fostering sportsmanship in kids, see this post from the  Nemours Children’s Health System.

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

fodder for tetanus…don’t get this stuck under your foot

Look at this rusty old anchor atop an old fort. Rust plus dirt equals a perfect breeding ground for tetanus. As my kids scampered between different anchors last week, I quickly calculated in my mind whether their preventative tetanus shots were up to date.

“Getting the tetanus shot” is part of the American societal childhood rite of passage, but most people don’t know much about why their kids are vaccinated. Everyone knows they want to avoid IT, but what is IT? Because it is somewhat rare in the United States, I still remember asking one dad about his child’s family history. I was startled when he erupted onto peals of laughter after he told me the child’s grandfather had died of tetanus. “Why are you laughing?” I said in disbelief.

“You’re right, it’s not funny… It’s just the look on your face is funny,” he said. “Everyone has the same shocked expression when I tell them that he died from tetanus.”

Also known as Lock Jaw, tetanus is an organism which thrives in places with little oxygen. Thus, it tends to live on rusty nails (and anchors!) and deep in dirt. Tetanus secretes a poison which causes muscles to spasm painfully and severely and also causes seizures. Exposed to tetanus, your jaw muscles clench into a sardonic smile which prevents eating – hence the name Lock Jaw. Eventually, the tetanus poison infiltrates the chest muscles that help you breathe, and if you are like nearly 40 percent of cases, you will stop breathing and eventually die.

We have no antidote for the poison of tetanus- but we do have a preventative immunization which causes our bodies to preemptively prepare antibodies as self-defense. At the time of a high risk injury, if needed, doctors will boost your child’s tetanus immunization. If your child is under- immunized, the doctor will also inject your child with tetanus antibodies (tetanus immunoglobulin) to further ensure that your child will not contract this disease.

Because tetanus thrives away from oxygen, it easily multiples in deep wounds contaminated by the germ. The germ surrounds us in soil and also lives in intestines of humans and animals. Since tetanus lives in dirt, the following are considered “high risk” injuries:

   -Bites from animals which dig and “eat” dirt such as dogs.

    -Deep puncture wounds from dirty, rusty nails.

    -Wounds with embedded rocks and gravel.

Be wary of tetanus in wounds possibly contaminated with stool, dirt ,or saliva. In developing countries, there are continued cases of infantile tetanus because poultices of mud are used to take care of the umbilical cord stump of newborns.

For kids, the recommended ages for tetanus shots are at 2 months old, 4 months old, 6 months old, 15-18 months old, 4-6 years old, 11-12 years old, and then every ten years through adulthood. Note, if a high risk wound is sustained, the last shot should be within five years. Thus, a kid around 9 years old may be up-to-date for shots, but because he received a tetanus vaccine at four-years-old (on time) he will still need an immunization at the time of a risky injury. Watch out also if you have a teen. His pediatrician will immunize him at 11-12 years of age, but after 16-17 years old he will need a booster if he sustains a dirty wound.

Nowadays, the tetanus immunization is in the same solution as an immunization against diptheria (a disease that causes a choking-inducing coating at the back of your throat), and usually in the same solution as pertussis (whooping cough). If your doctor gave your child an immunization recently against pertussis, she also received a tetanus immunization.

Kids are expected to get dirty. Enjoy the dirt—just not the tetanus.

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

Dr. Pat Cantrell, mother of two young boys (who can be picky eaters at times!), is a board certified pediatrician who has been practicing pediatrics at Southern California Permanente Medical Group for over 14 years. She has a special interest in pediatric obesity and is the President of KFIT Health, LLC (www.kidfitnessandhealth.com) which creates fitness and nutrition DVDs and products for children. A board member of the San Diego Childhood Obesity Initiative, Dr. Cantrell is also the Pediatric Obesity Champion for her medical group. Additionally she serves as Secretary of the San Diego Chapter of the American Academy of Pediatrics.

Two Peds in a Pod® turns three years old! In honor of our third birthday, we bring you our top ten parental experiences through the years list:

1. “Helping” your child manage his ice-cream cone (especially when he orders the soft chocolate kind with the chocolate sprinkles)
2. Coaching a sport you have not played in twenty years.
3. Playing hours of Mario Cart or Just Dance on the Wii (and losing every time)
4. Building snowmen
5. Coloring with brand new crayons (and the aroma of opening that new box of Crayolas!)
6. If you are a mom, discovering your teen daughter is the same shoe size and you can borrow her hip shoes
7. Experiencing your child’s first bike ride without training wheels
8. Getting to be the Tooth Fairy (shhh… don’t tell!)
9. Re-reading your favorite kid books (Dr. Seuss really was a genius)
10. Realizing your child honestly believes that you have a really good singing voice

We hope to celebrate many more birthdays with you. Please continue to send us your ideas at twopedsinapod@gmail.com, comment on our posts and tell your friends about us. 

Happy,

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

Vacation! As I watched my kids scamper across the beach today, I remembered a conversation I had with a family recently. “My kid sometimes coughs up sand,” the mom said to me. “Little hard specks sometimes come out of her mouth. ”

“Hmmm, bring me a speck of the ‘sand’ the next time he spits one out,” I said.

A few days later, rattling inside a small plastic container on my desk, I found a tawny-hued speck which resembled a chip of rock. The mom had kept her promise and now I was the owner of a tonsillolith. Pictured here next to a paperclip, this and other tonsilloliths are harmless hardened pieces of debris which lodge in crevices (crypts) of tonsils. No one is exactly sure why tonsilloliths form, but they do seem to run in families. A combination of the right type of saliva, food, and deep tonsillar crevices produce these white or tan specks which occasionally become the size of a small pebble. In fact, they are also known as tonsil stones. Most people consider tonsilloliths a nuisance, but sometimes they are associated with bad breath. Warm salt water gargles after meals (one teaspoon of salt per 8 ounces of warm water) is usually enough to dislodge the tonsilloliths and prevent new ones from sticking. People have been known to overcome gag reflexes and flick them out with their nails. Addressing any tonsillar irritation such as Strep throat infections (see our previous posts: part one and two) or post-nasal drip from allergies may also be helpful. For those having continual tonsillolith-induced bad breath, removal of the tonsils is the definitive answer.

Some people dream of getting away to Sannibel Island’s shell covered beaches, others to Bermuda’s wispy pink speckled beaches and still others to the jagged rock-strewn beaches of Maine. Do otolaryngologists (ENTs) dream of tonsillolith-covered shores?

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

Let’s think about universal parental admonishments:

                “Hold on tight.”

                “Be careful.”

                “Look out!”

                “Don’t let go.”

Now let’s think about the universal goal of parenting: to create children who grow up to become independent.

That means that at some point, after your child learns to hold tight, be careful, and look out, your child will need to let go.

This inevitable march toward independence does not begin when your child turns eighteen, but rather years before. Kids learn independence in small steps starting when they are still babies in our eyes.

For instance, take feeding. First you breastfeed or bottle feed. Eventually you encourage your young child to drink out of her own cup as SHE holds it. When she’s able to pick up lint from the floor and stuff it into her mouth, you know she’ll be able to feed herself finger foods from the family dinner table.  At 18 months, children are capable of wielding their OWN spoons and fork—so let her do so, no matter the mess. By constantly challenging her with self feeding, your toddler becomes the preschooler who eats lunch with her friends at “lunch bunch” and the college student who chooses to eat salad at the cafeteria. 

How does a child learn to maneuver stairs? If you always carry her, she will never learn. Older siblings often teach the younger ones how to crawl backwards to the top of the steps and then go down safely buttocks first. I have fond memories of my son crawling backwards like a dump truck nearly the entire length of the hallway before reaching the steps. I would imagine a high pitched beeping sound as he inched backwards. As walking becomes steadier, your kid will learn to hold onto the banister as she goes up and down. Fast-forward and someday she will be the dexterous mom who carries her coffee in one hand, the laundry basket in the other and her phone between her ear and shoulder as she heads downstairs.

What does “be careful” mean? I find that kids often have no frame of reference for “careful” So be specific with your advice. When my kids were toddlers and carried cups of milk to the table, instead of only saying “be careful” I would remind them to “walk slowly.” If they (gasp) cut paper with scissors, I would say, “watch where your fingers are.” 

For kids, personal safety is often not enough of a motivation to listen to advice. When my twins were almost two years old, I realized that I belted them in their double stroller so often in public, they did not have an opportunity to learn how to stay with me. So, one day I had them hold my hands as we crossed the parking lot at their older brother’s school. They immediately tried to escape and run in opposite directions. I instructed them to “hold tight to my hands” or “Mommy will have to carry you like a baby.” The thought of walking into their older brother’s school like “big boys,” kept them holding on. 

Sometimes we need to allow children to fall, literally and figuratively. If missing the carpeted step that leads to the living room means your toddler falls, then let her learn from her mistake. An older child who insists on leaving his jacket at home will learn from natural consequences if he is too cold outside (remember you can’t catch a cold from the cold, you just feel cold). Remember all those skinned knees you sustained as a child? Yet now you can ride a two wheeler bike and you run faster because you practiced running, even if you fell a few times. If you make your child too afraid of falling, then he will be unable to take the risks involved in learning new skills.

Let your child complete his own homework from a young age. Offer to proofread but don’t nag. Teachers already have consequences in place for children who do not complete homework, or for those who do a sloppy job. Let your middle schooler choose which foreign language or musical instrument or sport he wants to learn without pointing out the practicalities of what you consider the “better” choice.

Of course we need to protect and guide our children. But we need to learn to relinquish control over our children’s actions at the appropriate ages. 

As the viral internet sage Eva Witsel says, “I can spend my energy on limiting my child’s world so that he will be safe and happy or I can spend my energy on helping my child learn the skills to navigate our world himself so that he will be safe and happy. I think the latter has a better chance of success in the long term.”

In grade school I remember holding tight to the chains of the playground swing as I swung higher and higher. But I also remember that glorious feeling as I let go, sailed through the air, and landed on my feet.

Don’t deprive your child of that same glorious feeling of letting go.

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

Lucky kid!  My daughter’s first rock concert, and not only did her girlfriend score tickets to the hot teen band One Direction, but the girls sat in 9th row seats. Despite fears of appearing dorky, my kid took along a box of earplugs. A half-hour into the concert, the mom accompanying the girls texted me. “Earplugs a necessity,” she wrote.

No, it’s not a myth your parents told you as a teen to keep you miserable at home on a Saturday night. Loud music really can cause high frequency hearing loss. 

Sound is described by decibels (loudness) and by frequency (pitch). Examples of high frequency noises are the sound of a nail scratching a chalk board or a person whispering. A very high frequency noise is the sound of a dog whistle. By thirty years old, almost everyone experiences some hearing loss at frequencies above 15 hertz – if you are this age, this is why everyone now seems to mumble at parties. A few years ago, teens capitalized on this natural hearing loss phenomenon with “mosquito” ring tones– high frequency cell phone rings heard only by younger ears but not by prying adult ears. For kicks, check out your ability to hear high frequencies at this non-scientific site.

Exposure to loud sounds at high decibels hastens the natural progression of high frequency hearing loss. Damage to the hearing nerve (cochlear nerve) in an ear can occur from a one time exposure or from repetitive exposure over time. Sounds above 85 decibels cause damage. Those below 75 decibels rarely cause problems. The humming of a refrigerator is 40 decibels, ordinary conversations are 60 decibels and city traffic registers at 80 decibels. Lawn mowers and hair dryers are around 90 decibels and firecrackers explode at 120-140 decibels. After two minutes, exposure to rock concerts (which usually register at 110 decibels) may cause damage. For lawn mowing, the permissible exposure time is sometime between 2-4 hours. The site www.dangerousdecibels.com gives maximum recommended lengths of time for exposure to loud sounds.  

Amongst teens, high frequency hearing loss is on the rise. The exact cause is unclear, but doctors suspect that the loss is secondary to constant exposure to loud sounds. Limit your child’s exposure to high decibel activities. Give your teen earplugs as she mows the lawn this summer and uses the leaf blower this fall.  Because of differences in ear buds and how music is recorded, there is no uniform way to regulate volume produced by MP3 players. However, as a general rule of thumb, if you hear your teen’s music playing when he has ear buds in, it’s too loud. Kids should be able to hear normal conversations even when their devices are on.

So don’t fret if your teenager gets a mosquito ring for his cell. The ringing in the ears after a loud concert or a day of weed-wacking is the “sound” of hearing loss occurring— THAT’s the ring to avoid.

Thanks to Educational Audiologist Kristin Peppiatt, Au.D., CCC-A, the expert advisor who provided information for this post. An Audiologist for Bucks County Schools Intermediate Unit #22 in Pennsylvania, Dr. Peppiatt received her Bachelor’s of Communication Disorders and Masters of Audiology degrees from Penn State University and her Doctorate of Audiology from A.T. Stills University.   She holds her Certificate of Clinical Competency from the American Speech, Language and Hearing Association and is a fellow in the American Academy of Audiology.

Naline Lai, MD with Julie Kardos, MD

©2012 Two Peds in a Pod®

Kinda cute. At least that’s what the medical books lead you to believe.  They are described as little pink or flesh-colored dome-shaped harmless bumps with belly buttons. The little rash with the big name, Molluscum Contagiosum, is cute only until you discover the bumps on your child’s skin. Like your neighbor’s cute toddler, the little belly-buttoned rash can overstay its welcome.

Pictured here is the rash of molluscum. The bumps are generally flesh colored, but can be slightly pink.  Look carefully at the circled bump— this one has a tiny dimple in the center (the “belly button”). While the rash often appears on areas with irritated skin such as eczema, molluscum can show up on every part of the body. As with any new rash, visit your child’s doctor to confirm the diagnosis.

The best thing about molluscum is that it is not harmful. Children can attend school and camp with it. Yes it looks funny, but like warts, it is a virus that is only skin deep. Also, like warts, it can be very stubborn about going away. Probably because it is so benign, children’s immune systems don’t get excited about an out-cropping of molluscum and do not bother attacking the rash.