It’s June, a time of hellos and goodbyes.

Change in routine can be tough.  For some children and teens the transition from school year to summer unmasks depression.

The signs of depression in younger children can look different than depression in teens and young adults.  Younger children are less likely to tell you that they feel sad- often because they can not pinpoint what is wrong.    Of course everyone is allowed periodic “bad days”, but when there are more “bad days” than “good days” action must be taken.  Below are some warning signs that your child may be depressed:

Feels down or sad much of the time

Acts angry much of the time

Acts “out of control” or has new behavior problems that seem resistant to your usual discipline measures.

Loses interest in activities which normally bring pleasure, withdraws from friends

Exhibits changes in sleep patterns-difficulty falling asleep, numerous awakenings, or excess sleeping

Has feelings of worthlessness (feelings she let a family member or teacher down, etc.)

Finds it difficult to concentrate

Performs worse in school, grades slip, or tries to avoid going to school

Shows low energy or fatigue or conversely seems restless or “hyper”

Alcohol or drug use (attempts at “self-medicating”)

Expresses thoughts of being better off dead or desires to hurt himself.

If you suspect your child is depressed, ask him the hard questions. Ask him if he is thinking of hurting himself or others.  Ask if he wants to commit suicide. You will not be “planting an idea.” Asking will allow you to find the medical help he needs immediately.  Not asking may lead to death. We always tell patients and their parents not to hesitate to call “911” or go to the emergency room if the patient is suicidal.  After all, it is an emergency– a life is at stake.

Sometimes it’s not your child who is depressed.Your child’s friend may confide that he or she is extremely sad and may tell your child to keep the information a secret.  Let your child know that her friend is giving a “cry for help” and that it is appropriate to share information with adults.

Children and teens can have “real” depression just like adults and they need treatment from an experienced health care professional just like adults do. Consequences of untreated depression, just like adults, can include loss of enjoyment in life, estrangement from friends, school or job failure, and untimely death from suicide.

Naline Lai, MD and 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®

Your son’s baseball league has just upped the ante, moving from “coach pitch” to “kids pitch.” The good news is that your budding major league pitcher gets some practice. The bad news is that the pitches can be wild. Thank goodness for batting helmets!

So what if the unthinkable happens? You are cheering your child on, when suddenly the wild pitch (or the hit ball, or the wild throw to first base) wacks into your child’s head. He is knocked down and you go running.

First evaluate if your child is conscious. Passing out even momentarily is a reason to seek medical attention right away. Most likely he will not have passed out and will want to return to play. However, the safest bet is to have your child sit out the rest of the game.

Next determine if your child is bleeding inside his head. You may see a growing lump on his head which looks gruesome. However, we pediatricians are less concerned about bleeding or bruising that occurs on the outside of his skull than about possible bleeding inside his skull.

How can you tell where the bleeding is? Again, a loss of consciousness, or passing out, is a worrisome event that may signal bleeding on the inside. In addition, watch for blurry or double vision (“I see two mommies!”), inability to speak clearly or rationally, difficulty walking or loss of balance, vomiting more than once (some kids vomit once when they are scared or in pain), or headache so severe that it is not relieved by acetaminophen (Tylenol) or ibuprofen (Motrin, Advil).  Not all symptoms appear immediately.

So now your child has cheered the team on to victory, enjoyed the after-game snack, has forgotten about the trauma, and is nodding off in the back seat of your car. As you drive him home you remember some vague advice about not letting your child fall asleep after a head injury. Now what?

Go ahead and let your child sleep for a couple of hours, he probably is tired both from the game and from the injury.  You have the rest of the day to observe him.

Sometimes, injuries are not conveniently timed. If a head injury occurs right before bedtime, you will not be able to watch for signs of internal head bleeding because your child will be sleeping. The best way to assess him is to wake him briefly every 2-3 hours throughout the night. 

If your child makes it to 24 hours without symptoms, it is unlikely your child is bleeding inside his head. However, if your child still seems “off” he needs medical attention. Even if he is not bleeding, he may have a concussion (now termed “traumatic brain injury”).

Although it’s never easy to see your child hurt, whether it’s a scrape on the knee or a bump on the head, you can empower yourself by knowing what to watch for. Now that’s using your noggin!

Julie Kardos, MD and 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!

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®

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

This sign now sits on my friend’s lawn. I still remember four years ago when I pulled my big blue minivan up in front of their house after the moving van left. A mommy sat on the stoop with her children. “How old are they? I hollered out. The ages of the children matched my children’s and I was delighted. Indeed they became good friends. And now, there’s the “For Sale” sign.

It’s nearing the end of the school year, and “For Sale” signs dot lawns all over the United States. Chances are, one of them belongs to your child’s friend. Just as the child who moves will have to adjust to a new environment, your child will have to adjust to a world without a friend who was part of his daily routine.

Much has been written about how to transition the child who moves into a new environment, but how can you help your child when his close friend moves away? 

Your child may experience a sense of loss and feel that he was “left behind.” Some children perseverate over the new hole in their world. Others take the change in stride.

In the late 1960’s, psychiatrist Elisabeth Kubler-Ross described “the five stages of grief.” The stages were initially applied to people suffering from terminal illness, but later they were applied to any type of deep loss such as your child’s friend moving. The first stage is denial: “I don’t believe he moved.” Anger follows in the second stage: “Why me? That’s not fair!” Your child may then transition into the third stage and bargain: “If I’m good maybe he will hate it there and come back.” The fourth stage is sadness: “ I really miss my friend,” or, “Why make friends when they end up moving away?” The final stage is acceptance: “Everything is going to be okay. We will remain friends even if he doesn’t live here.”

Some pass through all stages quickly and some skip stages altogether. The process is personal and chastising your child to “just get over it” will not expedite the process. However, there are ways to smooth the journey:

· Reassure your child that feeling sad or angry is common. Parents need to know that sad children may not show obvious signs of sadness such as crying. Instead, rocky sleep patterns, alterations in eating, disinterest in activities or a drop in the quality of school work can be signs that a child feels sad. If feelings of depression in your child last more than a month or if your child shows a desire to hurt himself, consult your child’s health care provider.

· Set a reunion time. Plan a vacation with the family who moved or plan a trip to their new home.

· After the move, send a care package and write/ help write a letter with your child.

· Share stories about how you coped with a best friend moving when you were a child.

As for my children, when I told one of my kids that I will sign her up for soccer, she squealed with delight, “Oh, that’s the league Kelly belongs to.”

My heart sank. I said as gently as I could, “She’s moving- she won’t be here for soccer season.”

And so we begin the process…

Naline Lai, MD

© 2010 Two Peds in a Pod

This spotted the other day- tendonitis.  In plain English, wrist pain at the base of the thumb from the strain of playing too much Nintendo DS/iPod touch or texting on your phone with your thumbs. 

Imagine what the iPad will bring. 

Naline Lai, MD 2010  

© Two Peds in a Pod