Many times parents bring their children with sore throats to our office to “check if it’s strep.” Some are disappointed to find out that their child does NOT have strep. Moms and Dads lament, “But what can I do for him if he can’t have an antibiotic? At least strep is treatable.”

Take heart. Strep or no strep, there are many ways to soothe your child’s sore throat:

• Give  pain medication such as acetaminophen (Brand name Tylenol) or ibuprofen (brand names Advil or Motrin).  Do not withhold  pain medicine before you bring her in to see her pediatrician. Too many times we hear “We wanted you to see how much pain she is in.” No need for this! Pediatricians are all in favor of treating pain as quickly and effectively as possible. Pain medicine will not interfere with physical exam findings nor will it interfere with strep test results.
• Give lots to drink. Some kids prefer very cold beverages, others like warm tea or milk. Avoid citrus juices since they sometimes sting sore throats.  Frozen Slurpies on the other hand feel great on sore throats. Tell your child that the first three sips of a drink may hurt, but then the liquid will start to soothe the throat. Watch for signs of dehydration including dry lips and mouth, no tears on crying, urination less than every 6 hours and  lethargy.
  
• Provide soft foods if your child is hungry. For example, noodles feel better than a hamburger on a sore throat. And ice-cream or sherbet therapy is effective as well.
• Try honey (if your child is older than one year) – one to two teaspoons three times a day. Not only can it soothe a sore throat but also it might quiet the cough that often accompanies a sore throat virus. Give it alone or mix it into milk or tea.
  
• Kids older than three years who don‘t choke easily can suck on lozenges containing pectin or menthol for relief. Warning: kids sucking on lozenges may dupe themselves into thinking they are hydrating themselves. They still need to drink and stay hydrated.
  
• Salt water gargles are an age-old remedy.  Mix 1 teaspoon of salt in 6 ounces of warm water and have your kid gargle three times a day.
  
• Magic mouthwash: For those older than 2 years of age, mix 1/2 teaspoon of liquid diphenhydramine (brand name Benadryl 12.5mg/5ml) with 1/2 teaspoon of Maalox Advanced Regular Strength Liquid (ingredients: aluminum hydroxide, magnesium hydroxide 200 mg, and simethicone) and give a couple time a day to coat the back fo the throat prior to meals. Do not use the Maalox formulation which contains bismuth subsalicylate. Bismuth subsalicylate is an aspirin derivative and aspirin is linked to Reye’s syndrome.
  
• For kids three years and older, try throat sprays containing phenol (brand name Baker’s P&S and Chloraseptic® Spray for Kids). Use as directed.
  

Strep throat does not cause cough, runny nose, ulcers in the throat, or laryngitis. If your child has these other symptoms in addition to her sore throat, you can be fairly sure that she does NOT have strep. For a better understanding of strep throat see our posts: “Strep throat Part 1: what is it, who gets it and why do we care about it” and “Strep throat Part 2: diagnosis, treatment, and when to worry.”

Any sore throat that prevents swallowing or prevents your child from opening his mouth fully, pain that is not alleviated with the above measures, fever of 101F or higher for more than 3-4 days, or a new rash all merit a prompt visit to your child’s doctor for further evaluation. Please see our prior post on how to tell if you need to call your child’s doctor for illness.

Julie Kardos, MD and Naline Lai, MD

©2012 Two Peds in a Pod®

Photo by Lexi Logan

Picture the Mission Impossible theme song in your head… da da da DUM DUM da da da DUM DUM dadada…dadada…dadada…DA DA! Keep this background music playing as you read.

Recently, Two Peds in a Pod® went undercover as two unsuspecting moms surveying the scene on the shelves of a local chain pharmacy, seeking to uncover what medicines, ointments, and therapies avail themselves to the unsuspecting consumer. Today we break open the case.

All medication labels have an “active ingredient” list. This list contains the actual medicine that acts on your child’s body to hide symptoms or cure a condition.  Read this list carefully so that you know what you are actually giving your child. For example, Flu-Be-Gone claims it “cures the aches and cough of flu and helps your child sleep better.” In order to know just what is actually in Flu-Be-Gone, you need to read the active ingredients. Included might be acetaminophen (brand name Tylenol), a fever reducer and pain reliever, and diphenhydramine (brand name Benadryl), allergy medicine that has the common side effect of causing drowsiness and has some mild anti-cough properties. Notice neither active ingredient actually kills the flu germ. Additionally, you may already have these two medications in your medicine cabinet, or you might have already given your child diphenhydramine recently and giving Flu-Be-Gone would overdose your child.

Also note, diphenhydramine is everywhere. If you see the word “sleep” or “PM” in the name of a product, you will usually find diphenhydramine in the active ingredient list.

Now, let’s hone in on your choices for the anti-itch therapy, hydrocortisone. When your child’s health care provider advises treating an itchy bug bite, poison ivy, or allergic rash with hydrocortisone, make sure that the ACTIVE INGREDIENT in the product is “hydrocortisone 1%.” Hydrocortisone comes as a cream, ointment, spray, or stick (looks like a glue stick) and can have aloe, menthol, or other ingredients thrown in as well. Don’t bother with anything less than maximum strength. Regular strength is 0.5% and is generally ineffective.  Also, keep in mind that while ointment is absorbed a bit better, it is more greasy/messy than cream.

Don’t be fooled into thinking products with the same brand name contain similar active ingredients. Also, do not depend on your doctor to necessarily know the difference between the all the formulations. We noticed that the same brand name pain reliever, such as Midol, can have different active ingredients depending on which one you choose. Midol Teen contains acetaminophen, Midol liquid gels contains ibuprofen, and Midol PM contains acetaminophen and diphenhydramine.

Let’s talk bellyache. Did you know that kids should not take adult pepto bismol because it has a form of aspirin in it? Aspirin may cause Reye’s syndrome, a fatal liver disorder. However, we did see a product called Children’s Pepto Bismol and guess what the active ingredient is? It is calcium carbonate, which is the SAME active ingredient as in Tums, and is safe to give kids. However, watch your wallet: the children’s pepto bismol that we found cost $6.00 for a box of 24 tablets. The TUMS that we found cost $4.50 for a bottle of 150 tablets of the same stuff, just in slightly higher dose. Check with your child’s doctor but in most cases, the kids can take the adult dose.

Also, be aware that cold and cough medicine have not been shown to treat colds successfully or even to actually relieve symptoms in most kids. In fact these medicines have potential for harmful side effects, accidental overdose, or accidental ingestion and are just not worth giving your children. However, we found tons of cold and cough medicines marketed for children. Here are the three most commonly used active ingredients:

• If you see “suppressant” you will likely find “dextromethoraphan” in the active ingredient list.
• If you see “expectorant” you will likely find “guaifenesin” in the active ingredient list.
• If you see “decongestant” you will likely find “phenylephrine” in the active ingredient list.

Many products combine two or all three of the above. We ask, even if these ingredients did work well in kids and were not potentially dangerous, what is the POINT of combining a cough suppressant with an expectorant? Can you really have it both ways? (Remember, that Mission Impossible theme is still playing in the background.)

A few other tidbits. “Dramamine,” used for motion sickness, gets broken down in the body to diphenhydramine, that allergy medicine that we already talked about. So look at cost differences when choosing a motion sickness medicine. Both have the same side effect: sleepiness.

Many cough drops contain corn syrup and sugar. This is the same stuff lollipops are made of, so just call a candy a candy and keep your child’s throat wet with the cheaper choice, if you choose to do so.

Finally, we found one “natural children’s cough medicine” which claimed that it is superior because of its “all natural ingredients.” The first active ingredient listed? Belladonna. Sure it’s natural because it comes from a plant. So does marijuana. Just because it’s “natural” doesn’t mean it’s safe. Belladonna can cause delirium, hallucinations, and death and in fact has been used in high doses as a poison! Leave the cough medicine on the store shelf, and read our post about other ways to soothe a cough and cold symptoms.

Bottom line:  remember always to check the “active ingredient” list when buying any over-the-counter medication for your children.

As we were wrapping up our mission, one of the pharmacy employees came over to us, raised an eyebrow at our clipboard, and asked, “Can I help you ladies with anything?” We were tempted to answer “YES, can you help us take notes?”  but we just smiled and said “No, we’re fine, thanks. Just checking out what’s available.”

So now, we will don our stethoscopes and come out of hiding, go back into our offices and onto our website. Thanks for tuning in to this episode of Two Peds in a Pod®…. Da da da, DUM DUM da da da, DUM DUM dadada…dadada…dadada…DA DA!!!

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

As we head into this year’s cold and flu season, we re-release this post in response to recent questions  about “the best cold medicine for my kid.” Originally posted May 27, 2011

“DaDu.”

That’s how my oldest used to say “Thank you” when he was about two years old. Now that he is thirteen I find myself still reminding him to say “thank you” when he goes to a friend’s house or to a birthday party or when a friend’s parent drives him to school.

From Two Peds in a Pod®:  We are thankful for our readers, our facebook friends, and our subscribers for continuing to send us ideas and for telling parents around the world about our down-home source of “sound pediatric advice for parents on the go”. We’ll keep writing as long as you all keep reading. 

Today, may you enjoy cramming in folding chairs to your dining room table, the sleepy post Thanksgiving feast lull, and the sight of heaps of children piled onto a tiny couch.

Dadu and Happy Thanksgiving, 

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

A decade ago, we wondered if arsenic was in pressurized wood-containing playground equipment . Then we worried about the toxin turning up in apple juice . Now recent reports say arsenic is in the US rice supply .

Uh oh.

As an Asian-American I often cook rice for my family, so I emailed my toxicologist sister when the reports of arsenic in rice first surfaced.

“It’s okay,” my sister emailed back, “Just wash/rinse the rice several times. It’s not like we’re drinking water in Bangladesh.”

“That’s it?” I thought to myself and decided to call her. After all, I figured she is one of a small number of board certified medical toxicologists and an author of a paper on arsenic.

“What is arsenic anyway?” I asked when I got her on the line.

“It’s a naturally occurring element,” she said. To be more precise, it’s number 33 on the periodic table. Like other elements such as iron, lead or calcium, arsenic is found in the earth’s crust.

Here’s what  I learned about arsenic:

Why did my sister reference Bangladesh in her email? In the 1970’s drinking water
was in short supply in Bangladesh. Contamination of water by sewage and
monsoons lead to diarreheal illness and high infant mortality rates.
Hundreds of thousands of wells were drilled in order by well meaning aid
organizations. Unfortunately, unbeknownst to the drillers, Bangladesh
sits over a pocket of arsenic rich soil. As a result, some estimate one
in five of the drilled wells is contaminated with arsenic.

How does arsenic affect humans?

Organic arsenic is not toxic and is found in seafood. The inorganic form of arsenic, however, interferes with Adenosine–Tri- Phosphate (ATP), which is a building block for cellular energy. When a large amount is ingested at one time, the body goes haywire, causing many vital organs in the body to shut down.

Chronic effects of low amounts of poisoning are more subtle. Exposures to low levels over time are linked to some cancers such as bladder and skin cancer.

How does arsenic enter the body?

By eating or drinking of tainted substances. Rarely, arsenic is inhaled. Absorption of arsenic will not occur via touch.

Can I tell if something is tainted?

No. Arsenic is colorless and tasteless when dissolved in water. In fact, arsenic’s nick name is “Inheritance Powder” because it was used to speed up royal inheritances in medieval and renaissance Europe.

Should I run out and have my kids tested?

No. Arsenic does not accumulate in the body. It moves in and out quickly. A spot test is not meaningful. Think of eating trace amounts of arsenic like eating the charred part of a piece of steak.

To lower arsenic levels or any other potential contaminant on food, wash, wash, wash:

-Wash your hands before you prepare food.

– Wash your child’s hands before she eats.

–Wash your produce (meat does not need to be washed).

Also, serve a variety of foods to minimize the chances your family will be exposed to a large quantity of any potential toxin found in one food source.

What about rice cereal? Is it safe for my baby?

The jury is still out. For now, limit the amount of rice cereal you give to your baby. For details and the latest updates www.aap.org

Tonight my family will be eating ribs and rice…just hold the arsenic.

Naline Lai, MD with Julie Kardos, MD

With thanks to Melisa Lai Becker, MD, director of medical toxicology of the Cambridge Health Alliance

©2012 Two Peds in a Pod®

The cut of mental illness can be  sharper than any surgeon’s knife. What happens when a child’s emotional turmoil escalates beyond a family’s control?  In the  newly released book Suicide by Security Blanket, and Other Stories from the Child Psychiatry Emergency Service: What Happens to Children with Acute Mental Illness, Drs. Laura Prager and Abigail Donovan bring us behind the scenes of the Massachusetts General Hospital psychiatric emergency room. Although the discussion can be somewhat technical, the real-life stories are poignant and are fascinating not only for healthcare professionals, but for anyone interested in child mental health.

In this excerpt, a dialogue occurs between Dr. E, a child psychiatrist, and Tommy, a depressed fourth grader who has just tried to strangle himself:

“I hate myself. I want to die.” Tommy’s voice lacked any inflection.

“Why?”

“I’m bad. The world is bad. No one likes me. No one wants me as a friend.”

“No one?”

“I’m a loser. No one wants to be friends with a loser. They all hate me.”

“Why are you a loser?”

“I’m fat. I can’t do anything right. I got in to trouble at school.”

“What happened at school?”

“Nothing.”

“Nothing?”

“I wrote bad stuff.”

“Bad stuff?”

“This one kid farts all the time and I wrote ‘fart’ on his notebook.”

“Then what happened?”

“The teacher made me apologize.”

“That’s it?”

“My parents get mad when I do stuff like that.”

“Were they mad this time?”

“I don’t know. I always get in trouble. No one in my family likes me, either. They won’t care if I’m dead.”

…Tommy’s voice got just a bit louder. “After school, I was really mad. I went down to the playroom and I tried to strangle myself. I didn’t have any rope, so I used my scarf. I also thought about going upstairs and trying to jump out a window.”

Did you hurt yourself when you tied the scarf around your neck?”

“No, I couldn’t get it that tight.”

“Did you think that you could kill yourself that way?”

“If I pulled hard enough.”

“So what happened then?”

“My mother came downstairs and found me.”

“I guess it was lucky that your mother was keeping an eye on you. Do you know why she came down?”

“I don’t know. She took the scarf and called the doctor. Here’s the scarf.” Tommy pushed the sheet away from him. He was wearing maroon hospital PJ’s that were slightly too big for him. Around his neck hung a dirty grey-colored knit scarf that looked as if it might once have been another color, perhaps light blue. It had remnants of fringe hanging from each end. The scarf hung loosely, and the ends tumbled into his lap. As he spoke, Tommy absentmindedly started stroking the tattered fringe on one end.

Dr. E tried to regroup. How could the nurses have let this kid sit in a bay with a scarf around his neck when apparently he had just tried to strangle himself with that very scarf?

“Is this the same scarf?”

“Yes. I just told you that. I had it with me.”

“Is this scarf your security blanket? Do you sleep with it?” Dr. E hoped she didn’t sound quite as incredulous as she felt.

“Well, I don’t take it to school, usually. It usually stays on my bed during the day.” He paused before adding, “I had it with me today. It was in my backpack. It used to be light blue. I’ve had it for as long as I can remember. I think my father gave it to my mother but she didn’t like it.”

“You tried to strangle yourself with the scarf you have held on to forever?”

Tommy was silent.

Dr. E fell silent, too.

Reprinted with permission. Courtesy of Praeger Publishers/ABC-Clio, 2012. Available on Amazon.com

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

[youtube https://www.youtube.com/watch?v=iJmLclzctPM]

Thanks to the folks at CBTV local access cable and CBCares, who believe in empowering not only parents close at home but around the world, and reformatted this segment of Parent Connections for the internet.

Julie Kardos, MD and Naline Lai, MD

Do you live in the Central Bucks School District in Pennsylvania? We just got back from filming a segment on sleep and breakfast hints on Parent Connections- running through September.

CBTV community cable
Comcast 28/Verizon 40
7:30 pm on Tuesday, Thursday and Sundays

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

Ouch! This kid’s index finger has a finger nail infection called a paronychia. Often seen in nail biters and cuticle pickers, this infection occurs in the skin around fingernails. Although most kids are not dexterous enough to bite their toenails, infection can also occur in toes. Bacteria which normally live on skin (Staphylococcus or Streptococcus) find an opportunity to enter the body through openings in broken skin.

The area at the periphery of the nail bed is red, swollen, and painful. At times pus drains from under the nail bed.

Caught early, warm, soapy soaks several times a day may be enough to soften the tense skin and encourage germ-fighting cells to migrate to the infection. After soaking, apply topical antibiotic, such as Bacitracin, to the area.  Often the infection improves after 2-3 days of diligent soaking.

Sometimes the infection persists and oral antibiotics are needed to treat the bacteria. In this photo, the redness of the child’s paronychia is spreading beyond the area immediately next to her nail. Besides increased redness, other worrisome signs of worsening infection include red streaks up the affected digit (a sign that the germs are trying to make it up to the heart),  increasing pain, or fever. Your child’s pediatrician will make the call after examining your child.

Although I do not keep formal track, I do seem to see more of these infections at the start of the school year when kids at their desks begin to bite or pick their nails and cuticles. To prevent infection, remind your kids to wash their hands. If you have a biter/picker, have her substitute a different habit such as picking at a hair scrunchie or Silly Bandz. A more expensive and time consuming option, which Dr. Lai has seen work—offer a fancy manicure.  Kids rarely want to ruin beautifully painted nails by chewing on them.

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

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: