Our guest blogger, Dr. Kristann Heinz, a doctor who practices with a holistic and integrative approach, shares her knowledge about melatonin use in children. — Drs. Kardos and Lai

When we got back from Hawaii my three year old daughter, Ruby, was a hot mess! The eight-hour time difference made it hard for her to adjust her internal clock. At first, I just attributed it to routine jet lag but after a week of the same sleep-wake cycle, I knew something was going on. She was wandering around the house in her pink spotted pajamas WIDE AWAKE until 1am, 2am, and 3am. And then in the morning, she was dead asleep and I could barely get her up. So at this point, I took her to our doctor to make sure everything was all right. The doctor told us my daughter’s jet lag was leading to a sleep disturbance and suggested I try melatonin. I gave melatonin to Ruby that night. She was asleep by 11pm and slept soundly until morning. Over the next few days, she adjusted beautifully and we were back to a normal sleep routine in 3 days. After that, we stopped the melatonin.

What is Melatonin?
Melatonin is a hormone that occurs naturally in our bodies. A hormone is a signal containing a message from one part of the body to another. Melatonin is naturally secreted by the pineal gland, a gland located in the brain that is very sensitive to light. As night falls, the pineal gland secretes melatonin to tell the brain that it is time to sleep. This process is sometimes described as the “opening of the sleep gate.”

Why would my doctor prescribe melatonin to my child?
People often use melatonin to help adjust their sleep-wake cycles. For adults melatonin is used to treat a variety of medical disorders including cancer, headaches, and autoimmune disorders as well as insomnia. In children however, the primary reason melatonin is prescribed is for sleep disturbance. Some children with certain medical conditions are thought to have lower levels of naturally produced melatonin, which contributes to sleep-wake disturbances. For these children supplementing with melatonin can be beneficial and enhance sleep. Melatonin has been studied and shown to be helpful to children with developmental delays, ADHD, cerebral palsy, autism, and jet lag.

What dose should I use?
The dose of melatonin should be discussed with your doctor. Doses can range from 0.03mg – 6mg, generally given at bedtime. To establish the appropriate therapeutic dose, your doctor will take into account your child’s weight and the health condition you are trying to treat.

Are there different kinds of melatonin?
Melatonin is synthetically produced but there are also products that contain biological glandular material, a source of natural melatonin. Synthetically produced melatonin is recommended by most doctors because it provides a more consistent dose and is less likely to be contaminated.

Melatonin comes in three different forms: immediate release, sustained released and sublingual. The most convenient form of melatonin for children is the sublingual form because their bodies begin to absorb it as soon as it is placed in the mouth. The sublingual form is easier than swallowing a pill, which can be difficult or uncomfortable for some children. There are many different liquid brands available as well, which have the same benefit. Another good way to administer melatonin to a child is to dissolve an immediate release melatonin tablet in juice or mix it with applesauce before offering it to your child. Taking melatonin with food does not change the effectiveness of the supplement.

How long does it take to work?
Melatonin should work the first night it is given to a child and it does not require multiple doses to be effective. It can take up to 30 minutes after taking the medication to experience its full effect. Often your child will begin to feel drowsy and tired soon after taking the supplement.

Let’s use jet lag as an example of how to use melatonin. You may give the melatonin to your child just before bedtime in the new time zone. The supplement will facilitate sleep within 30 minutes of taking it. But, remember, our internal clocks usually adjust one hour a day when we travel to different time zones, and melatonin can only help to a point. The greater the time difference the more difficult it is for our bodies to resume a normal sleep pattern in the new time zone. If, for instance, there is a twelve-hour time difference, it will still take time for our biologic rhythms to change, even with the help of melatonin. However, the transition is often faster and smoother with the aid of melatonin. Melatonin is not a sleeping pill. It is used to enhance the onset of sleep naturally.

Are There Side Effects or Contraindications?
Melatonin is very safe. The most common side effect for children is excessive sleepiness, which can be moderated by decreasing the dose. In high doses, which are used mostly in treating adults (10mg-60mg melatonin), side effects include headaches, nausea, dizziness and fatigue. For children, taking melatonin is not associated with any short or long-term side effects in relation to growth, development or puberty. Drug interactions can take place between melatonin and sedatives, antidepressants and hormones, so if your child is taking medications of this kind, be sure to discuss whether it is safe to give your child Melatonin with your child’s doctor before doing so.

Kristann Heinz, MD, a graduate of University of Pennsylvania School of Medicine, is board-certified in Family Medicine and Integrative-Holistic Medicine, as well as certified in Medical Acupuncture. She is also a Registered Dietician and Licensed Nutritionist. A mom living in Bucks County, PA, she practices medicine at Stockton Family Practice in Stockton, NJ.

©2014 Two Peds in a Pod®

We welcome pediatrician Dr. Marion Mass to talk about starting a garden from a piece of suburban lawn. — Drs. Kardos and Lai

A few years back, my family was getting ready for my parents to come for dinner and I was peeling the skins off the roasted beets we had grown for my mother.  One of her favorites…but not mine.  My five-year-old Brian had picked the beets and was eager to try them. As Brian brought a sliver of beet up to his mouth I braced myself for a “ yucky face”. Instead, I was shocked to see him gobble the beets up.  He loved them.  To this day, beets are one of his favorite veggies.

Hands down, the best activity I have ever done with my family is planting and nurturing an organic garden for 11 years.  Along the path to growing delectable vegetables, we have discovered together gardening’s health, intellectual and social benefits.

Actively tied to the process of supplying their own food, gardening kids will naturally want to eat more and more produce. Kids develop a sense of pride (truly, a basketful of beans, lettuce and cucumbers is so attractive) and eventually they develop a positive association with the outdoors and vegetables.  In addition to eating more quantity, what your kids eat will be healthier than store bought veggies.  Produce closer to harvest contains more nutrients and you don’t get closer than your own yard to table.   If you garden organically, you will also avoid potentially harmful chemicals.  Lastly, there is a sense of relaxation upon stepping into a garden.  It is a balm for anxiety, for depression, for anger; in short, one of the best adjuvants to mental health therapy that I know.

If you want to harvest a crop next year, and you live in a cold weather area of the northern hemisphere, NOW is the best time to start.  The most cumbersome task of starting a garden is to dig up the sod (existing lawn), but a few tricks in the fall can prevent this disc-slipping chore.

• Chose a spot in your yard that gets at least 6 and preferably 8 hours of sunlight a day.
• If possible, stay away from edges, tree lines and spots where large garden parasites (such as deer, rabbit and groundhogs) lurk.
• If you live next to a pesticide happy neighbor, you will want to locate your garden away from a spray zone and will want to think about runoff.  A helpful site to determine runoff capabilities of specific pesticides is: http://www.pw.ucr.edu/
• Remember you may need to water your organic garden bed once in awhile, so keep it close to a water source (or at least someplace to which you don’t mind lugging a hose).
• Start small:  a 3 x 10 foot plot can grow a good bit if you plan well.  Lay out a 12 layer thick plot of newspaper over the grass where you want your garden to grow and dump 4 inches of composted manure, manure and hummus mix or mushroom soil over top of the newspaper.  You can purchase in bulk from a garden center (I would do 2 cubic yards for a 3 x 10 spot) or in bags (about 15 40 lb bags).

That’s it.  Now go away and leave the garden alone until spring. During the fall and winter, the grass will die and the newspaper will rot.  Both will become a source of composted nutrients for your garden veggies. While you hibernate this winter, start your wheels turning and think about what crops you will grow. Buy a few packs of discounted seeds now; they will still germinate next year.

When the ground is ready in the spring, rent a tiller or get a sturdy pitchfork (trust me, the tiller is SO much easier!!) and turn over the soil mixing the composted manure, rotted newspaper and dead sod into the rocky soil we have around here.  The result will be a much richer garden soil that your vegetables will love.

What are you waiting for??  Get cracking now and start your produce garden.  Hopefully, by next spring your kids will be eating and enjoying organic beets that they grew !!!!

Marion Mass MD, FAAP

©2014 Two Peds in a Pod®

Three of my son’s high school classmates died in a tragic car accident just before school started this year. As parents, many of us may have lost someone close to us, and we know from our experience that over time, the acute pain of loss decreases as we ultimately derive strength and joy from our memories of our loved one instead of experiencing only sadness and pain over their loss. Our hearts ache watching our kids experience death first hand, often for the first time. But teens need time to experience this transition for themselves. Telling them “it will get better” will not help them.

If you are parents of a grieving teen who has lost a friend or classmate, following are some things that you can do to help:

• Offer to be available, to listen, or to find someone outside your family for your teen to talk to if he wants. Do not insist that your teen talks about his feelings.
• Refrain from lecturing– it does not help your teen at this time to hear things like “THAT’S why we won’t let you drive with young drivers.” She’s already figuring this out for herself.
• Allow her to talk or gather with friends during the daytime.
• Go back to basics: make sure your teen eats, drinks and sleeps. Enforce bedtime. Turn off phones and computers by a bedtime that allows your teen to get at least 8-9 hours of sleep. Do not allow your teen to text late into the night or to continue talking to friends late into the night, even if this means insisting that YOU take his phone for the evening. Be cautious of sleepovers, which only cause sleep deprivation, leading to exhaustion and more difficulty handling strong emotions.
• Offer to go for a walk with your teen. Exercise is helpful and encourages dialogue.
• Allow your teen to grieve by attend viewings and funerals. However, do not mandate that she goes. Giving her an idea of what to expect (e.g., there may be an open casket, here are some things you can say to the family) may help ease any discomfort. Offer to go with your teen, but again, don’t insist on going.
• Help your teen to do something constructive to help other survivors. Send a condolence card to the deceased friend’s parents that includes an anecdote of how their teen helped your teen, or of how his deceased friend encouraged, made him laugh, or inspired him. Suggest that your teen cook a meal for the grieving family, mow their lawn, run some errand, or to babysit a younger sibling of the deceased.
• Utilize community resources. School guidance counselors provide a wealth of information and support.

Your teen may experience intermittent, intense sadness even months or years after a tragedy, but as time goes by more time should pass between feelings of sadness. Kids who lose close friends learn, over time, to live with their grief. Continue to acknowledge your teen’s feelings of loss and continue to be available for your teen. Initial depression usually fades into sadness in a month’s time.

It is normal for the death of a classmate to trigger, for the first time, your teen’s contemplation of his own mortality. It is normal for him to express fears of his own death.

Normal grief behaviors include:
• Crying
• Talking about their loss
• Wanting to talk to other friends
• Spending more time with friends
• Some might want to be alone with their grief.
• Some kids might want to busy themselves with sports, reading, etc, in order to distract themselves from their grief.
• Temporary altered appetite and difficulty sleeping.
• Temporary difficulty with concentrating on schoolwork.

Abnormal grief behaviors:
• Inability to eat or sleep
• Gaining or losing more than a couple of pounds
• Inability to stop crying
• Refusing to attend school
• Failing classes
• Using alcohol or other drugs to cope with sadness
• Withdrawal from things your teen used to take pleasure in such as sports, hobbies, music, friends, or family.
• Preoccupation with death
• Suicidal thoughts, wishes, or plans

If you see any of these abnormal signs, or you are concerned about how your teen is coping, consult with your pediatrician or a psychologist. For more signs of clinical depression in children, please see our post on child and teenage depression. Also know that the National Suicide Prevention Lifeline is 800-273-8255.

Julie Kardos, MD and Naline Lai, MD
©2014 Two Peds in a Pod®

We gave our kids their back-to-school haircuts, donated their pants that fit like floods, and bought them new folders and notebooks. As shown on our back-to-school supply list photo, back-to-school also means the start of hand sanitizer and tissue season. Yes, it’s time for your child’s yearly flu vaccine. Even if you gave your child a flu vaccine last year, she’ll need another one this season. Not only does the flu or influenza virus (not to be confused with “the stomach bug/stomach flu”) usually come back every season in a slightly different form, but your child’s immunity has waned over the past year. With every flu season, the Centers for Disease Control comes out with new recommendations. Here is a snap shot:

Who needs the flu vaccine?
All children aged 6 months or older, with a few exceptions discussed below, should receive a flu vaccine every year.

How many doses of flu vaccine does my child need this year?

If your child is nine years or older, your child only needs one dose this season.

If your child is younger than nine, your child only needs one dose this season UNLESS:

• This year will be the first time your child receives the flu vaccine. Then, she will need a second (booster) dose at least 4 weeks later.
• Your child skipped last year’s flu vaccine. Then, she may need a booster dose this year. Check with your child’s doctor.

Which type of flu vaccine is better, a shot or the mist (squirt in the nose)?

This year, the Centers for Disease Control suggests,  if available, to give children aged 2-8 years the squirt in the nose. However, if the mist is unavailable, do not delay the vaccine. Give your child a flu shot instead. For older kids, the data is not as clear cut as to which vaccine works better to prevent the flu. Give your child either form of the vaccine.

Who cannot receive the mist?
Kids younger than 2 years; kids with certain medical conditions such as ongoing asthma (wheezing in the past year, or 2 through 4 years of age with asthma) and diabetes; kids undergoing  aspirin therapy; kids who have had influenza antiviral therapy in the last 48 hours; kids with immune deficiencies; and kids around immunosupressed people who require a protective environment (e.g. around people hospitalized in a bone marrow transplant unit), should not receive the mist. These kids should receive the injectable form of flu vaccine. Your child’s doctor can provide the complete list of contraindications.

Who should NOT receive any flu vaccine?
Babies younger than 6 months old and children with severe egg allergy (anaphylaxis) should not receive the flu vaccine.

Our office is slotted to receive our annual supply of flu vaccine in the next few weeks. Our own families have learned to expect the annual flu vaccine with the start of each school year. Now we just need to convince them that they needed the haircuts.

Julie Kardos, MD and Naline Lai, MD
©2014 Two Peds in a Pod®

Friends make birthdays better

I have been musing ever since our hosting site told us they were switching blog platforms. In a blink of an eye, our blog was slated to disappear. The dynamic Two Peds in a Pod community would be plunged into silence. At first, disbelief gave away to intrigue. Was this a sign to change personal paths? As I started to think of all the things I could do with the time that I would have spent writing the blog, my to-do list grew and grew. I could hear my son’s closet, overflowing with outgrown clothing, crying out to be re-organized.

When I told friends of the opportunity to dissolve the blog, I heard time and time again “I think you should save it.” Even friends without children were aghast. When I told my own children that the blog was on the verge of imploding they looked at me blankly and said, “Why would you stop writing for Two Peds?”

Then I remembered the mom who read our article on croup seven times in one night. I remembered Dr. Kardos’s patient whose dad said our strep throat article  helped him decide not to cut his family’s vacation short. I thought of the many times parents thanked me  for posts which allayed their fears of fever.

The blog did eventually stop when the old hosting site went down. But as my friends and family reminded me, the goal of the blog is to positively impact children globally by guiding their caretakers; and by the time the blog went down, we had reached nearly three million views. Two Peds in a Pod is “Practical pediatrics for parents on the go.” After more thought, I decided it would be difficult to accomplish this goal from the back of one of my kid’s closets.

So today, I am happy to post that the stop was just a temporary suspension. I credit my friends and family for reminding me of the original goal of the blog. In particular, thanks to Dr. Kardos. While I was mulling, Dr. Kardos was busy staying up past midnight valiantly importing posts from the rapidly fading old site.

We’re back, albeit a little rough around the edges as we construct the new site. And it’s just in time for our 5th birthday!

Thanks, my friend, Dr. Kardos. I wouldn’t be able to blow those candles out without you.

Happy 5th Birthday Two Peds in a Pod- may there be many more.

Dr. Lai

Naline Lai, MD and Julie Kardos, MD
©2014 Two Peds in a Pod^®

This year we asked our dad readers to help us write our Father’s Day post. They completed this thought: “Before I became a dad, I never thought I’d…”

…Learn to curl hair for cheerleading competitions

…BE RESPONSIBLE

…Become a stay at home dad AND love it so much after everything I’ve been through!!

…Learn all of the names of Thomas The Tank Engine’s friends and the many songs associated with them.

…Have a toys r us in my house.

…Go food shopping at midnight.

…Make so many pancakes on Sunday mornings.

…Volunteer in a dunk tank and have pie thrown at me.

One of our readers summed up his thoughts on becoming a dad:

Since I’ve become a father, nearly seven years and two beautiful daughters later, my life has become a series of jobs that I never thought I would have to tackle. These include:

Beautician: I never thought in a million years that I would be learning how to do pony tails, side pony’s, braids (not that I can braid yet), and painting little finger and toe nails.

Disney Princess Aficionado: At one point in my life I thought I was cool because I knew a lot about beer, how it was made, where it was from, where the best IPA’s were being poured. Now I am “cool” because I know where Mulan lived, and because I know the story about Ariel falling in love with Prince Eric.

Doctor: I am well versed here and can cover almost everything from the simple band-aid application and boo-boo kissing, to the complex answering of why daddy is different and why he gets to go to the bathroom standing up.

Cheerleader: Both of my daughters enjoy participating in sports. It’s been such a great experience to cheer them both on from the side line. I enjoy watching them grow with the sport and gain confidence game after game.

Becoming a father was one of the best choices I have made with my life. I love being a dad, and I look forward to the future dad challenges, good and bad, and beingthe best mentor I can be.

Thank you to our readers for contributing to this post.

Happy Father’s Day!

Julie Kardos, MD and Naline Lai, MD

©2014 Two Peds in a Pod®

Every child with a lemonade stand hopes for hot sunny days to drive in customers. But if your kids squeeze fresh lemons for their stand, make sure they wash their hands after squeezing the lemons. Otherwise, after a sunny day, your child’s hands may turn out looking like the kid’s feet pictured to the left.The juice of some fruits or plants will cause a dark discoloration of the skin if exposed to sunlight. The reaction, called phytophotodermatitis, usually starts a day after the juice comes into contact with the skin. Redness and mild blistering eventually leads into a discoloration which can that can last for months. Citrus fruits are the most common culprits, but wild parsnip, wild dill, wild parsley and buttercups also cause the photosensitivity. Often the initial redness and blistering is missed. The kid in the photo was walking in bare feet on leaves near an apple tree. Makes you almost want to only use powdered lemonade mix…almost.

©2014 Two Peds in a Pod®

Just in time for Field Day and pool openings, today we provide sunburn protection information. 
 
Hot!

Until I became a mother I never thought…

I’d care if a birthday party was cancelled

I’d obsess about bowel movements and gas

I’d remember to reapply sunscreen

I’d bake zucchini muffins and count them as a vegetable serving

I’d wipe someone else’s nose

I’d relearn my most dreaded school subject in order to help my child with homework

I’d feel compelled to ask if anyone needs to go to the bathroom before I go anywhere in a car

I’d go on nauseating upside-down amusement park rides because my kid needed to be accompanied by an adult

I’d spend my Friday night driving and picking up kids from parties and then spend my Saturday morning driving and picking up kids from the ice hockey rink starting at 5:00am.

I’d get to play Tooth Fairy

I’d (try to) answer questions such as “What does God look like?” and “Who was the mom of the first man?”

I’d willingly read the same book out loud night after night after night

And finally-

Until I became a mother I never thought… I’d wipe away tears when reading sappy Mother’s Day cards.

Happy Mother’s Day from your two Peds

Naline Lai, MD and Julie Kardos, MD

©2014 Two Peds in a Pod®