On our minds: Concussions

concussions in kids Dr. Lai will be up at Brown University this weekend giving a primary care pediatrician’s perspective on concussions (traumatic brain injuries) at a parent forum. A lot has changed since you were a kid. As she prepared, we mulled over questions we commonly encounter and thought we’d pass them on to our parents:

What is a concussion? A concussion is an injury to the brain which does not show up on head scans such as CT Scans and MRIs. Think of a concussion like a sprained ankle, but instead of an injury to the ankle, it’s an injury to the brain. Just like an ankle sprain, it may not show up on X-ray, but your child is affected by the injury.

What are the signs of a concussion? Immediately after a head injury, we first look for signs of bleeding in the head. After we know there is not any bleeding, we look for signs of a concussion. Concussions affect kids physically, cognitively, and emotionally. Common symptoms include persistent head ache, nausea, fatigue, sleep disturbances, light and noise sensitivity, balance problems, difficulty with memory, difficulty with concentration, and emotional lability. Parents often describe their children as moving or thinking slowly- as if they were in a fog. Teens and young adults tend to belittle any injury, so if your kid tells you that she hit her head when you weren’t around, scrutinize your child very closely. If you “just know” your kid is not 100 percent his baseline, then she probably has a concussion.

How long is recovery?

In the not-so-old days we would clear kids for athletics 2 weeks after a teen had a normal neurological exam and symptoms disappeared. But the prescription for recovery has changed. Now there is a new emphasis on brain rest and returning a kid to school before returning to sports. Just like you rest a sprained ankle, doctors now recommend resting the brain. For the brain, that means no thinking or concentrating. Examples of prohibited activities include texting, video games, and homework. Interestingly TV watching is considered mindless enough to be permitted during the period of brain rest. Once there are no symptoms we allow a little more brain activity in a stepwise fashion until a kid can return to school. Only then can a kid consider starting a stepwise program to return to playing sports. For most kids, recovery takes about a month. Kids with baseline neurological issues such as migraines or attention deficit hyperactivity disorder tend to take longer to recover fully.

I’ve heard it’s dangerous to hit your head again before you have fully recovered from a concussion- is that true? YES! The scary stuff you hear about possible brain swelling and death if a concussion occurs on top of a concussion is not just internet mumbo-jumbo. Called second-impact syndrome, these secondary concussions occur during a window of vulnerability while the brain is healing from an initial concussion.

How many concussions can you have before there is permanent brain damage? There is still a lot of research that still needs to be done on concussions and this is one area where people are actively seeking answers. So far, studies in youth are unclear on the impact of repetitive concussions and the development of long term neurodegenerative diseases.

My kid wears a helmet or mouth guard to prevent concussions-right? While helmets and mouth guards help prevent skull fractures and jaw dislocations, current designs do little to prevent concussions.

I’m not going to keep my kid wrapped in bubble wrap, but do some activities pose a greater concussion risk than others? While there is still a paucity of sports data at the grade school and middle school level, we do know that according to the Centers for Disease Control (CDC), over half of concussions in those under 14 years old are caused by falls. Boys’ football followed by girls’ soccer lead the injury rate amongst high school athletes according to a 2010 paper published in Pediatrics .

I have seen kids receive concussions from standing too close to swing sets, concussions from sudden stops on school busses, and from jumping off beds. Once, a parent came into my office dazed after hitting her head on her trunk door in my parking lot. So, concussions can occur in any activity. The most important “take-away” is to take head injuries seriously and learn to recognize and report concussions.

For more information on concussions the pathway to recovery, please visit the CDC website and the Children’s Hospital of Philadelphia webite.

See you up at Brown.

Naline Lai, MD with Julie Kardos, MD

Sunscreens and sunburns: your burning questions answered

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

Hot!

Pictured is a kid with a second degree burn. No, this burn wasn’t caused by hot water or by touching the stove, but by the sun. A sunburn is still a burn, even if it was caused by sunlight.

Treat sunburn the same as you would any burn:

Apply a cool compress or soak in cool water.
Do NOT break any blister that forms- the skin under the blister is clean and germ free. Once the blister breaks on its own, prevent infection by carefully trimming away the dead skin (this is not painful because dead skin has no working nerves) and clean with mild soap and water 2 times per day.
You can apply antibiotic ointment to the raw skin twice daily for a week or two.
Signs of infection include increased pain, pus, and increased redness around the burn site.
A September 2010 Annals of Emergency Medicine review article found no best method for dressing a burn. In general, try to minimize pain and prevent skin from sticking to dressings by applying generous amounts of antibiotic ointment. Look for non adherent dressings in the store (e.g. Telfa™). The dressings look like big versions of the plastic covered pad in the middle of a Band aid®.
At first, the new skin may be lighter or darker than the surrounding skin. You will not know what the scar ultimately will look like for 6-12 months.
If the skin peels and becomes itchy after a few days, you can apply moisturizer and/or hydrocortisone cream to soothe the itch.
Treat the initial pain with oral pain reliever such as acetaminophen or ibuprofen.

Preventing sunburn is much easier, more effective, and less painful than treating sunburn.

What is SPF? Which one should be applied to children?

SPF stands for Sun Protection Factor. SPF gives you an idea of how long it may take you to burn. SPF of 15 means you will take 15 times longer to burn… if you would burn after one minute in the sun, that’s only 15 minutes of protection!

The American Academy of Pediatrics recommends applying a minimum of SPF 15 to children, while the American Academy of Dermatology recommends a minimum of SPF 30. Dr. Lai and I both apply sunscreen with SPF 30 to our own kids.

Apply all sunscreen liberally and often– at least every two hours. More important than the SPF is how often you reapply the sunscreen. All sunscreen will slide off of a sweaty, wet kid. Even if the label says “waterproof,” reapply after swimming.

Why does the bottle of sunscreen say to ask the doctor about applying sunscreen to babies under 6 months of age?

Sunscreens were not safety-tested in babies younger than 6 months of age, so the old advice was not to use sunscreen under this age. The latest American Academy of Pediatrics recommendation is that it is more prudent to avoid sunburn in this young age group than to worry about possible problems from sunscreen. While shade and clothing are the best defenses against sun damage, you can also use sunscreen to exposed body areas.
Some clothes are more effective than others in blocking out sunlight. Tighter weaves protect better than loose weaves. Cotton t-shirts are horrible for sun protection. Clothing uses a UPF rating. UPF measures the amount of UV light that reaches your skin. Higher numbers are better. For example, a rating of 100 means that 1/100, or one percent of UV rays reach your skin.
Hats help prevent burns as well.
Remember that babies burn more easily than older kids because their skin is thinner.

Which brand of sunscreen is best for babies and kids?

For babies and kids, no one brand of sun screen is better than another. Dr. Lai and I tell our patients to apply a “test patch” the size of a quarter to an arm or leg of your baby and wait a few hours. If no rash appears, then use the sunscreen on whatever body parts you can’t keep covered by clothing.

Remember when we used to call sun screen lotion “suntan lotion,” and tolerating red, blistering shoulders was considered a small price to pay for a tan? Live and learn.

Julie Kardos, MD with Naline Lai, MD
©2014 Two Peds in a Pod®
Originally posted 6/19/2013

Until I became a mother I never thought…

mother hen cartoon 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

Avoid Allergy Eyes

Arrggh, sitting on top of kid’s items that need to be returned to Target are the allergy eye drops that need to go back to the pharmacy. With growing kids, it’s an endless cycle of buy-return-buy-return. I suppose I was duped by the sale price, but the drops which contain “red out” ingredients are not appropriate for long term use. Hoping the post below doesn’t have you running back and forth from the store this allergy season:

allergy eyes

“I see green stuff all over my car and I park in the garage,” a mom said to me today.

It’s finally spring on the east coast and with it comes green cars and itchy eyes. Eighty percent of the older kids I saw today, including those seen for routine check-ups, had red irritated eyes.

So what to do? Pollen directly irritates eyes, so start with washing the pollen off. One parent told me he applied cool compresses to his child’s eyes. This is not enough- get the pollen off. Plain tap water works as well as a saline rinse. Have your child take a shower. Filter the pollen out of your house by running the air conditioning. Pollen counts tend to be higher in the morning, so plan outdoor activities for later in the day. Some people will leave shoes outside the house and wipe the paws of their dogs in order to keep the green stuff from tracking into the house.

Oral medications do not help the eyes as much as topical eye drops. Over-the-counter antihistamine drops include ketotifen fumarate (eg. Zatidor and Alaway). Prescription drops such as Pataday or Optivar add a second ingredient called a mast cell stabilizer. Avoid use of a product which contains a vasoconstictor (look on the label or ask the pharmacist) for more than two to three days to avoid rebound redness. Contacts can be worn with some eye drops– first check the package insert. Place drops in a few minutes before putting in contacts and avoid wearing contacts when the eyes are red.

Hopefully allergy season will blow through soon. After all, as a couple teens pointed out-prom is around the corner and allergies can make even the young look haggard. One teen male told his mom that he shaved today because having a beard and blood shot eyes made him look THIRTY years old. Miserable allergies!

Naline Lai, MD with Julie Kardos, MD
modified from a 2011 post, ©2014 Two Peds in a Pod®

I have Autism.

According to the latest CDC report, 1 in 68 children have some form of autism. April 2 is World Autism Awareness Day, and today we post, with permission, a speech that a 15-year-old friend of mine with autism gave to his classmates when school started last year.
—Dr. Kardos

Good morning everybody. Today, I wanted to talk to you about Autism. I have Autism. Don’t worry, it’s not something you can catch from me… it’s not a like a virus or anything like that. When I was very young, a doctor diagnosed me with Autism. My parents took me to the doctor because I didn’t talk much – I talked a lot less than kids were supposed to. Actually, I still talk a lot less than other kids.

A lot of people think things about Autism that just aren’t true. They really shouldn’t because everybody is different and has different things they do well. Actually, I am pretty smart. So are a lot of my friends with Autism. I just have a hard time with words. So reading, writing, and speaking are kind of hard, but I’m very good at math, science and stuff like that.

Every person with Autism has different things that they do well and other things that they have trouble with. For me, like I said, I have a hard time with words, I have a hard time remembering people’s names, and sometimes, I may have trouble knowing if someone is joking with me. You may see me walking around by myself – sometimes I pace back and forth when I’m thinking. I also sometimes flap my hands when I get excited or frustrated. So, if you see me doing that, just come over and say “Hey, Rob!” or something like that to me. That usually helps me stop right away. It may look funny, but really everybody does this a little bit. Other people may jump up and down when they are excited or clench up when they get angry. Unfortunately, I flap. But don’t worry, I’m OK.

Other than that stuff, I am just like everybody else. I really like movies and music. I go to concerts all the time… the next concert I’m going to is Bruno Mars. By the way, if anyone likes Bruno Mars, let me know – my sister doesn’t want to go… so we have a free ticket!

That’s really all I have to say. Just remember that you shouldn’t judge anyone without getting to know him or her. I’m just a normal kid that happens to have Autism. I don’t mind if you don’t mind.

Thanks for letting me tell you about myself. Does anyone have any questions?

Robbie

2014 Two Peds in a Pod®

Poison Control 1-800-222-1222

Put poison control’s phone number on the back of your cell phone, on your cell phone case, and on your wall phone. Put it everywhere: 1–800-222-1222.

Did your toddler eat dog food? Or a berry from your backyard bush? Did you give the wrong medication to your child? Call poison control. Experts at poison control will direct your next step. They have access to extensive data on poisoning, and they can give you that information much quicker than a drug-manufacturer or pharmacist or even your own doctor. One of Dr. Lai’s kids ate a mushroom from the yard when she was 20 months old—she called poison control. A mom asked Dr. Lai about carbon monoxide exposure—she called poison control. If doctors have a question about any ingestion or poisoning—we call poison control. But don’t wait for us to call, go ahead yourself and call.
People often first jump to the internet for information. However, a recent small study found that the internet is NOT the best place to research questions about toxins. Many sites fail to direct readers to the US Poison Control Center, and those who do, fail to supply the proper phone number – again, that’s 1–800-222-1222.

If your child needs emergent treatment, surfing the internet for what to do next wastes precious time. Don’t reach for your phone to “google it,” in the case of a possible poisoning, reach for your phone and make a CALL. It could be life-saving.

Julie Kardos, MD and Naline Lai, MD

Dry chapped hands- home remedies

I wash my hands about sixty times a day, maybe more. This frequent washing, in combination with cold Pennsylvania air, leads to chapped hands.

To prevent dry hands:

• Don’t stop washing your hands, but do use a moisturizer afterwards.

• Whenever possible, use water and soap rather than hand sanitizers. Hand sanitizers are at minimum 60% alcohol- very drying. Be sure to fully dry hands after washing.

• Wear gloves or mittens as much as possible outside even if the temperature is above freezing. Remember chemistry class- cold air holds less moisture than warm air and therefore is unkind to skin. Gloves will prevent some moisture loss.

• Before exposure to any possible irritants such as the chlorine in a swimming pool, protect the hands by layering heavy lotion (Eucerin cream) or petroleum based product (i.e. Vaseline or Aquaphor) over the skin.

To rescue dry hands:

• Prior to bedtime, smother hands in 1% hydrocortisone ointment. Avoid the cream formulation. Creams tend to sting if there are any open cracks. Take old socks, cut out thumb holes and have your child sleep at night with the sock on his hands. Repeat nightly for up to a week. Alternatively, for mildly chapped hands, use a petroleum oil based product such as Vaseline or Aquaphor in place of the hydrocortisone.

• If your child has underlying eczema, prevent your child from scratching his hands. An antihistamine such as diphenhydramine (Benadryl) or cetirizine (Zyrtec) will take the edge off the itch. Keep his nails trimmed to avoid further damage from scratching.

• For extremely raw hands, your child’s doctor may prescribe a stronger cream and if there are signs of a bacterial skin infection, your child’s doctor may prescribe an antibiotic.

Happy moisturizing. Remember how much fun it was to smear glue on your hands and then peel off the dried glue? It’s not so fun when your skin really is peeling.

Naline Lai, MD and Julie Kardos, MD
©2014 Two Peds in a Pod®
Adapted from our 2009 post

Pseudo flu

Award-winning journalist, mystery book author, and syndicated humor columnist Nicole Loughan interviews Two Peds about the “stomach flu” vs “real flu.”
Drs. Lai and Kardos

Despite up to date flu shots, my children and I found ourselves holding our hair back and praying to the porcelain goddess last week. I wondered why this terrible flu had happened to us? This rhetorical question usually just lingers, but this time, I had a chance to get answers and took it. I got the ear of Dr. Naline Lai, MD, FAAP and Julie Kardos, MD, FAAP from Two Peds in a Pod and cornered them about why exactly my brood and I experienced a terrible flu this season, and what we could have done to prevent it, and what’s to blame for it.

Click here to read on.

Nicole Loughan

Nicole writes for two daily newspapers in the Greater Philadelphia area, blogs as “The Starter Mom,” and has two books out: To Murder a Saint and All Saints’ Secret. She is the mom of two young children.

Avoid Carbon Monoxide poisoning

More polar vortex! Here in Bucks County, PA, we are recovering from power outages and preparing for yet another winter blast. As the generators are started up, we remind our readers about a potentially deadly exposure.

Unfortunately, one of the biggest winter hazards is not loud and obvious. As the temperature drops, deaths rise from this insidious poisonous gas: carbon monoxide.

According to the Centers for Disease Control, about 400 unintentional deaths occur a year from carbon monoxide poisoning.

Carbon monoxide results from the incomplete combustion of fuel. The gas causes a chemical suffocation by competing with oxygen in your body. The colorless, odorless gas is impossible for human senses to detect, and unfortunately, loss of consciousness usually occurs before any symptoms appear. Those lucky enough to have warning symptoms before passing out may experience headaches, nausea, vomiting, or confusion.

Because carbon monoxide is a by-product of incomplete combustion, sources are related to energy use. Poisoning occurs more during the winter months when fuel is used to heat closed spaces and ventilation from exhausts is poor. My sister, toxicologist and Harvard medical school instructor, Dr. Melisa Lai, tells the story of a snowplow operator a few years ago who left the house early in the morning to plow snow, only to return and find his family dead. The reason—snow blocked the exhaust pipe from the furnace and caused lethal levels of carbon monoxide to accumulate in his home.

Carbon monoxide also occurs in warm weather. To avoid carbon monoxide buildup in all climates:

–Install carbon monoxide detectors. My sister says a $20 detector such as Kidde works as well as the $150 models. Put them on every level of your home and check that the batteries work. Smoke detectors are not the same as carbon monoxide detectors. However, combination detectors are available.

–Ventilate all appliances, heating units, and your chimney adequately. Have them serviced yearly.

–Shovel well around vents: While some furnaces vent out of a home’s chimney, other vents are located just two feet off the ground on the side of the house. If these vents become blocked with snow, deadly carbon monoxide levels can build up inside the home. Aim for three feet of snow clearance around the vents.

–Be wary of the exhaust from of any vehicle.

Parents have put their infants in running cars while they shovel snow, unaware that the car’s tailpipe is covered in snow. By the time they return to the car, the infant, who is extremely susceptible to carbon monoxide poisoning because of his size, is dead. Even opening the garage door when you run your car is not enough ventilation to prevent poisoning.

Like cars, boats also produce carbon monoxide. Since boats are less energy efficient than cars, they spew more of the gas. While your teen boogie boards behind a motor boat, the carbon monoxide can knock her tumbling unconscious into the water.

–Keep anything meant to burn fuel outdoors, OUTDOORS. Even an innocent barbeque can turn into a nightmare if you decide to grill inside your garage. Emissions from any type of grill, charcoal or gas, can send carbon monoxide levels skyrocketing. Additionally, hurricane season in the southern United States is known by toxicologists as “Carbon Monoxide Season.” During hurricanes (as with winter storms), people buy outdoor generators and auxiliary heating units. They work so well that people then bring them indoors, trapping fumes in their homes.

My sister says she has hundreds of stories about carbon monoxide poisoning, all which end tragically. Maybe I’ll let my husband store that larger-than-life-take-up-car-space neighborhood snow blower here this winter. Then, at least I know I’ll be able to make sure no one starts up the blower in a garage.

For more details please visit http://www.cdc.gov/co/faqs.htm.

Adapted from our 2010 post

Raising an optimist

If you are in a part of the United States affected by the polar vortex shift, it’s tough to stay sanguine about the weather. How to create an optimistic child who can look at the “warm” side of winter? Guest bloggers psychologist Dr. Gage and pediatrician Dr. Penaflor join us today with ideas.

Recently, my daughter’s friend announced before a race, “I’m just not going to try my best.”

Why would a child give up before even starting? Why such pessimism?

It turns out that her friend’s mother would say after every race, “You just didn’t meet your potential. Did you at least beat Sarah (a fellow competitor)?”

This scenario illustrates how a parent who constantly gives negative responses can build pessimism in a child.

Why is optimism important?

An optimistic child is strong, enterprising, and resilient. He or she does not wait passively for good things to happen to him or her. The optimist consciously plans, works hard to make things happen, and persists through challenges.

Research shows important benefits:

• A healthier heart and a greater ability to fight infections and survive disease

• Better response to stress

• Less likelihood to develop anxiety and depression

• More success in school, sports, social and recreational activities

• Greater accomplishments in life

• Higher motivation to keep on trying even when things get tough

How do I begin?

Does your child tend toward optimism or pessimism? Is the glass half empty or half full? Which would your child say, “It doesn’t matter… I won’t get it right anyway,” or “I did my best… I’ll get it next time”? Optimism is a learned skill that you can teach your child at home.

Here are some important tips.

Model positive behaviors and attitudes.

“This is tough, but I can do it!”

“I will find that lost pair of socks!”

Create an environment that fosters love and trust.

When children have a sense of security and trust at home, they view the world as a positive place to explore and try new things.

Encourage your child to view life in a positive way and to rise above negativity.

For example, one of our favorite techniques is “Rise up! Don’t dwell on it.” If someone did or said something hurtful to your child, teach your child to pause. Have her ask herself “How important is it? Will it matter in 5 minutes, 5 months, or in 5 years?” Think of the big picture.

Another is to approach mistakes calmly. Say “Oops!” and move on.

Validate your child’s feelings of disappointment or sadness, but teach your child that failures and mistakes are opportunities to learn and do something different and better.

After all, in life “Sometimes you win, sometimes you learn.”

Patricia Gage, PhD, NCSP and Gina Penaflor, MD, FAAP

Dr. Patricia Gage runs Brain Smart Academics, her own private practice as a school psychologist in Stuart, Florida, and has taken the lead in many charitable organizations that help promote children’s social/emotional wellness and women’s health. Dr. Gina Penaflor, mother of a school-aged child, tween and teen, is a primary care pediatrician in South Florida with a background in emergency and hospital medicine. She and Pat have combined their knowledge and experiences to create a Hang-In-There educational card series. Their mission is to help busy moms and dads lead a more rewarding (and less stressful!) parenting experience.

To learn more, please visit their website at www.HangNthere.com or Facebook page, or e-mail them at busymoms@HangNthere.com.