Two Peds in a Pod®

Graduation time and new horizons

This time of year is always a joy as kids graduate and move onward. Having sent off my own children and my patients to daycare, kindergarten, high school and college, I am amazed how the graduations change, but the parental emotions remain the same. In honor of Dr. Kardos’s soon-to-be high school graduate, I share with you a post from years ago… a letter I had written to my child the night before kindergarten, and pointers on easing the transition. Shhh- it’s a surprise. We’ll see when Dr. Kardos notices.— Dr. Lai

My Child,

As we sit, the night before kindergarten, your toes peeking out from under the comforter, I notice that your toes are not so little anymore.

Tomorrow those toes will step up onto to the bus and carry you away from me. Another step towards independence. Another step to a place where I can protect you less. But I do notice that those toes have feet and legs which are getting stronger. You’re not as wobbly as you used to be. Each time you take a step you seem to go farther and farther.

I trust that you will remember what I’ve taught you. Look both ways before you cross the street, chose friends who are nice to you, and whatever happens don’t eat yellow snow. I also trust that there are other eyes and hearts who will watch and guide you.

But that won’t stop me from worrying about each step you take.

Won’t stop me from holding my breath.

Just like when you first started to walk, I’ll always worry when you falter.

I smile because I know you’ll hop up onto the bus tomorrow, proud as punch, laughing and disappearing in a sea of waving hands. I just hope that at some point, those independent feet will proudly walk back and stand beside me.

Maybe it will be when you first gaze into your newborn’s eyes, or maybe it will be when your child climbs onto the bus.

Until then,

I hold my breath each time you take a step.

Love,

Mommy

No matter the stage, even when they are bigger than you, aways remember the basic rules of daycare drop-off:

Always convey to your child that the transition is a positive experience. You give your child cues on how to act in any situation. Better to convey optimism than anxiety.
Take your child and place her into the arms of a loving adult- do not leave her alone in the middle of a room.
Do not linger. Prolonging any tears, only prolongs tears. The faster you leave, the faster happiness will start.
It’s ok to go back and spy on them to reassure yourself that they have stopped crying- just don’t let them see you.

June 3, 2017 by twopedsinapod

Discussing suicide: how much should I tell my kids?

how to breech the topic of suicide

“Hi, it’s me, Hannah. Hannah Baker.” So begins the first episode of 13 Reasons Why, a thirteen installment Netflix series that focuses on the aftermath of the suicide of a 17-year-old high school student. Based on the novel by Jay Asher, the series has sparked quite a bit of debate and concern among parents and mental health professionals. At its best, the series has served as a conversation starter; at its worst, it has glamorized suicide and the fantasy of revenge. At the end of the day, however, an important question remains: How do we talk with our kids about suicide? While many difficult topics have become increasingly safer to discuss, suicide is one that is still shrouded in secrecy and shame. In fact, it is so difficult to talk about that I had a hard time writing this post. Finding the right words about something that often remains unspoken is not an easy task. So if circumstances require it, how are we to explain suicide to our children?

According to the American Foundation for Suicide Prevention, research has shown that over 90% of people who died by suicide had a diagnosable, though not always identified, brain illness at the time of their death. Most often this illness was depression, bipolar disorder, or schizophrenia, and was complicated by substance use and abuse. Just as people die from physical illnesses, they can die as the result of emotional ones. If we can change the narrative about suicide from talking about it as a weakness or character flaw to the unfortunate outcome of a serious, diagnosable, and treatable illness, then it will become easier for us to speak with honesty and compassion.

Telling the truth about any death is important. While it is natural for us adults to want to protect our children from pain, shielding them from the truth or outright lying will undermine their trust and can create a culture of secrecy and shame that can transcend generations. We can protect our children best by offering comfort, reassurance, and simple, honest answers to their questions. It is important to recognize that we adults typically offer more information than our children require. We should start by offering basic information, then let them take the lead on how much they actually want to know.

For young children, your statements may look something like this: “You have seen me crying, that is because I am sad because Uncle Joe has died.” They may not even ask how the death occurred, but if they do, you can say “He died by suicide. That means he killed himself.” The rest of the conversation will depend on the child’s response. With older children, the narrative can follow a similar theme yet use more sophisticated language. The older the child, the more likely they are to ask direct questions. Some examples of honest answers are “Do you know how people have illness in their bodies, like when Grandma had a heart attack and our neighbor had cancer? People can get illness in their brains too, and when that happens, they feel confused, hopeless, and make bad decisions. Uncle Joe didn’t know how to get himself help to stop the pain.” If they ask how the suicide occurred, you can say “With a gun” or “She cut herself.” Sometimes you will have to say “I don’t know. I wish I knew the answer.” Whatever the age of your child, do your best to use simple, truthful language.

Regardless of age, children converse about and process death differently than adults. If you tell your child about a suicide, it is likely that he/she will want to talk about multiple times over the course of days, weeks, or even years. Keep the dialogue open, and check in with them periodically if they have questions. If you find that you or your family is in need of the support of a professional, you might want to consider a bereavement group or a trained professional who specializes in grief. These resources are available through online directories, local hospitals, and the Psychology Today therapist finder. Overall, be aware that providing truthful information, encouraging questions, and offering loving reassurance to your children can allow your family to find the strength to cope with terrible loss.

(Excerpts taken from The American Foundation for Suicide Prevention’s “Talking to Children about Suicide”, www.afsp.org.)

Links:

Sesame Sreet Workshop’s When Families Grieve
The Dougy Center for Grieving Children and Families
The American Foundation for Suicide Prevention
Hands Holding Hearts (Bucks County, PA)
The Jed Foundation

Dina Ricciardi, LSW, ACSW

Guest blogger Dina Ricciardi is a psychotherapist in private practice treating children, adolescents, and adults in Doylestown, PA. She specializes in disordered eating and pediatric and adult anxiety, and is also trained in Sandtray Therapy. Ricciardi is a Licensed Social Worker and a member of the Academy of Certified Social Workers. She can be reached at dina@nourishcounseling.com.

June 1, 2017 by twopedsinapod

Lyme Disease…it’s back

The classic bullseye rash of Lyme

Just like last year, experts are predicting more Lyme disease. While it used to be a pesky disease only in our midatlantic/Lyme Connecticut area of the world, Lyme continues to appear across the northeast and has been reported on the west coast of the United States. According to the American Academy of Pediatric’s Redbook, about fifty percent of reported Lyme disease is during June and July. We’ve already had children come to our office with tick bites concerns, so here’s an update:

Lyme disease is spread to people by blacklegged ticks. Take heart- even in areas where a high percentage of blacklegged ticks carry the bacteria that causes Lyme disease, the risk of getting Lyme from any one infected tick is low. Most of the little critters DON’T carry Lyme disease… but there are an awful lot of ticks out there. Blacklegged ticks are tiny and easy to miss on ourselves and our kids. In the spring, the ticks are in a baby stage (nymph) and can be as small as a poppy seed or sesame seed. To spread disease, the tick has to be attached and feeding on human blood for more than 36 hours, and engorged.

In areas in the United States where Lyme disease is prevalent (New England and Mid-Atlantic states, upper Midwest states such as Minnesota and Wisconsin, and California), parents should be vigilant about searching their children’s bodies daily for ticks and for the rash of early Lyme disease. Tick bites, and therefore the rash as well, especially like to show up on the head, in belt lines, groins, and armpits, but can occur anywhere. When my kids were young, I showered them daily in summer time not just to wash off pool water, sunscreen, and dirt, but also for the opportunity to check them for ticks and rashes. Now that they are older I call through the bathroom door periodically when they shower: “Remember to check for ticks!” Read our post on how to remove ticks from your kids.

“I thought that Lyme is spread by deer ticks and deer are all over my yard.” Nope, it’s not just Bambi that the ticks love. Actually, there are two main types of blacklegged ticks, Ioxdes Scapularis and Ioxdes Pacificus, which both carry Lyme and feed not only on deer, but on small animals such as mice. (Fun fact: Ioxdes Scapularis is known as a deer tick or a bear tick.)

Most kids get the classic rash of Lyme disease at the site of a tick bite. The rash most commonly occurs by 1-2 weeks after the tick bite and is round, flat, and red or pink. It can have some central clearing. The rash typically does not itch or hurt. The key is that the rash expands to more than 5 cm, and can become quite large as seen in the above photo. This finding is helpful because if you think you are seeing a rash of Lyme disease on your child, you can safely wait a few days before bringing your child to the pediatrician because the rash will continue to grow. The Lyme disease rash does not come and then fade in the same day, and the small (a few millimeters) red bump that forms at the tick site within a day of removing a tick is not the Lyme disease rash. Knowing that a rash has been enlarging over a few days helps us diagnose the disease. Some kids have fever, headache, or muscle aches at the same time that the rash appears.

If your child has early localized Lyme disease (just the enlarging red round rash), the diagnosis is made by having a doctor examine your child. Your child does not need blood work because it takes several weeks for a person’s body to make antibodies to the disease, and blood work checks for for antibodies against Lyme disease, not actual disease germs. In other words, the test can be negative (normal) when a child does in fact have early localized Lyme disease.

Other symptoms of early Lyme disease may accompany the rash or can occur even in the absence of the rash. This stage is called Early Disseminated disease. Within about one month from the time of the tick bite, some children with Lyme develop a rash that appears in multiple body sites all at once, not just at the site of the tick bite. Each circular lesion of rash looks like the rash described above, but usually is smaller. Additional symptoms include fever, body aches, headaches, and fatigue without other viral symptoms such as sore throat, runny nose, and cough. Some kids get one-sided facial weakness. Blood testing at this point is more likely to be positive.

The treatment of early Lyme disease is straightforward. The child takes 2-3 weeks of an antibiotic that is known to treat Lyme disease effectively such as amoxicillin or doxycycline. Your pediatrician needs to see the rash and evaluate other symptoms to make the diagnosis. Treatment prevents later complications of the disease. Treated children fortunately do not get “chronic Lyme disease.” Once treatment is started, the rash fades over several days and other symptoms, if present, resolve. Sometimes at the beginning of treatment the child experiences chills, aches, or fever for a day or two. This reaction is normal but you should contact your child’s doctor if it persists for longer.

Later stages of Lyme disease may be treated with the same oral antibiotic as for early Lyme but for 4 weeks instead of 2-3 weeks. The most common symptom of late stage Lyme disease is arthritis (red, swollen, mildly painful joint) of a large joint such as a knee, hip, or shoulder. Some kids just develop joint swelling without pain and the arthritis can come and go.

For some manifestations, IV antibiotics are used. The longest course of treatment is 4 weeks for any stage. Again, children do not develop “chronic Lyme” disease. If symptoms persist despite adequate treatment, sometimes one more course of antibiotics is prescribed, but if symptoms continue, the diagnosis should be questioned. No advantage is shown by longer treatments. Some adults have lingering symptoms of fatigue and aches years after treatment for Lyme disease. While the cause of the symptoms is not understood, we do know that prolonged courses of antibiotics do not affect symptoms.

For kids eight years old or older, if a blacklegged tick has been attached for well over 36 hours and is clearly engorged, and if you live in an area of high rates of Lyme disease-carrying ticks, your pediatrician may in some instances choose to prescribe a one time dose of the antibiotic doxycycline to prevent Lyme disease. The study that this strategy was based on and a few other criteria that are considered in this situation are described here. Your pediatrician can discuss the pros and cons of this treatment.

Bug checks and insect repellent. Protect kids with DEET containing insect repellents. The Centers for Disease Control recommends 10 to 30 percent DEET- higher percent stays on longer. Spray on clothing and exposed areas and do not apply to babies under two months of age. Grab your kids and preform daily bug checks- in particular look in crevices where ticks like to hide such as the groin, armpits, between the toes and check the hair. Ticks can be tough to spot. Dr. Lai once had a elementary school patient who had a blacklegged tick in the middle of his forehead. The mother noticed it at breakfast, tried to brush it off, thought it was a scab and sent the boy to school. Later that day the teacher called saying, “I think your son has a bug on his face.”

Misinformation about this disease abounds, and self proclaimed “Lyme disease experts” play into people’s fears. While pediatricians who practice in Lyme disease endemic areas are usually well versed in Lyme disease, if you feel that you need another opinion about your child’s Lyme disease, the “expert” that you should consult would be a pediatric infectious disease specialist.

For a more detailed discussion of Lyme disease, look to the Center for Disease Control website: www.cdc.gov.

Julie Kardos, MD and Naline Lai, MD

May 21, 2017 by twopedsinapod

Mother’s Day 2017: The Mother Warns the Tornado

Today we bring you a fierce depiction of maternal love, written by poet Catherine Pierce PhD- who is Dr. Kardos’s sister-in-law.
We hope your Mother’s Day is full of flowers and free of tornados.
–Drs. Lai and Kardos

The Mother Warns the Tornado

I know I’ve had more than I deserve.

These lungs that rise and fall without effort,

the husband who sets free house lizards,

this red-doored ranch, my mother on the phone,

the fact that I can eat anything—gouda, popcorn,

massaman curry—without worry. Sometimes

I feel like I’ve been overlooked. Checks

and balances, and I wait for the tally to be evened.

But I am a greedy son of a bitch, and there

I know we are kin. Tornado, this is my child.

Tornado, I won’t say I built him, but I am

his shelter. For months I buoyed him

in the ocean, on the highway; on crowded streets

I learned to walk with my elbows out.

And now he is here, and he is new, and he

is a small moon, an open face, a heart.

Tornado, I want more. Nothing is enough.

Nothing ever is. I will heed the warning

protocol, I will cover him with my body, I will

wait with mattress and flashlight,

but know this: If you come down here—

if you splinter your way through our pines,

if you suck the roof off this red-doored ranch,

if you reach out a smoky arm for my child—

I will turn hacksaw. I will turn grenade.

I will invent for you a throat and choke you.

I will find your stupid wicked whirling

head and cut it off. Do not test me.

If you come down here, I will teach you about

greed and hunger. I will slice you into palm-

sized gusts. Then I will feed you to yourself.

Catherine Pierce
From The Tornado is the World (Saturnalia Books, 2016)

An associate professor and co-director of the creative writing program at Mississippi State, Dr. Pierce has authored three books of poems and won the Mississippi Institute of Arts and Letters Poetry Prize. She is a mom of two young boys.

May 13, 2017 by twopedsinapod

A shred of advice: How to remove splinters

Sometimes a photo is worth a 1,000 words

Hopefully a splinter of the size in the photo is not lurking on your deck this weekend. The only redeeming feature of a splinter this size is that it is easy to yank out.

More often than not, splinters are teensy-weensy and too small to grab with tweezers. If the splinters in your child’s foot are tiny, seem near the surface of the skin, and do not cause much discomfort, simply soak the affected area in warm soapy water several times a day for a few days. Fifteen minutes, twice a day for four days, works for most splinters. Our bodies in general dislike foreign invaders and try to evict them. Water will help draw out splinters by loosening up the skin holding the splinter. This method works well particularly for multiple hair-like splinters such as the ones obtained from sliding down an obstacle course rope. Oil-based salves such as butter will not help pull out splinters. However, an over-the-counter hydrocortisone cream will help calm irritation and a benzocaine-based cream (for kids over two years of age) can help with pain relief.

If a splinter is “grab-able”, gently wash the area with soap and water and pat dry. Don’t soak an area with a “grab-able” wooden splinter for too long because the wood will soften and break apart. Next, wash your own hands and clean a pair of tweezers with rubbing alcohol. Then, grab hold of the splinter and with the tweezers pull smoothly. Take care to avoid breaking the splinter before it comes out.

If the splinter breaks or if you cannot easily grab the end because it does not protrude from the skin, you can sterilize a sewing needle by first boiling it for one minute and then cleaning with rubbing alcohol. Wash the area with the splinter well, then with the needle, pick away at the skin directly above the splinter. Use a magnifying glass if you have to, make sure you have good lighting, and for those middle-age parents like us, grab those reading glasses. Be careful not to go too deep, you will cause bleeding which makes visualization impossible. Continue to separate the skin until you can gently nudge the splinter out with the needle or grab it with your tweezers.

Since any break in the skin is a potential source of infection, after you remove the splinter, wash the wound well with soap and water. Flush the area with running water to remove any dirt that remains in the wound. See our post on wound care for further details on how to prevent infection. If the splinter is particularly dirty or deep, make sure your child’s tetanus shot is up to date. Also, watch for signs of infection over the next few days: redness, pain at the site, or thick discharge from the wound are all reasons to take your child to his doctor for evaluation.

Some splinters are just too difficult for parents to remove. If you are not comfortable removing it yourself of if your child can’t stay still for the extraction procedure, head over to your child’s doctor for removal.

Now you can add “surgeon” to your growing list of parental hats.

Julie Kardos, MD with Naline Lai, MD
©2012 , rev 2016, 2017 Two Peds in a Pod®

May 4, 2017 by twopedsinapod

Allergy eyes: When spring rubs you the wrong way

allergy eyes: note the dark circles, heavy lids and slight redness of the white of the eyes.

It seems like all of the patients we saw this past week had “allergy eyes.” Their eyes looked watery and red, some had crusty stuff in their eyelashes, their eyelids looked mildly swollen, and the kids spent at least half of the office visit rubbing their eyes.

So what to do? Pollen directly irritates eyes, so start with washing the pollen off. One parent told me they applied cool compresses to their 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 and close the windows. 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 (pollen) 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 olopatadine hydrochloride (brand names Pataday and Patanol) 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.

If your child’s eyes lids seem tender and red, especially if their eyes are not itchy, consider that they may not have “allergy” eyes. Perhaps they have an infection in the skin around the eye (periorbital cellulitis), or a stye. Infections in the skin around the eye are particularly worrisome because infection can spread back into the eye socket. Ask your child’s doctor if you are not sure.

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 one morning during allergy season because having a beard and blood shot eyes made him look THIRTY years old. Miserable allergies!

Naline Lai, MD with Julie Kardos, MD
rev 2019 Two Peds in a Pod®

April 30, 2017 by twopedsinapod

Mom guilt: the sunburn

Second degree sunburn

Mom guilt! After a day at the beach with my teenage kids over spring break, ALL THREE of them had some sunburn. Gone are the days when my kids were small squirming toddlers whom I distracted as I reapplied sunscreen to them every two hours. Gone are the days when wearing bright-colored rash guard t-shirts on the beach was cool. I was duped by the “Mom, I’m good!” response when I passed them the sunscreen after the ocean romp and again after they played a sweaty round of beach football. For the first time in my 17 years of Momhood, I found myself giving my kids ibuprofen for sunburn pain.

Don’t fall for the, “Mom, I’m good,” trick—especially in the spring when the sun is strong but the temperature is cool. But in case your kids do get a sunburn, here’s what to do. Remember, a sunburn is still a burn, as you can see in the picture above, which shows a kid with a second degree burn caused from the sun.

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 such as Bacitracin to the raw skin twice daily for a week or two.
We worry about infection, infection and infection. The skin serves as a barrier to germs, so burned damaged skin is prone to infection. 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 over-the-counter hydrocortisone cream to soothe the itch.
Treat the initial pain with oral pain reliever such as acetaminophen or ibuprofen.

Of course, prevention is easier than burn treatment. Always apply sunscreen with an SPF of at least 15 to your children, and reapply often even if it is labeled “waterproof.” Encourage your kids to wear hats and sunglasses. Clothing can protect against sunburn, but when the weather is hot, your kids may complain if you dress them in long sleeves and long pants. For my own kids, I’m hoping their experience over spring break will prompt them to apply sunscreen in the upcoming months.

Julie Kardos, MD and Naline Lai, MD

April 23, 2017 by twopedsinapod

Teething tablet recall and safe alternatives for teething

Amber bead necklace

In light of the recent recall of all lots of Hyland’s teething tablets because of safety concerns, we thought it was time to update parents about how to relieve teething pain.

About seven years ago, we started noticing amber bead necklaces adorning the necks of infants. We also noticed a plastic giraffe named Sophie. These relative newcomers were the latest in a long line of treatments that claim to soothe the discomfort of teething. Some work. Some don’t. And some are dangerous.

Ultimately, the best cure for teething discomfort is the emergence of a tooth. Until then, chewing on a safe toy or cool wash cloth and an occasional dose of acetaminophen or ibuprofen (if over six months old) can be helpful.

Be patient with teething. “Curing” teething does not cure all maladies. In fact, parents should be aware of these symptoms which are NOT caused by teething:

Teething does not cause fever. Fever usually indicates infection somewhere: maybe a simple viral infection such as a cold, or maybe a more severe infection such as pneumonia, but parents should NOT assume that their baby’s fever is caused by teething. These babies could be contagious. Parents should not expose them to others with the false sense of security that they are not spreading germs
Teething does not typically occur in four-month-olds. Usually the first teeth erupts at around six months of age. Some don’t get a tooth until their first birthday. Most drooling and mouthing behavior prior to six months, such as babies putting hands in their mouths, is developmental. Although you may not see a tooth erupt for a few months, babies at this age still enjoy gnawing on a toy.
Teething does not cause diarrhea severe enough to cause dehydration. If a child has severe diarrhea, then he most likely has a severe stomach virus or another medical issue.
Teething does not cause a cough severe enough to increase work of breathing. Babies make more saliva around four months of age and this increased production does result in an occasional cough. But babies never develop problems with breathing or a severe cough as a result of teething. Instead, suspect a cough virus or other cause of cough such as asthma.
Teething does not cause pain severe enough to trigger a change in mental state. Some children get more cranky as their gums swell and redden with erupting teeth. But, if parents cannot console their crying/screaming child, the child likely has another, perhaps more serious, cause of pain and needs an evaluation by her pediatrician.

Safety Concerns

It’s not only the ingredients of teething tablets that we worry about. Many teething devices can turn into choking hazards. If you look at the consumer product safety recalls over the years, many toys are recalled because they have small pieces that can cause gagging or can come off and become a choking hazard.

We worry about amber bead necklaces and maternal teething jewelry. They fit all the potential safety hazard criteria. You never know when a bead will pop off and pose a choking hazard. A general rule of thumb is that anything that can easily fit through a toilet paper tube is small enough to get stuck in a baby’s airway. Additionally, any necklace on a baby could get caught and cause strangulation.

Sophie the giraffe

Also, the FDA has repeatedly warned against the use of topical anesthetics. Benzocaine gels can lead to methhemoglobinemia, a rare but serious and potentially fatal condition. Adults will sometimes use viscous lidocaine prescribed for themselves on a baby’s gums, but any numbness extending to the back of the throat can make it difficult for babies to swallow.

Interestingly, nearly every babyhood malady in the past has been blamed on teething, including seizures, meningitis, and tetanus. According to a 2009 article in Pediatrics in Review, teething was listed as the official cause of death in about five thousand infants in England in the early 1800s. In France from 1600 to 1900, fifty percent of all infant deaths were blamed on teething!

This truth we know for sure: teething causes teeth.

April 20, 2017 by twopedsinapod

Taking the stress out of tests: conquering test anxiety

test stress

This test ticket hangs from the bulletin board of one of Dr. Lai’s kids. Whether its the ACT, SAT or a ten question quiz, testing can provoke anxiety. Today our guest blogger, child psychologist Dr. Jessica Collins, gives tips for calming test anxiety.

Test anxiety is a common source of stress for both students and parents. Despite your best efforts to help your child study more effectively, instructing your child how and what to study may actually increase their anxiety as your suggestions are likely to be based on your own study style preferences. Instead of offering your advice or opinion, we suggest you try some of the following:

Breathe. Help your child relax by practicing diaphragmatic breathing. Diaphragmatic breathing increases oxygen in the bloodstream. It is a way to interrupt the body’s response to stress and promote a relaxation response instead. This strategy can be used before, after and DURING test taking!

Relax. When you are feeling anxious or stressed, one of the ways your body responds is with muscle tension. Progressive Muscle Relaxation (PMR) is a strategy that helps relieve that tension by completing a series of exercises in which you tense your muscles as you breathe in and relax them as you breathe out. PMR can also be used, anytime and anywhere! *

Promote Organization. Before your child begins to study, ensure that he/she has all of the necessary materials (i.e., pens, highlighters, note cards, books). Help your child group his/her study information into categories or test subjects. Organizing information before your child begins to study will allow him/her to spend more time with his/her nose in the books and less time searching for missing papers.

Break It Down. Work backward and help your child identify smaller content areas, within a test subject that he/she can focus on, one at a time. This will help your child feel less overwhelmed and make studying more manageable.

Encourage Time Management. Once your child has organized and identified the test content areas, help your child create a study schedule. Make sure to start studying early. Information is more easily remembered when it is studied for shorter periods of time over a longer time period rather than spending hours cramming for 1 or 2 days. Also, make sure to schedule in study breaks.

State-Dependent Learning. As much as possible, the environment in which your child studies should mimic the test environment. Help your child find a quiet place to study in your home or at the library. Have him/her sit at a desk or table instead of lying on his/her bed. Limit distractions including background noise or music. Use a timer and offer periodic breaks if your child’s testing environment will be doing the same.

Remember the Bigger Picture. Children who experience test anxiety may easily forget how much the test grade counts towards a final grade. Help your child put the test into perspective by highlighting their successes in other areas and how those achievements are linked to future goals. For tests which are used to help determine a child’s future academic placement (e.g., SATs, ACTs, AP exams, etc.), make a list of ALL the other criteria (i.e., letters of recommendation, grades, extracurricular activities) that are also incorporated into applications. The longer the list, the easier it will be for your child to see his/her test score as one factor, out of many, that are used in this decision making process.

It is very common for students to become nervous or anxious when they must take quizzes and tests. By developing effective study skills and engaging in routine practice of relaxation exercises, many child are able conquer test-anxiety.

Jessica Collins, Psy. D.

Dr. Jessica Collins is a licensed PA psychologist who earned her degree from La Salle University. She completed both her internship and fellowship at the Kennedy Krieger Institute and Johns Hopkins School of Medicine in Baltimore, MD, where she specialized in Pediatric Psychology. Currently, Dr. Collins is a clinical psychologist with Children’s Hospital of Philadelphia.

*NOTE: original link to a script to Progressive Muscle Relaxation script is broken, here is one your Two Peds found.

April 6, 2017 by twopedsinapod

Don’t hold your breath! Understand your child’s asthma medications

asthma cartoon Now that spring is finally here, many kids are experiencing the start of spring allergy season, and those allergies are triggering their asthma symptoms.

Perfecting a treatment regimen for a child with asthma can be initially tricky and confusing for parents. But don’t panic. There are simple medication schedules and environmental changes which not only thwart asthma flare ups, but also keep lungs calm between episodes. The goal is to abolish all symptoms of asthma such as cough, wheeze, and chest tightness.

For asthma flares
Albuterol (brand names Proair, Proventil, Ventolin) or levalbuterol (brand name Xopenex): These are the “quick fix” medications. When inhaled, this medicine works directly on the lungs by opening up the millions of tiny airways constricted during an attack. Albuterol is given via nebulizer or inhaler. A nebulizer machine areosolizes albuterol and pipes a mist of medicine into a child’s lungs through a mask or mouth piece.

For kids who use inhalers, we provide a spacer. A spacer is a clear plastic tube about the size of a toilet paper tube which suspends the medication and gives the child time to breathe in the medication slowly. Without a spacer, the administration technique can be tricky and even adults use inhalers incorrectly.

Prednisone/prednisolone (brand names include Prelone, Orapred): Given orally in the form of pills or liquid, this prescription steroid medicine acts to decrease inflammation inside the lungs. This kind of steroid is not the same kind used illegally in athletics. While steroids in the short term can cause side effects such as belly pain and behavior changes, the advantages of improving breathing greatly outweigh these temporary and reversible side effects. However, if your child has received a couple rounds of steroids in the past year, talk to your pediatrician about preventative measures to avoid asthma flares and to avoid the long term side effects of continual steroid use.

Quick environmental changes: One winter a few years ago, a new live Christmas tree triggered an asthma attack in my patient. The only way he felt comfortable breathing in his own home was for the family to get rid of the dusty tree. Smoke and perfume can also spasm lungs. If you know Aunt Mildred smells like a flower factory, run away from her suffocating hug. Kids should avoid smoking and avoid being around others who smoke. And have your kids wash hands and face well or shower off after playing outside to keep the outside allergy triggers, such as pollen, off of your child’s face. The goal is to alleviate allergy symptoms, which can in turn avoid triggering asthma symptoms.

For asthma prevention

Taking preventative, or controller medicines for asthma is like taking a vitamin. They are not “quick fixes” but they can calm lungs and prevent asthma symptoms when used over time.

Inhaled steroids (For example, Flovent, Pulmicort, Qvar) work directly on lungs and do not cause the side effects of oral steroids because they are not absorbed into the rest of the body. These medicines work over time to stop mucus buildup inside the lungs so that the lungs are not as sensitive to triggers such as cold viruses and allergens.

Combination inhalers (such as Advair, Symbicort) contain both a steroid and a longer acting version of the above-mentioned quick fix medications, and are sometimes prescribed to prevent asthma flares.

Monteleukoclast (brand name Singulair), also used to treat nasal allergies, limits the number and severity of asthma attacks by decreasing inflammation. It comes as a tiny pill kids chew or swallow once daily.

Avoid allergy triggers and respiratory irritants such as smoke. Even if you smoke a cigarette outside, smoke clings to clothing and your child can be affected. Treating allergy symptoms with appropriate medication will help avoid asthma attacks as well.

Treat acid reflux appropriately. Sometimes asthma is triggered by reflux, or heartburn. If stomach acid refluxes back up into the food pipe (esophagus), that acid could tickle your child’s airways which lie next to the esophagus.

Avoid respiratory viruses and the flu. Teach your child good hand washing techniques and get yearly flu shots. Parents should schedule their children’s flu vaccines as soon as the vaccines are available.

Some parents are familiar with asthma because they grew up with the condition themselves, but these parents should know that health care providers treat asthma in kids differently than in adults. For example, asthma is one of the few examples where medicine such as albuterol can be dosed higher in young children than in adults. Also, some treatment guidelines have been improved upon recently and may differ from how parents managed their own asthma as children. For example, a doctor friend now in his 50’s said his parent used to give him a substance to induce vomiting during his asthma attacks. After vomiting, the adrenaline rush would open up his airways! Please don’t do that. We can do better.

Hopefully now that allergy season has descended upon us, this information helps you to keep your child’s asthma under good control and helps you to know which medicine to reach for when it flares up.

Julie Kardos, MD and Naline Lai, MD

March 31, 2017 by twopedsinapod

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