Two Peds in a Pod®

Sore throat relief

sore throat

Many times parents bring their children with a sore throat 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 parents say, “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 or milkshakes, on the other hand, feel great on sore throats. Tell your child that the first three sips of a very cold 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 six 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 to 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. The Maalox coats the throat and the benedryl acts as a weak topical anesthetic (pain reliever). Do not use the Maalox formulation which contains bismuth subsalicylate because 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 typically does not cause a bad cough, profuse 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 updated post on this topic.

The following are each a very important sign that a child with a sore throat needs to see a doctor for further evaluation:

1-can’t swallow (kids might even spit out their own saliva)

2-can’t open his mouth fully

3- hurts so much that the pain is not alleviated with the above measures in this post

4- presence of fever 101F or higher for more than 3-4 days

5-is accompanied by a new rash

Please also 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

November 17, 2016 by twopedsinapod

Stop a bully: talk, walk, squawk, and support

photo by Lexi Logan

Can you identify your child in any of these scenarios?

-Your second grader comes off the school bus crying because another student was teasing him the entire ride home about his new glasses.
-Your fifth grader was punched on the school yard by a sixth grader and none of the playground teachers saw it happen. Your child’s friend shoved the older child off your child before more damage was done.
-Your ninth grader keeps missing the school bus so you have to drive her to school. When she comes home from school she uses the bathroom immediately. You find out she avoids the bus and the school bathroom because kids make fun of her in both places.

Whatever your child’s age, when you realize he or she is being bullied you will be outraged. In fact you might be tempted to retaliate against the bully yourself. However, here are more appropriate ways to help your child.

Bullying should never be tolerated. Teach your child how to directly deal with a bully, but be quick to talk also to the adult supervising your child when the bullying occurs. Your child should always feel safe in school, day camp, on a sports team, or any other adult-supervised activity.

Bullies are always in a position of power over their victims; either they are physically larger, older, or more socially popular. Teach your child first to try a strong verbal response (talk) such as “STOP talking to me that way!” or “Don’t DO that to me!” Speaking strongly and looking the bully in the eye may take away some of the bully’s power as well as attract attention of nearby peers or adults who can help your child.

Teach your child to walk away from a fight. Tell him to keep on walking toward a teacher, a classroom, a peer, or anyone else who can offer safety from a bully. Train him to breathe deeply/ignore/de-escalate situations to diffuse a bully’s anger.

Have your child tell a teacher, camp counselor, coach, or other supervising adult about the abuse (squawk) as soon as it occurs. Always encourage your children to talk to you as well. Remember at home to ask your child questions such as “How is school,” “How are your friends,” “Do you know any kids who are being bullied?,” and “Are YOU being bullied?” Dr. Lai always advises her patients to tell as many different adults as possible if he is not feeling safe. Even if one adult is unsure of how to help, sooner or later some one will.

If your child says he is angry at a friend or a classmate, be sure to ask questions that encourage your child to elaborate, such as “Oh, what happened?” or “Did something happen between you?” Listen carefully to his response. He may be taking out his anger at a bully on his own friends. This response is in retaliation for his friend’s failure to protect him from a bully. Also, is your child becoming more reluctant to attend school, “missing” the bus more often and thus requiring a ride, or acting angry or sad more often? Kids who are victims of bullying can act like this.

In school, once you are aware that your child is a victim, talk not only to your child about how she should handle a bully but also alert your child’s teacher and/or school principal about the situation (support). You should tell them in your child’s words what happened, what was said, and be clear that you are asking for more supervision so that the bully has less access to your child. Ask for more supervision during times when there is usually less adult presence such as in the lunchroom or on the schoolyard. Your school may already have a “no bullying” policy. Often, the aggressor gets the heavier consequence in the event of a conflict. Again, children have a right to feel safe in school.

Restore your child’s self-confidence. Bullies pick on kids who are smaller and weaker than they are, physically as well as psychologically. So your child has more positive experiences with kids who do not bully, encourage your child to invite friends over to your home or host a fun group activity (kickball game in your backyard, show a movie/supply popcorn, etc.). Do family activities and show your child that you enjoy spending time with him. Enroll your child in activities that increase his self esteem such as karate, sports, or music lessons. A child who feels good about himself “walks taller” and is less likely to attract a bully

As a parent, you might read this post and think, “Yes, but I’d rather just teach my child to take revenge.” Unfortunately, escalating the situation only breeds anger and in fact may get your child into trouble. Rather than “hate” the bully, help your child see that a bully deep down feels insecure. A bully resorts to making himself feel better by making others feel bad. Teach your child to pity the bully. With your guidance, your child will project self-confidence and a bully will never, ever, be able to touch him.

While the topic of cyper-bullying could occupy an entire separate post, we just want to alert you to the power that social media has over our kids as well. Ask your kids and teens directly about bullying that occurs on-line just as you would ask about bullying at school. Virtual bullying, unfortunately, is just as potentially harmful as in-person bulling, and is a known risk factor for teen suicide. Remind your children how important it is to refrain from revenge: better to disengage from social media than to respond to on-line bullying because your child will leave a permanent footprint on their on-line presence. Lay down the general rule of never posting anything negative (even a simple “dislike”) online.

Help your child talk, walk, squawk and seek support. All kids deserve to feel secure in themselves and in the world around them.

Additional resources:

The American Academy of Pediatrics

Stopbullying.gov—Bully prevention site managed by U.S. Department of Health and Human Services

Cyberbullying Research Center—an organization dedicating to providing up to date information on cyberbullying

Teaching tolerance— a site where parents and educators can learn ways to foster tolerance

Julie Kardos, MD and Naline Lai, MD
© 2016, 2010 Two Peds in a Pod®

November 13, 2016 by twopedsinapod

How to raise an optimist (even in an election year)

In this time of United States “election stress,” we bring back guest bloggers psychologist Dr. Gage and pediatrician Dr. Penaflor’s post on how to build optimism in your children.

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

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.

October 30, 2016 by twopedsinapod

Potty training: the advanced course

Even after potty training, some kids refuse to use the toilet at times

Just when you thought your child graduated from potty training …there’s more

Believe it or not, this post is for parents of kids who are already potty trained. Because sometimes even kids who are potty trained will refuse to use the toilet.

Changes and transitions, such as the start of a new school year, can trigger regression in kids who have been potty trained for years. Now that your children have been back to school for a few weeks take the quiz:

-Does your child come home from school and make a mad dash for the bathroom before he even gets his shoes off or asks you for a snack?

-Does your child stop eating and complain of belly pain after two bites of dinner?

-Does your child’s poop routinely clog your toilet?

-Is your child’s underwear sometimes damp?

-Have you noticed skid marks (small streaks or smears of poop) on your child’s underwear?

If you answer “yes” to ANY of these questions, then read on.

Advanced Potty Training

The main problem many kids encounter is that once school starts, they have a lot of new distractions and can’t be bothered to pee or poop. First, the morning routine might be more rushed. In school, the teacher is teaching. Your kid is interacting with other kids. The school’s bathroom is foreign, and may even have an auto-flush toilet: scary for the newly-trained. And unlike your newly potty-trained toddler who often finds it thrilling to try out every public restroom he sees, kids in school may feel more self-conscious, and not as adventurous, about visiting new bathrooms.

School bathrooms can be smelly, loud, and even places where kids bully each other. Some kids develop an aversion to using the school bathroom. These kids hold their pee and poop all day long until they get home, then run into the house and make a mad dash for the bathroom.

A child’s internal debate

For a kid who becomes overstimulated at school or who develops an aversion to the school bathroom, his bladder and brain have a conversation that goes like this:

Bladder: I am full.

Brain: Hold it, I don’t want to use the bathroom right now.

Bladder: But I REALLY have to pee.

Brain: Tough luck, Bladder, just wait till we get home.

Bladder: But I have no more room for pee!

Brain: Deal with it, Bladder!

So, the bladder has two choices:

1-Bladder overflows, at least enough to relieve a bit of pressure. This causes damp underwear. (For other reasons click here to review our post on damp underwear.)

2-Bladder distends to accommodate more urine and confuses the nerves that supply sensation to the bladder. Kids lose the ability to tell if they have to urinate, which leads to full bladder-emptying accidents, and can lead to urinary tract infections.

A similar discussion can occur between your kid’s brain and his rectum:

Rectum: I am full of poop, Brain. Take us to the bathroom.

Brain: In school? Are you kidding? I am enjoying this game the class is playing/I am embarrassed to poop in school/I am afraid of the school bathroom. HOLD IT!

Rectum: OK, but you’re not going to like how this comes out in the end.

The rectum also has two choices: release just a bit of stool so it doesn’t feel so full and uncomfortable – these are skid marks. OR it will just hold onto the stool, making it larger and harder all the while, so it becomes painful and scary to pass and ultimately clogs the toilet.

This cycle leads to more problems – over time, the distended rectum develops decreased sensation (sound familiar?) and ultimately the child loses the ability to feel when he has to poop. Large poop masses in distended intestines can lead to pain while eating (the kid who eats two bites of dinner, then stops because of belly pain). Poop can leak out without your child knowing because he is unaware of the sensation of the chronically-ignored-full-rectum. In addition, a full rectum will also press on the bladder changing the way the brain is sensing whether or not to void.

How can we parents prevent these problems?

Remind your child to use the bathroom upon waking up in the morning and again before leaving the house for school. Even if he says he does not have to go, tell him to “Just check- sit for 2 minutes.”

Ask your child if he uses the bathroom in school. Preschool and early elementary school teachers often have scheduled bathroom breaks, but then it’s entirely up to your child to remember to use the bathroom. Encourage him to stop in the bathroom around lunch time in school.

Once home from school, remind your child to use the bathroom or “just check” if he hasn’t already done so.

If you leave the house again for an after-school activity, insist that he “just check” again to decrease your chances of having to use another “foreign” toilet.

Incorporate a potty check into your child’s bedtime routine, even if he went relatively recently. Ideally the healthy bladder empties four to six times a day and the healthy bowel easily passes a stool at least once a day or every other day.

Because boys usually stand to urinate, remind them to sit at least once or twice a day, even if they don’t feel the urge to poop. As a mom of three boys, trust me: they often surprise themselves.

Even middle school and high school kids can have these problems. Suggest to your older child who, for whatever reason, avoids school bathrooms, that she can stop by the school nurse’s office to use the bathroom. She could also get up in the middle of class, if needed, and use the bathroom when it is most likely to be empty of other students, unlike during change-of-class time.

School cafeteria food and snacks provided at sports or other after school activities are not always healthy and can contribute to making stools too hard, so make sure to provide healthy choices at home with plenty of fruits and vegetables. Teach your kids to avoid too many cookies and other high fat foods – these are constipating foods. Encourage water-drinking. Caffeine-containing drinks (ice tea, soda) cause excess urine production and thus more stress on the bladder that your child might already be forcing to “hold it” for too long.

As for the children who frequently run to the bathroom in the daytime, but only pee a tiny bit, beware of something called urinary frequency syndrome.

Final exam

1-Does your child use the bathroom regularly, without stress or pain?

2-Can your child “go with the flow” in school as well as home, without any toilet clogging?

3-At the end of the day, is your child’s underwear without urine or skid marks?

If you can answer YES to all of the above, then you and your child have passed advanced potty training!

Julie Kardos, MD and Naline Lai, MD
© 2016 Two Peds in a Pod®

October 27, 2016 by twopedsinapod

Potty training 101: the nuts and bolts

teddy-bear-potty-training A shout out to Trinity Day School in Solebury, PA where we spoke with a group of parents yesterday about the pearls and pitfalls of potty training. Today we share some of what we discussed.

At Trinity day School

“Will it ever end?” many parents ask. Time moves in slow motion for parents teaching their kids to use the potty. For those trapped in a potty training time warp, take heart. It’s been seven years since we first released out podcast on potty training and we’re proud to report that the parents who first listened to that podcast have moved onto new parenting challenges like helping with homework. For those in the midst of training, and those who are contemplating training, this post is for you.

Children master potty training typically between the ages of two and four years. Be patient, not everyone is “typical.” More important than your child’s age is whether she shows she is developmentally ready to train. These signs include:

– is generally agreeable/ can follow directions.

– gets a funny expression before passing urine or poop, or runs and hides, then produces a wet or soiled diaper.

-asks to be changed/ pulls on her diaper when it becomes wet or soiled- remains dry during the day time for at least two hours (look for a dry diaper after nap time.)

-NOT because grandparents are pressuring you to start training their grandchild.

– NOT if the child is constipated—the last thing you want to do is to teach withholding to a kid who already withholds.

-NOT if a newborn sibling has just joined the family. A new baby in the house is often a time of REGRESSION, not progression. However, if your toddler begs to use the potty at this time, then by all means, allow him to try.

Make the potty a friendly place. Have a supply of books to occupy your child while she sits. Make sure her feet are secure on the floor if using a potty chair or on a stool if using the actual toilet. If using the real toilet for training, consider placing a potty training rim on the toilet seat to prevent your child from jack-knifing into the toilet. If your child is afraid of the bathroom, put the potty chair in the hall just OUTSIDE of the bathroom.

Have reasonable expectations based on age. A two year old’s attention span is two minutes. Never force your child to sit on the potty. If he doesn’t want to sit, then he isn’t ready to train.

Your can lead a horse to water… Reward your child for sitting on the potty, even if she does not “produce.” Reward by giving a high-five, verbal praise, or a small, cheap trinket such as a sticker. Do NOT promise your child a trip to Disney for potty training—otherwise, what will you do when she learns to ride a bike or tie her shoes? Plus, unless you are prepared to leave right away, the toddler/preschooler does not developmentally understand the concept of long term reward. Accept that she may simply enjoy sitting fully clothing on the potty while singing at the top of her lungs for a few weeks.

Let your child learn by imitation At home, have an open door bathroom policy so she can imitate you and her older siblings. At school, she will imitate her potty-trained classmates.

Initially, kids rarely tell their parents they “have to use the potty.” For these kids, schedule potty visits every 2-3 hours throughout the day. Do potty checks at key times such as first waking up, right before nap, and before bedtime. Be sure to spend extra time a half an hour after meals or after a warm bath. Both meals and warmth stimulate poop!

A child is potty trained when she can do the whole deal: use the potty, help wipe, help un-dress and re-dress, and wash hands.

If the child refuses to wash hands after using the potty, she is not trained. Ultimately, the goal is for her to gain independent toileting skills. However, she will need your supervision for a while.

Important note for parents of BOYS: First potty train your son to sit for ALL business. Teach him to gently press his penis downward so pee lands in the toilet and not all over the room. Once your son stands up to urinate, he may become so excited that he may never sit down again. Better to wait until he uses the potty consistently with few accidents before teaching him to stand up. Even after he begins to stands to pee, have him sit on the potty daily to allow him time to poop.

Don‘t be surprised if your child trains for pee before poop. In fact, many kids go through a phase when they ask for a diaper to poop in. After all, it’s frightening to see/feel a chunk of your body fall into an abyss. Dump the poop from the diaper into the potty and practice waving bye-bye.

A note about night time and naps: Potty train for when your child is awake. Your child will spontaneously, without any training, stay dry at night and during naps. Some kids sleep more soundly than others and some kids are not genetically programmed to stay dry overnight until they are elementary school aged. For more information about bed-wetting please see our post on this topic. No amount of daytime training will affect what happens during sleep. Moderate fluids right before bed and continue putting on the diapers at night until you notice that the diapers are dry when your child wakes up. After a week of dry mornings, try your child in underwear overnight. Occasional accidents are normal for years after potty training, so you might want to put a water proof liner under your child’s sheets when first graduating to sleep underwear.

Disposable training pants: We like sticking to underwear while potty trainers are awake and diapers while asleep. A reluctant trainer tends to find training pants just absorbent enough that he does not care if he is wet. However, the pants are not absorbent enough to prevent rashes from stool or urine. Plus they are more expensive than underwear AND diapers. Explain to your child “sleep diapers” are perfectly acceptable until their “pee pee learns to wake them up.” Use the training pants when your child is older and is mortified by the idea of a diaper or if your family is going on a long car ride and you don’t want to risk urine on a car seat.

Above all: avoid power struggles. If potty training causes tears, tantrums, or confusion then STOP TRAINING, put those diapers back on, and try again a few weeks later.

After the training, keep an eye on how often he pees and poops. Older kids get “too busy” to go to the potty. Make sure he is in the habit of emptying his bladder four to six times a day and having a soft bowel movement every day or every other day.

Ultimately… you just have to go with the flow. And remember, everything eventually comes out right in the end.

Julie Kardos, MD and Naline Lai, MD
©2016, 2013 Two Peds in a Pod®

October 21, 2016 by twopedsinapod

Local Peeps, come talk with us about Potty Training!

potty-training We invite you to come out on Thursday, October 20, from 9:30 to 10:30am when we will lead a discussion for parents about a topic near and dear to all toddler parents’ hearts. Join us for Potty Training: Pearls and Pitfalls at Trinity Day School in Solebury, PA, 6587 York Rd, Upper Solebury, PA. This talk is FREE & open to the community. Attendees from outside the school must pre-register by emailing dayschool@trinitysolebury.org with “Potty Training Talk” in the subject. There’s even a potty training basket that they will raffle off at this event.

We are excited about the talk. And we are thrilled to be the inspiration for a potty training basket!

Julie Kardos, MD and Naline Lai, MD

October 16, 2016 by twopedsinapod

A story of life and hope

www.twopedsinapod.org

At this time of the Jewish High Holy Days, Dr. Kardos offers us a glimpse into lessons learned as a doctor in training. This is a true story she wrote years after meeting Beth and, until recently, had only shared with a few close friends.

Tonight starts Yom Kippur and my two youngest children are asleep in their beds. As my oldest sits in the rocker next to my desk reading the last book in the Lord of the Rings series, my husband relaxes playing a computer adventure game. The Jewish High Holy Days are a time for reflection about the past year. But my mind goes back to a Yom Kippur Eve when I was working as a resident in the Pediatric Intensive Care Unit (PICU) as part of my pediatric training.

Residents work through most holidays, even ones they consider important. This night, I wished I had off, but I consoled myself with knowing that I would be off on Thanksgiving. Luckily I was partnered with Amy, the lead physician in the PICU.

The sickest patient that night was twelve-year-old Beth. She had leukemia and had just started chemotherapy. Because her immune system was weak, Beth was very ill with a bacterial infection in her blood. Despite powerful antibiotics, the infection raised havoc in her body. She developed such difficulty breathing that a tube from a mechanical ventilator was placed down her throat to force air into her lungs. Even the comfort of sleep escaped her. Beth was afraid of what was happening to her body. She refused to accept medicine that could help her sleep because she was so afraid that she would never wake up.

That night, despite her incredibly ill state, she got her period. Usually when a girl’s body is stressed, the body preserves all blood and the periods stop. But hers came, and because her blood cells were so abnormal from a toxic combination of infection, chemotherapy, and leukemia, she began bleeding to death. We transfused her with bag after bag of blood to keep her alive.

In the middle of the night, Beth’s blood pressure suddenly plummeted so we added even more medication. Because my mentor Amy was not certain that Beth would survive the night, we called her family at the hotel near the hospital where they were staying and told them come to Beth’s side. And through it all, Beth refused to sleep. Her eyes always opened in terror whenever we approached her bed. Her face was gray. Her chest rose and fell to the rhythm of the mechanical ventilator, and you could smell the fear all around her.

I stood with Amy just outside Beth’s room as Amy reviewed a checklist for Beth’s care. It went something like: “Ok, we just called blood bank for more blood; we called her family; we called the lab; we called the pharmacy. We are currently attending to all of her problems, we now just have to wait for her body to respond.” She paused,” But you know what?”

“What?” I asked her.

“We need to address her spiritual needs as well. Do we know what religion her family is? They may want a clergy member with them.”

I was startled. In the midst of all the tubes and wires of technology, Amy remembered to summon the human factor in medicine. We looked in her medical chart under “religious preference” and there it was: Jewish.

“Amy,” I said, “of all nights. Tonight is Yom Kippur…the holiest night of the Jewish year.”

I knew that the hospital had a Rabbi “on call” just like they had priests, nuns, ministers, and other spiritual leaders. But that night I was sure that every rabbi in Philadelphia would be at synagogue for Kol Nidre, the declaration chanted at the beginning of the Yom Kippur evening service. We were unlikely to track down a Rabbi.

Despite this, we asked her mother if they wanted us to call a Rabbi for them. She shook her head no. I remember feeling relieved, then guilty that I felt relieved. Amy left to check on another patient. Beth’s mom, dad, and older sister stood together watching Beth. Her sister’s hand lay on her mother’s arm. Her mother’s eyes darted from me to Beth to the mechanical ventilator next to the bed. Beth’s eyes were closed and it was difficult to know if she even knew we were there.

Her family walked out into the hall to talk. Beth at that moment opened her eyes and started tapping on the bed with her foot to get my attention. She couldn’t talk because of the tube down her throat and her hands were taped down with IVs. Yet she reached out with one hand as best she could.

I walked close to her bed so she could touch me and I asked, what is it, Beth?

Her lips formed the words around the breathing tube very deliberately, her body tensing. “Am I going to die?”

All in a split second I am thinking to myself: How do I know/it could very well happen/how can I lie to her/how can I tell her the truth of what I fear could very well happen/how am I going to answer this child?

What I answered was, “Not tonight, Beth.”

She relaxed into her pillow but kept her eyes on mine. I waited to see if she would say anything else, but the effort to ask that one question had exhausted her. I stood, holding her hand, until her family came back into the room. Her eyes followed them to her bed and I left so they could be together.

Beth did survive the night and in fact survived a month in the PICU. She became well enough to be transferred to a regular hospital floor. By this time I was working in a different part of the hospital, but one of the oncologists pointed her out to me.

I don’t know what happened to her in the long term.

So now I tell my oldest child it’s time for him to stop reading and go to sleep, and I walk him to his room to say goodnight. My husband and I decide what time we’ll attend Yom Kippur services tomorrow. Part of me feels joined with Jews everywhere who will also be spending the next day reflecting, praying and celebrating a new year. But mostly, like every year at this time, I remember the sounds and the smells and the fear in the PICU where sickness doesn’t care who your God is or what your intentions are. I remember Amy caring enough to think about a dying child’s family religion, and always, I remember Beth.

Originally posted in fall, 2010

October 9, 2016 by twopedsinapod

How to transition to milk in a cup

photo by Lexi Logan

While “drinks from a cup” is often listed as a developmental milestone for one-year-olds, it is a good idea to start teaching this skill BEFORE your child’s first birthday. Go ahead and introduce a cup when you baby is around six months old.

Here’s why six months is a great time to start a cup:

Six-month-olds are starting to sit propped and even unsupported
Six-month-olds can bring their hands together and pull most objects into their mouths – this is why baby proofing is so important starting at this age as well!
Six-months-olds are usually not afraid or wary of new things, new experiences, or new people. As an example, when I walk into the exam room and start examining a 6-month-old baby, he usually smiles and “talks” to me. When I hand him 2 wooden tongue depressors to play with, he reaches for them eagerly and puts them into his mouth as soon as he grabs them. In contrast, a 9-month-old or one-year-old will often look back at his dad when I enter the room, he might cry when I go to examine him, and may eyeball the wooden tongue depressors suspiciously.
One-year-olds are much more willful and oppositional than 6-month-olds and so may balk at a new way of drinking.

“You mean a “sippy cup, right?”

We have an entire post devoted to sippy cups but the short of it is that even babies as young as 6 months can start learning to drink out of open cups. Parents have told me that their 6-month-old will pull their mom’s water bottle to his mouth and drink from it.

The origin of the non-spill sippy cup:

According to this article in the New York Times , mechanical engineer and dad Richard Belanger first developed his own non-spillable cup because he was tired of always cleaning up his toddler’s spills. In other words, he developed the cups for parents with an aversion to mess, not as a “stepping stone” for kids learning to drink out of a cup. His non-spill cups were specifically for kids who already drank out of open cups but often spilled them. He eventually pitched his prototype to Playtex, and the rest is history: non-spillable sippy cups are now ingrained into toddler culture.

So, when parents of my patients lament, “My child throws the sippy cup away! He won’t suck from it!” I smile and answer, ok, take the vacuum seal or valve out or skip the sippy cup and just give a regular open cup.

WHAT should you put in the cup?

Water is a great choice. It is healthy and does not stain so is easy to clean when your new cup-user spills it.

You can put formula or breastmilk in the cup if you want, but don’t worry if your baby won’t drink it. Remember, you are not replacing bottles or nursing yet, you are simply adding a cup.

After your child turns one year, you can put whole or two-percent cow’s milk (reduced- fat milk) in the cup. No need for toddler formulas. Your pediatrician will guide you as whether to start with whole or the two-percent.

How much milk do kids need in their cups?

Remember that once your child weans from breast milk or formula, she no longer receives a lot of iron through cow’s milk. In fact, the calcium in milk hinders iron absorption from food, so be sure to cap your child at 24 ounces of milk per day and give iron rich foods.

Most juice, even 100% juice, has the same sugar content as soda (such as Coke or Sprite), so juice is not a great choice of beverage for kids. Children should eat fruit but most do not need to drink juice.

Do I have to mix cow’s milk in with the formula or breast milk to “get my child used to it?”

Not at all! Think about how you fed your baby solid foods. You didn’t have to, for example, start with cereal and then mix every other food into the cereal. Just start cow’s milk in a cup alongside your last supply of formula in a bottle or at the same time you are still giving breast milk. For social reasons and to make it easier for yourself later, offer “big kid milk” in cups and “baby milk” in bottles. Then when you stop giving formula, you won’t need to continue to give (and wash- ugh!) bottles anymore!

One trendy question we hear these days is: Can I give raw milk in the cup?

The answer is: NO.

Raw milk contains many bacteria, such as salmonella, Listeria, and E.coli. The reason we pasteurize milk is to get the bacterial count down. Out of 121 dairy-related outbreaks in the US reported between 1993 and 2006, 73 (60 percent) were linked to raw dairy, despite the fact that only about 3 percent of the dairy products consumed in the U.S. was unpasteurized. These statistics prompted the American Academy of Pediatrics to issue a statement in 2013 recommending against raw milk.

If your child won’t drink cow’s milk, that’s ok too. Cow’s milk is a convenient, but not a necessary, source of protein, fat, vitamin D, and calcium, all of which are found in other foods.

If your child is allergic to dairy or is lactose intolerant, you can offer almond milk, soy milk, or even no milk.

After one year of age, it’s fine if water is the only fluid your child drinks. He can get all of his nutrition from food. Liquid intake is more for hydration than for sustenance.

A word about vitamin D: Even though cow’s milk is fortified with vitamin D, continue to provide a vitamin D supplement. The recommended daily allowance of vitamin D intake starting at one year of age is 600 IU a day. Since most toddler/child vitamins contain 400 IU per tablet/gummy, most kids will take in the recommended daily allowance of 600 IU a day if they drink some milk and take any of the over-the counter chewable vitamins. If your child does not drink any milk or you prefer not to give a supplement, 600 IU a day can be achieved through yogurt or cheese that is vitamin D fortified as well as vitamin D containing foods such as salmon and shiitake mushrooms ( I know, I know… shiitake mushrooms are not usually a toddler favorite).

Beware of Grazing: Just as a “dieter’s trick” is to drink eight ounces of water prior to meals to curb the appetite, too much fluid = less appetite for solids. Grazing in the day or at night hinders picky eaters from eating. Additionally, grazing milk promotes dental caries (cavities) because milk sugar constantly bathes the teeth. Even if your child initially drinks a bedtime cup of milk, remember to always brush his teeth afterwards and to eventually stop offering milk before bed. Your goal is to offer the cup with meals or snacks. Your child does not need a cup in between.

We hope this post quenched your thirst for knowledge about transitioning to a cup!

Julie Kardos, MD and Naline Lai, MD

October 6, 2016 by twopedsinapod

Where the boys are: raising emotionally healthy sons

photo by Lexi Logan, www.lexilogan.com

We welcome back guest blogger Dina Ricciardo LSW, ACSW who addresses how to support the emotional health of a boy — Drs. Kardos and Lai

Your son is crying. A mad dash across the playground has led to a spectacular trip and fall, complete with a bloody knee and hands full of dirt. Part of you wants to hold him on your lap and console him until he stops crying. The other part of you wants to firmly wipe away his tears and tell him to be brave. Which part of you is right?

In a world where there is a great deal of emphasis placed on the emotional health of girls, our boys are frequently overlooked. While girls are typically encouraged to develop and express a broad range of emotions, boys are socialized from a young age to suppress their feelings. As a result, many boys and men struggle to express fear or sadness and are unable to ask for help. It is time for us adults to stop perpetuating stereotypes and myths about manhood, and help each other raise emotionally healthy boys. Here are five ways for us to do so:

Make his living environment a safe space to express emotions. Give your son permission to express all of his feelings. Boys typically do not have the freedom to show the full range of their emotions in school and out in the world, so it is essential that they have that freedom at home. Nothing should be off limits, as long as feelings are expressed in a manner that is not destructive.

Expose him to positive male role models. Boys need to be exposed to positive male figures who can to indoctrinate them into their culture and teach them how to be men. It is an important rite of passage in a boy’s development. Take a look around your social ecosystem and ask yourself, “Who would be good for my son?” Other parents, coaches, teachers, and pastors are examples of individuals who can play a positive role in his life.

Understand your unique role. Each parent plays a unique role in the development of a son, and that role changes over time. A mother is a son’s first teacher about love and what it looks like, and this dynamic can breed a particular kind of closeness. As a boy grows and begins to develop his sexuality, however, it is natural for him to pull away a bit from his mother and turn more towards his father for guidance. While this distance can be unsettling for mom, it marks a new phase in a son’s relationship with his father, who typically provides a sense of security and authority in a family as well as support for a boy’s developing identity. Mothers still play an important role, but that role may look different. As parents, it is important to re-evaluate what our sons need from us at each stage of their development.

Look at the world with a critical eye. Our culture not only glorifies violence, it equates vulnerability in males with weakness and attempts to crush it. That does not mean we have to accept this paradigm. Talk honestly with your son about how and when to be gentle and compassionate, educate him on how the world view softness in men, and never tolerate anyone shaming him when he exhibits these traits. There is no shame in showing vulnerability, it is actually an act of courage.

Take a look in the mirror. Whether you are a mother or a father (or both), be honest with yourself: what are your beliefs about manhood? Do you feel safe expressing all of your feelings, or are some of them off-limits? If you are perpetuating negative stereotypes about men or are not comfortable with a full range of emotions, then your son will follow in your footsteps. Regardless of our own gender, we cannot expect our children to be comfortable with their feelings if we are not comfortable with our own.

There are times when insuring the emotional health of your son will feel like an uphill battle. Keep the conversation open, and do not be afraid to talk with others about the dilemmas of boyhood and manhood. And if you are looking for an answer to the playground dilemma, then I will tell you that both parts of you are right. Sometimes our sons need loving compassion, and sometimes they need a firm nudge over the hump. You know your child better than anyone else, so it is up to you to decide which approach to use and when.

Dina Ricciardi, LSW, ACSW

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.

September 25, 2016 by twopedsinapod

When your child says, “My belly hurts”

This week Two Peds joined Kelley on her blog Happy Health Kids as she talked about the dreaded phrase, “My belly hurts.”

If I crunched the numbers on how often my kids have uttered certain phrases, “my belly hurts,” ranks pretty darn high. So common is this refrain, and typically uneventful the outcome, that there’s a cry-wolf quality to it; I typically point my child towards the pantry or bathroom and go about my day. But sometimes, a stomachache persists, and then figuring out the cause can be like falling into a rabbit hole (and equally unpleasant)….click here to continue

September 18, 2016 by twopedsinapod

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