Two Peds in a Pod®

Baby and toddler nails: Tricks for managing your munchkin’s mani-pedi

The prom preparation aftermath

It’s not your imagination: baby and toddler nails are funky and warped. Now add the fact that babies and toddlers wiggle and squirm, and taking care of your young child’s nails will appear to be a daunting task.

Even soft newborn finger nails leave significant scratches on newborn faces. Newborns need their first “manicure” within days of birth. Although the nails are long enough to scratch, most of the nail is adherent to underlying skin. A nail clipper can not get underneath the edge of the nail easily. We recommend using an emery board or nail file for the first few weeks of nail trimming. File from the bottom up, not just across the nail, in order to shorten and dull the nail.

Babies gain weight rapidly in the first three months at a rate of about one ounce per day, and they grow in length at a rate of about an inch per month. Their finger nails grow rapidly as well and therefore need trims as often as two or three times a week. Toe nails grow quickly as well but because they do not cause self-injury, infants seem to be okay with less frequent toe nail trimming.

Once the nails are easier to grab, you can advance to using nails scissors or clippers. Dr. Kardos used to hold her babies in a nearly sitting position on her lap facing outward. Once you have a good hold, gently press the skin down away from the nails and then clip or cut carefully.

Unfortunately, no matter how careful you are, many well-intentioned parents end up cutting their child’s skin at some point. Both Dr. Kardos and Dr. Lai have nicked their kids accidentaly. Dr. Kardos recalls snipping a bit of skin from one of her twins when he was a few months old. Picture a tiny benign paper-cut that seems to cause a disproportunate amount of bleeding. He wasn’t even all that upset, but the guilt! If you accidentally cut your child, wash the cut with soap and running water to prevent infection and apply pressure for a few minutes with a clean wash cloth to stop the bleeding. Avoid band-aids: they are a choking hazard in babies who spend most of their waking moments with their fingers in their mouths. Thankfully, rapidly growing kids heal wounds rapidly.

While Dr. Lai gave most of her kids manicures while they were sleeping, Dr. Kardos trimmed her kids’ nails while awake to get them used to the feeling of a “home manicure.” She likes to think this practice avoided some later toddler meltdowns over nail trimming. However, as she found out in one of her three kids, some kids are just adverse to nail trimming, or have sensitive, ticklish feet and balk at trims. Yet, trim we must! Clip an uncooperative toddler’s nails about 10-20 minutes after she has fallen asleep- this, or wait until you have another adult at home with you. Have your helper hold onto your child’s hand or foot while distracting the toddler with singing, book reading, or watching a soothing video together. Then you can (quickly) trim nails.

However, even in infants, the sides of big toe nails grow into the skin. Luckily the nails are very soft, and with some soaking in warm water, you can pull the skin away from the nail and cut the nail to avoid having them dig in and result in infection, or paronychia.

While it’s tempting to complete your child’s mani-pedi with a coat of nail polish, keep in mind that a young children spend a lot of time with their hands, and their toes, in their mouths. We’ve seen kids as old as ten years bite on their toe nails. Unfortunately, the nail polish on your bureau may contain toxic hydrocarbons such as toluene and formaldehyde. Even non-toxic nail polishes will still contain dyes, and just because a manufacturer uses the term non-toxic, it doesn’t necessarily mean a product is absolutely harmless. There are no specific standards for the use of the term non-toxic. Bottom line, the only route that avoids any chemicals is not to apply any polish in the first place. (If you are wondering about any cosmetic, the California department of public health keeps a database of cosmetics with ” ingredients known or suspected to cause cancer, birth defects, or other reproductive harm.” )

Who ever thought parental obligations would include cutting someone else’s finger and toe nails? If you haven’t perfected the process yet, take heart. You’ll have plenty of practice over the years, and if you are lucky, you’ll get a chance like Dr. Lai did last weekend to help prep nails for the prom.

Julie Kardos, MD and Naline Lai, MD

June 2, 2016 by twopedsinapod

Pleeeease- can we get a dog?

getting a pet Many of our patients have dogs in their homes, and many families choose to adopt a dog during summer. Unfortunately, dog bite rates are also highest in summer, and occur most often in five to nine year olds, according to the Centers for Disease Control. Today we re-post tips on how to introduce a dog into a home with children and how to best avoid dog bites. We thank our expert consultant, veterinarian Sharin Skolnik, DVM.

–Julie Kardos, MD and Naline Lai, MD

Two Peds: Are some breeds of dogs better for children?

Dr. Skolnik: Breed recommendations are tough, because there are such different personalities within every breed. Breeds bred to protect will tend to guard their family, but may not be friendly with other kids. I have had to euthanize golden retrievers and labs for severe aggression, and know some truly stellar pit bulls. I would like every family bringing a dog into their home to think about how much time and energy they can devote to the following: exercise/walks/play dates/ mental stimulation, grooming, feeding, veterinary care, and arranging travel concerns/contingency plans. If I had to pick a good family breed, I would suggest a Cavalier King Charles spaniel, but only if you forced me to pick one! Choosing the right dog for your family is the first big step, but do many people think about what comes with getting a new member of the family?

Two Peds: Any suggestions for screening a dog before bringing it into the family?

Dr. Skolnik: Many rescue groups use experienced foster homes to get an idea of where a dog is at before placement, which is wonderful. Look for a puppy or dog that is not too hyper or timid, unless you have the time and energy to devote to modifying these behaviors. Inquisitive but not pushy is ideal. Having said that, dogs are incredibly trainable in the right hands. Use care when bathing, feeding, or taking things away from a newly adopted dog. Trust is a two-way deal, and positive and gentle first interactions will set the stage for the relationship.

Two Peds: Why are young kids prone to dog bites by the family dog?

Dr. Skolnik: Many factors: kids are usually very bad at reading dog body language. For that matter, many adults I meet think that a wagging tail indicates a friendly dog, when in fact it means the dog is willing to interact, positively or negatively. Kids are usually loud and move unpredictably and quickly. Never leave kids and dogs unsupervised, because the kids may not understand how to be gentle and respectful of the dog. It is important to set clear and consistent expectations for both kids and dogs on what counts as acceptable behavior.

Two Peds: What should parents teach their children about approaching a dog?

Dr. Skolnik: Teach them to always ask an owner’s permission with unknown dogs. Look for “soft” features like relaxed ears, floppy wagging tail, wiggling body. Tense body, rigid tail (wagging or not), backing up, dilated pupils– leave that dog alone. Supervision by responsible adults is key.

Two Peds: How can a dog be taught to “respect” a child?

Dr. Skolnik: The same way dogs learn to leave people’s houses and other pets alone. “Claim” items as yours, and not the dog’s, while meeting their needs. When I adopt a new dog: Guinea pigs/cats/shoes/etc. are mine. Every time the dog shows an interest in one of these things, he is told firmly “No.” The dog is given plenty of walks through the woods, praise for desired behaviors, some one-on-one time, and a few weeks later and we usually are on the same page. Consistency in training is key. The dog can’t be allowed to chase the cat when you are not home, so keep them separated! Set the dog up for praise, gently but firmly correct missteps, don’t overcorrect or correct after the fact. The latter only increase anxiety and the likelihood of future behavior problems

A common mistake in dog discipline is relying too much on punishment/ negative corrections and ignoring “good” behavior. For example; yelling at the dog for grabbing at the kids’ clothes, hands, whatever and ignoring the dog when it is chewing one of its own toys. Dogs are pack creatures; they rarely will play by themselves. Single-dog homes especially need to budget enough time each day to meet the dog’s mental and physical needs.

Two Peds: Should a dog that bites a kid be given a second chance? Can dogs be rehabilitated?

Dr. Skolnik: Depends on the scenario. A very forward dog with a history of unprovoked aggression towards kids is going to require a huge commitment to prevent injury and likely needs to go where there are no children, or humanely put to sleep. Most vets are pretty intolerant of dog aggression towards children. Now if an adult dog unfamiliar with kids snaps when a kid grabs an ear, or tries to take something away, or if the dog gave some warning that the kid should back off– I would blame the adults that put those two in the situation. Dogs (and people) can be rehabilitated, but there will always be the possibility of relapse. There are no guarantees with behavior modification.

Sharin Skolnik, DVM, holds a Bachelor’s degree from Cornell University School of Agriculture and Life Science and a veterinary degree from University of Pennsylvania School of Veterinary Medicine. She has been practicing veterinary medicine for over 20 years and is a member of the AVMA and the NJVMA. She currently works at Chesterfield Veterinary Clinic in Bordentown, New Jersey.

Her “children” include horses, dogs, cats, guinea pigs, hamsters, sheep, chickens, and rabbits. She is also a long time friend of Dr. Kardos’s. Their children play well together under close supervision.

May 22, 2016 by twopedsinapod

Pretty earrings- but what you see in the back will surprise you

We see this a couple times a year… an earring which looks fine when viewed from the front…

earring

…is actually embedded when viewed from the back. When you flip up this child’s ear lobe, you will notice how the skin has nearly completely engulfed the earring back. Young children heal well and the skin in the back of an ear can grow over the back of an earring fairly easily. So, change earrings often and “watch their backs.” It’s not enough just to spin the earrings around from the front.

embedded earring back

Naline Lai, MD and Julie Kardos, MD

May 20, 2016 by twopedsinapod

Mom “nose” best: Happy Mother’s Day 2016

elephant nose

This Mother’s Day, we honor Dr. Kardos’s mom, who passed earlier this year.

Dr. Kardos and I had been planning a post on nasal congestion in kids, but because we couldn’t have said it any better, we share a poem that Dr. Kardos’s mom wrote on this topic.

–Drs. Lai and Kardos

Runny Noses

My grandsons seem always to have runny noses;

They drip from their noses and land on their toeses;

One kid especially, his name is Aaron,

Will hug you so tight that what’s runnin’ you’re sharin’.

Alex will wipe with the back of his hand;

His runs in the house, on the beach, on the sand.

Jacob is older and he’ll use a tissue,

So his runny nose is not much of an issue.

In case they have colds, I hand each one a sweater,

But wearing a sweater does not make things better.

Allergic to dust? That’s the answer I’m seeking;

But while I keep dusting, their noses keep leaking.

They eat well and sleep well and play hard all day

In spite of their dripping that won’t go away.

So I’ve come to conclude, and I’m happy to say

That the noses of kids prob’ly just come that way.

by Felice Kardos (1943-2016)

May 7, 2016 by twopedsinapod

The best sunscreen: questions answered

An inadvertent sunburn tattoo

I was greatly relieved recently when my teen arrived back from a music department trip to Disney without a sunburn. I had pictured a bright red cherry tomato coming off the plane. For those of us stuck in the middle of an East Coast perpetual rain cloud, it’s hard to believe that anyone outside of the South needs to worry about sunscreen. But soon enough, you will be scratching your head in a pharmacy aisle asking yourselves these questions:

What is SPF?

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 without sunscreen. 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. We both apply sunscreen with SPF 30 to our own kids (mom hint: the high SPF sunscreens tend to be watery).
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.
Watch out for sunlight reflecting off water as well as sunburning on cool days. One pediatrician mom I know was aghast at seeing signs posted at her kid’s school reminding parents to apply sun screen “because it will be in the 80’s.” Kids burn on 60 degree days too. Lower temperatures do not necessarily mean less UV light.

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 on exposed body areas.
Clothing helps to block out sunlight. In general, tighter weaves protect better than loose weaves. Expensive “sun-protective clothing” is not always better— a study from 2014 suggests regular clothing may be as protective.
Hats help prevent burns as well.
Remember that babies burn more easily than older kids.

Which brand of sunscreen is best for babies and kids?

Although clothing and shade block harmful rays the best, no one brand of sunscreen is better for children than another. We both 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. Look for UVA and UVB protection. More expensive does not always mean “better” and SPF above 50, according to the American Academy of Dermatology, has not been proven to be more effective than 50.

What do we know about the ingredients in sunscreen such as oxybenzone? In the United States sunscreen ingredients are considered medications and are regulated by the FDA. Oxybenzone is one of the oldest broad-spectrum (UVA and UVB) sunscreens, and was approved by the FDA in 1978. Oxybenzone’s main side effect is that it can cause allergic reactions of the skin. Recently, some people question whether oxybenzone can be a hormone disrupter and have questioned the use of oxybenzone. At this point, no hormonal disturbances have been clearly found in humans and the American Academy of Dermatology continues to support the use of oxybenzone.

Sunscreens made with zinc oxide and titanium dioxide (the white stuff on a lifeguard’s nose) have not garnered any questions nor sparked any debate about safety. Interestingly, zinc oxide is not only an effective sunscreen but also you will recognize it as the main ingredient in many newborn diaper rash creams.

Any info about the popular sprays? For spray formulations of any type of sunscreen, many doctors are concerned that any aerosolized oily substance will irritate the lungs and are looking into long term effects now. Avoid spraying sun screen near a child’s head to avoid inhalation. Also with the spray, some dermatologists worry that people might not be as thorough when they apply a spray as when they apply a cream.

Can I use last year’s sunscreen? Most sunscreens have expiration dates, as long as your bottle hasn’t expired, then it should be effective. In general, sunscreens are designed to last about three years before they expire.

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

Naline Lai, MD and Julie Kardos
Two Peds in a Pod® rev ©2016 , 2015

May 7, 2016 by twopedsinapod

The best antihistamine for your kid

Lately, whenever I take my dog for her walk, she sneezes as soon as we get outside. I find it interesting that my vet says I can give her Claritin—the same dose that I take for my own seasonal allergies. Must be time to repost our allergy medicine post featuring Dr. Lai’s poem.

–Drs. Kardos and Lai

The Quest for the Best (antihistamine)

Junior’s nose is starting to twitch
His nose and his eyes are starting to itch.
As those boogies flow , you ask oh why, oh why can’t he learn to blow?
It’s nice to finally see the sun
But the influx of pollen is no fun.
Up at night, he’s had no rest,
But which antihistamine is the best?

It’s a riddle with a straight forward answer. The best antihistamine, or “allergy medicine” is the one which works best for your child with the fewest side effects. Overall, I don’t find much of a difference between how well one antihistamine works versus another for my patients. However, I do find a big difference in side effects.

Oral antihistamines differ mostly by how long they last, how well they help the itchiness, and their side effect profile. During an allergic reaction, antihistamines block one of the agents responsible for producing swelling and secretions in your child’s body, called histamine. Prescription antihistamines are not necessarily “stronger.” In fact, at this point there are very few prescription antihistamines. Most of what you see over-the-counter was by prescription only just a few years ago. And unlike some medications, the recommended dosage over-the-counter is the same as what we used to give when we wrote prescriptions for them.

The oldest category, the first generation antihistamines work well at drying up nasal secretions and stopping itchiness but don’t tend to last as long and often make kids very sleepy. Diphendydramine (brand name Benadryl) is the best known medicine in this category. It lasts only about six hours and can make people so tired that it is the main ingredient for many over-the-counter adult sleep aids. Occasionally, kids become “hyper” and are unable to sleep after taking this medicine. Another first generation antihistamine is Clemastine (eg.brand name Tavist).

The newer second generation antihistamines cause less sedation and are conveniently dosed only once a day. Loratadine (eg. brand name Alavert, Claritin) is biochemically more removed from diphenhydramine than Cetirizine (eg. brand Zyrtec) and runs a slightly less risk of sleepiness. However, Cetirizine tends to be a better at stopping itchiness.
Now over-the-counter, fexofenadine (eg brand name Allegra) is a third generation antihistamine. Theoretically, because a third generation antihistamine is chemically the farthest removed from a first generation antihistamine, it causes the least amount of sedation. The jury is still out.

If you find your child’s allergies are breaking through oral antihistamines, discuss adding a different category of oral allergy medication, eye drops or nasal sprays with your pediatrician.
Because of decongestant side effects in children, avoid using an antihistamine and decongestant mix (often, first generation antihistamines such as brompheniramine are combined in this fashion).

Back to our antihistamine poem:

Too many choices, some make kids tired,
Paradoxically, some make them wired.
Maybe while watering flowers with a hose,
I’ll just turn the nozzle and wash his nose.

Naline Lai, MD with Julie Kardos, MD

Updated from the original post April 10, 2011

April 25, 2016 by twopedsinapod

Update on Lyme disease: Is it bug-check season in your area of the United States?

The classic bullseye rash of Lyme

Our infectious disease colleagues warn us that this year, winter in the Northeast United States was not cold enough for long enough to kill off as many ticks as usual. Thus, we folks in Pennsylvania are in for a more burdensome Lyme disease season. We’ve already had children come to our office this spring with concerns of tick bites, so here’s an update on Lyme disease:

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. Niney-nine percent 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. In order 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 primary Lyme disease (enlarging red round rash), the diagnosis is made by a doctor examining 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 tests 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 Lyme disease.

The second phase of Lyme disease occurs if it is not treated in the primary phase. It occurs about one month from the time of tick bite. Children develop a rash that looks like the primary rash but 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 primary rash but typically 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 the fever but no rash. Some kids get one-sided facial weakness. This stage is called Early Disseminated disease and is treated similarly to the way that Early Lyme disease is treated- with a few weeks of antibiotics.

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 to make the diagnosis. This treatment prevents later complications of the disease. While the disease can progress if no treatment is undertaken, fortunately children do not get “chronic Lyme disease.” Once treatment is started, the rash fades over several days. 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 3-4 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. 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. Be suspicious of random scabs. 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 could 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

*link corrected 4/18/2016

April 17, 2016 by twopedsinapod

Rolling along: Teach your child to ride a bike

Helmets on, ready to roll
photo credit: Sylvia Aptacy pixabay

About 95 percent of all Americans know how to ride a bike and who taught them? Probably their parents. Joining us today is frequent guest blogger Dr. Deb Stack with pointers on teaching your kid how to ride. – Drs. Lai and Kardos

I live in beautiful Bucks County, PA, an area known for its rolling hills, bike paths and covered bridges. With spring here, it’s a great time to head out for a family ride.

Yet with less outdoor playtime, more and more children are struggling with learning to ride. A child’s readiness is very individual. My own children ranged in age from 6-11 years old when they learned. Interestingly, my oldest learned by hopping on a friend’s bike and being pushed down a gentle, grassy hill by the neighborhood children while I huddled out of sight around the corner. It turns out, their technique was right.

Riding a bike is an interplay of several components:

INTEREST – if the child is not interested, it is not time to try.
ABILITY to maintain PEDALing at a walking speed at least, even with distraction.
ABILITY to BALANCE when sitting.
STEERING
STARTING and STOPPING

After making sure your child is interested, check the bike:

The seat should be low enough that the rider can place both feet flat on the ground at the same time.

If there are hand brakes, the brake to the front wheel should be disconnected. This will prevent the rider from accidently squeezing only the front brake and being sent over the handlebars.

Remove the pedals or practice balancing on a Skuut bike, or balance bike, (two-wheeler without pedals). These are readily available and not too costly, but tend to be needed for only a short time.

Mountain bikes or BMX style bikes are not recommended for learning. Look for a bike where the pedals are nearly directly under the seat and the child does not have to raise the knees too high at the top of the pedal cycle.

Wear a helmet and make sure it is securely fastened under the chin.

Location: Look for a gently sloping grass hill (the kids were right!) or a large, fairly level, empty parking lot

What to do:

1. Practice pedaling separately if possible. Try a trike or stationary bike and practice pedaling at a steady rate and even singing or carrying on a conversation without stopping before heading out to try a two-wheeler.
2. Practice balancing: Use both feet to push off the ground and glide forward as far as the rider is able. Have the rider place feet down if he feels uncomfortable and then push again. Practice for about 15-20’. Keep practicing, trying to decrease the number of pushes per overall distance. Make sure the rider is looking ahead. Everyone, but most especially children, relies heavily on vision to balance.
3. Practice balancing and using hand brakes (if equipped). Work on glide-squeeze-feet down. This will allow the rider to slow down using the brakes and then place the feet down to stop or remain upright once stopped. It also allows the child to be in control of the speed.
4. Add the pedals back to the bike. Practice gliding. This time trying to place feet on the pedals for the glide. At this point, it can be helpful for the rider to start by being pushed by a spotter. Getting started and getting feet on the pedals is the most difficult part of riding and should be the last step taught.
5. Teach the rider how to start. Either pushing two to three times with both feet and placing on pedals, or with one foot while keeping the other on the pedal both work. Children will quickly let you know their preference.
6. Keep practicing in a large, open space and go in large circles before trying to make sharper turns. Make sure to practice going in circles both to the left AND the right to practice both types of turns. Once the child has good control, you can transition to wide bike paths.

Some helpful reminders:

To keep a bike upright, the rider must lean into the turn, or in other words, turn handles into a fall rather than away.

Training wheels often teach the children to lean the wrong way and often slow learning. Better not to start them!

If you want to use a handle to attach to the back of the bike, make sure it is the type that clamps onto the seat post or frame. Your hand should hover over the top of the handle and just tap it gently to help a child rebalance; don’t hold on. You can use an open hand on the end of the handle to push the child to start.

If your child is not quite ready, you can still enjoy a family ride; tag-along bikes foster good bike habits and let you bring along a child who is not quite ready to go solo. Don’t miss the beautiful spring. Head out and ride!

Deborah Stack, PhD

With over 20 years of experience as a physical therapist, Dr. Stack heads The Pediatric Therapy Center of Bucks County in Pennsylvania. She holds both masters and doctoral degrees in physical therapy from Thomas Jefferson University.

April 10, 2016 by twopedsinapod

We’re in Parents Magazine Best of the Web!

web award

Parents Best of the Web Awards

“We clicked, liked, and followed our way through more than 500 expert-driven nominations to unravel the gems that will make your life easier and more fun. How did anyone raise a kid in the predigital age?”

By Karen Cicero from Parents Magazine

We’re under the category Living Well

April 7, 2016 by twopedsinapod

How to take your toddler to a restaurant without an iPad

take your toddler to a restaurant and have fun Have you wondered if you could take a toddler to a restaurant and have a good time without relying on an iPad for entertainment? This is absolutely possible as long as you have the right expectations, a sense of humor, and a desire to build family memories. In the “old” days when our kids were toddlers, there were no iPads or smart phones so we thought we’d share some ideas to keep your toddler engaged in a restaurant.

Before we go further, understand this: when you go to a restaurant with your toddler(s), you are “going out to eat,” NOT “going dining.” Always have the back-up plan that at any time, if needed, you will convert the entire meal to “take out” status. As long as you accept this backup plan, you are set.

Choose the restaurant wisely. You do not have to eat junk food or “fast” food. Many restaurants with really yummy and nutritious cooking can work for families with toddlers. An important feature to look for: the restaurant offers high chairs or booster seats. If it does, you can infer that the restaurant is “toddler friendly.” Without this attribute, attempt to eat at this restaurant at your own risk and don’t say we didn’t warn you! In addition, find out if the service is fast or slow. Even some “family friendly” restaurants have slow service- this is asking for trouble. Avoid these establishments.

Set the stage. Teach your children how to behave in a restaurant. Play restaurant in your house. Practice “Yes, please” and “No, thank you.” Tell them how they will get to make a choice of what to eat and unlike at home, to try a variety of foods at one meal if you all order something different.

Have reasonable expectations: Research the menu beforehand to make sure you will find something on it that your toddler will eat. Alternatively, just bring your own toddler meal with you and take it out once your own food arrives. Or bring toddler “hors d’oeuvres” that will not spoil his appetite but can be used in emergency if the service is slower than you expected. Examples are thinly sliced apples, portable fruit cup packed in juice, or a stash of low-sugar cereal such as Cheerios® to hand out very slowly.

If the wait staff is young, they probably are not familiar with toddlers and may not understand that waiting is difficult for young children. Ask for your check to come with your food. Consider skipping appetizers so that everyone’s food comes out all at once. Usually toddlers are not happy waiting for food while their parents munch on arugula.

Focus all of your attention on your children. Going to a restaurant with toddlers is not date night, it is family night.

Help your toddler be successful at waiting for the meal to be served or at waiting for everyone to finish eating. Bring along one or two (not the library!) favorite books that either your toddler likes to flip through or likes you to read to her. Bring some paper and crayons – many “family friendly” restaurants supply these but it’s always better to be prepared. My oldest was always entertained with a small matchbox car. We could draw roads for the car on paper or he would just drive the car along the table edge or chair – anything can become a road.

Play games such as “I Spy” with your toddler to pass time while you wait to order or wait for your food. “Where is the man wearing a hat? Where is the picture of the fish?” Talk about the restaurant. Point out where the kitchen is. Point out the food servers: “They write down what we want to eat. They bring us our food!” Point out the bus crew “See, they are cleaning up!” Count the tables. Count how many babies are in the restaurant.

Convert items on the table into make-shift toys. Developmentally toddlers love putting things into other things. Put the pretty pink sugar packet and the white packet into a cup. Dump them out, and do it again. A paper placemat can be scrunched into a ball to roll around. And with a little paper folding, you can make a cootie catcher for pinching little noses. Also, there’s nothing more fun than touching ice sliding around a plate.

We do not recommend walking around the restaurant while waiting to be served because of the potential danger of crashing into a waiter or waitress. Certainly one parent can walk outside with a toddler and the remaining parent can call/text when the food comes. BUT remember, if you are in the habit of all sitting down for at least one meal a day at home, it will be natural for all of you to sit together in a restaurant, and a luxury for the parent who does the most jumping up and down during a home-served meal.

Restaurants are not only for dinner! While my twins did not eat out much as toddlers (hassle factor outweighed the fun factor), we did note that they ate the most food willingly over the longest period of time at breakfast. So we occasionally went to a local deli for Very Early Weekend Breakfast where they could feast slowly on enormous delicious pancakes and my husband and I could enjoy some coffee while it was actually still hot. Bonus: we even could talk to each other because of the concentration my twins paid to picking up every piece of pancake on their own.

Help clean up, and give generous tips. You want to endear yourself to the restaurant staff. It’s great when the wait staff WANTS to serve you when you return (“Oh, it’s that great family with the really cute toddler who loves my Elmo impersonation, says “thank you” when I bring her extra saltines, AND they tip well. That’s MY table!”).

Build your toddler’s self-esteem: Praise your toddler for eating calmly, for sitting without yelling, for his patience: “Good job waiting for your food to come!” As soon as your toddler is done eating and running out of entertaining things to do while sitting at the table, the meal is over! Try to end on a positive note.

Finally, if you end up with a toddler tantrum, just remember the back-up plan. Don’t kill the meal for the rest of the diners in the restaurant. Just pick up your melted-down toddler, convert to take-out, and try again another time. Rome wasn’t built in a day, and sometimes it takes a few tries of eating out with your toddler before you actually all have fun. Fortunately, God/Nature makes toddlers cute even when they are crying and covered in tomato sauce!

Julie Kardos, MD and Naline Lai, MD

March 24, 2016 by twopedsinapod

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