Two Peds in a Pod®

Potty training tips

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 on her face 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
-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 her to try.

Hit play to listen to our potty training podcast:

Naline Lai, MD and Julie Kardos, MD

August 11, 2014 by twopedsinapod

The return of measles- What to look for in your child

Yet another reminder about the signs and symptoms of measles from a health agency landed in our email inbox the other day. The reason? According to the Centers for Disease Control, as of this point, the United States has seen more measles cases this year (almost 600 reported) than in the past decade (typically 60 cases per year). Organizations are reminding physicians about the symptoms of measles because thanks to vaccinations, many pediatricians have not seen a case of the measles in decades. In this post, we pass the information on to you. After all, you will be the first to recognize that your child is ill.

Measles typically starts out looking like almost every other respiratory virus— kids develop cough, runny nose, runny bloodshot eyes, fever, fatigue, and muscle aches.

Around the fourth day of illness, the fever spikes to 104 F or more and a red rash starts at the hairline and face and works its way down the body and out to arms and legs, as shown here at the Immunization Coalition site. Many kids also develop Koplik spots on the inside of the mouth (small, slightly raised, bluish-white spots on a red base) 1-2 days before rash.

In the US, one in 10 kids with measles will develop an ear infection and one in 20 will develop pneumonia. Roughly one in 1000 kids develop permanent brain damage, and up to two in 1000 who get measles die from measles complications. Kids under age 5 years are the most vulnerable to complications. These statistics are found here. For global stats on measles, please see this World Health Organization page.

There is no cure for measles and there no way to predict if your child will have a mild or severe case. Fortunately, one dose of the MMR (Measles, Mumps, Rubella) vaccine is 92% effective at preventing measles, and two doses are 97% effective at preventing measles. That’s the best we can do, but this 97% protection rate works great when everyone is vaccinated. The American Academy of Pediatrics recommends giving the first dose of MMR vaccine at 12-15 months and the second dose at school entry, between 4-6 years of age.

If parents refuse the MMR vaccination for their children, then more people are left susceptible to measles. This leads to more people who can spread the disease when it hits a community. Measles is one of the most contagious diseases known: 9 out of 10 unvaccinated people exposed to measles will become sick, and infected people are contagious even before symptoms appear. One of the reasons behind the increase in measles cases is the increase in unvaccinated children. One patient of Dr. Kardos’s was a four-year-old boy who was behind on his vaccines and hospitalized for measles pneumonia. Before he was diagnosed he exposed an entire Emergency Department to measles.

In our global world, another reason for the spike in measles cases is the increase in travel between countries. In fact, young children traveling internationally often need to get the MMR vaccine outside of the routine schedule. If you plan on traveling, check here to see if you need to give your child the MMR vaccine on an early schedule.

With increased vigilance and vaccination, hopefully measles will once again become a disease few doctors have ever encountered. After all, vaccines did eradicate small pox. The last case of smallpox in the United States was in 1949, and the last case in the world was in 1977. In the meantime, you’ll know how to “spot” a case of measles too.

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

July 30, 2014 by twopedsinapod

On letting go and coming back

Friends make birthdays better

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

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

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

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

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

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

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

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

Dr. Lai

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

July 6, 2014 by twopedsinapod

Hand-foot-mouth Disease

We’re seeing a lot of this stuff around the office. It’s “hand-foot-mouth” disease, a common, self-limited illness caused by the Coxsackie virus, and it strikes most often in the spring and summer. Named for rashes which can affect the hands, feet, or mouth, this illness can cause fever for the first few days as well as some loose stools.

What does it look like?

If you look carefully at the photos, you will see faint red bumps on this child’s feet. The rash may also look like tiny blisters and will always blanch (if you press on it and lift up your finger, the redness will briefly disappear- just as if you pressed on a sunburn). The same rash may appear on the hands and is not itchy. The child’s throat above is red in the back and has several ulcers, or canker sores. The hands, feet and mouth are not always simultaneously affected, and although we don’t call the illness “hand-foot-mouth-tush” disease, sometimes kids also get a red bumpy rash on their buttocks.

Is hand-foot-mouth disease painful?

The throat ulcers can be quite painful and the rash on the feet may be slightly tender. Usually the rash on the hands is not felt by the child. You can alleviate your child’s throat pain with acetaminophen (brand name Tylenol) or ibuprofen (brand names Advil or Motrin). For toddlers and older, Magic Mouthwash, a mix of 1/4 tsp diphenhydramine (plain liquid Benadryl) and 1/4 tsp Maalox (the regular adult stuff) squirted over mouth ulcers prior to eating a meal (three times a day) is an age-old way to sooth sores.

How is it spread?

This virus is contagious through saliva. Prevent kids from sharing cups, eating utensils, and tooth brushes, and clean up toddler drool. This vigilance can help prevent the virus from spreading to family members and friends. Children with this virus can still attend daycare as long as they are not feeling ill. Typically after the first few days of illness, fever and pain subside. Most commonly the rash and mouth ulcers last about a week or two.

What is the treatment?

Unfortunately there is no treatment for hand-foot-mouth disease, but fortunately your child’s body is fully capable of fighting off the virus. Your role is to help soothe pain. Otherwise, kids may refuse to drink and end up dehydrated. When my son had this illness at age two, he liked sucking on a washcloth soaked in very cold water. I also gave him lots of sherbet, ice cream, milk shakes, and noodles. These foods were easier for him to swallow while his throat was sore.

When should I call my kid’s doctor?

Kids can get this virus more than once, and many strains of this virus circulate. Even parents are not always immune. So now add Coxsackie virus, or hand-foot-mouth disease, to your Dr. Mom and Dr. Dad list of manageable diseases. Knowledge is power. However, if your child’s fever lasts more than three days, if he does not drink enough to urinate his baseline amount, if he is inconsolable, seems disoriented, or if your parent gut-instinct tells you something more might be wrong, do get your child to medical attention.

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

Originally posted June, 2011, and right on cue, Coxsackie is back again this summer.

June 17, 2014 by twopedsinapod

Father’s Day 2014: real words from real dads

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

…Learn to curl hair for cheerleading competitions

…BE RESPONSIBLE

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

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

…Have a toys r us in my house.

…Go food shopping at midnight.

…Make so many pancakes on Sunday mornings.

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

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

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

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

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

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

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

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

Thank you to our readers for contributing to this post.

Happy Father’s Day!

Julie Kardos, MD and Naline Lai, MD

June 14, 2014 by twopedsinapod

Pediatric photo puzzler: What caused this skin discoloration?

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

Naline Lai, MD and Julie Kardos, MD

June 3, 2014 by twopedsinapod

Your thoughts on fatherhood

To all of the dads who read our blog: we invite you to help us with our Father’s Day post. Are there things you find yourself doing now that you are a dad that you never imagined you would be doing before you had a child? Try to finish this thought: “Before I became a dad, I never thought I’d…”

Please comment to this post or send us an email at: twopedsinapod@gmail.com.

We will post your responses on Father’s Day.

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

May 31, 2014 by twopedsinapod

FAQs about swimming

baby sand sculpture Babies and children love bath time and are drawn to water play. Today we bring you the splash on swimming.

We’re going to the beach- can my baby go swimming? How about a pool?

Most pools, oceans, and lakes are much colder than bath water. Babies feel colder more quickly than adults. Remember your own parent telling you to come out of a pool because your lips were blue? Limit a baby’s exposure to cold water accordingly.
Chlorine will not hurt babies, but it can dry out skin. Apply moisturizer after swimming if your child’s skin gets dry. Kids with eczema can be particularly sensitive to chlorinated water.
Salt water is safe for babies and kids to swim in.
Young kids try to drink the water they swim in. Don’t let them. It’s not just your nephew who pees through his swim diaper that you need to worry about. Unfortunately chlorine and salt fail to kill all viruses, bacteria, and parasites that might lurk in swimming water.
If your child swims outside, remember that sunburns occur more easily because sunlight reflects off the water. Apply sunscreen liberally before and after swimming. Better yet, try to keep that baby hat on and have your child wear a sun protective shirt.

When should I start swim lessons for my child?

Start swim lessons as early as toddlerhood — it is a great life skill. However, swim lessons will not make your child “drown proof.” You can find more data in this drowning prevention article from The American Academy of Pediatrics. Unfortunately, even under adult supervision, drownings occur. When an adult’s attention is briefly diverted to answer the phone, their meal, etc, a drowning can take place. The bottom line:

Always stay arm’s length of babies and toddlers in the water. Also stay at arm’s length of your older children who have not yet learned to swim.
Even if your child can swim well, never let your child or teen swim alone or without a life guard.

A note about Baby Swim Lessons:

Babies can take “swim lessons,” meaning “spend quality time with a parent in the pool.” Despite the claims of some swim instructors, no studies have shown that infant swim lessons make infants “drown proof.”

Any other water safety tips?

A few years ago, Dr. Lai’s toddler-aged neighbor waddled over to the ice bucket at a Fourth of July party. Toddlers have big pumpkin shaped heads and before Dr. Lai could blink an eye, her neighbor tumbled into the water head first. Luckily Dr. Lai’s husband was standing next to the bucket and pulled the toddler out.

As this case shows, you can’t let your guard down, even if no pool or large body of water is in sight.
Small blow-up backyard pools are the same as bath tubs in terms of drowning risk, so never leave kids unattended around these pools. Stay at arm’s length of your babies and toddlers when they play in these pools.
Additionally, never leave kids unattended, even briefly, in the bathtub.

Ideas on how to play with water?

Water tables (which can double as sand tables in the spring, leaf tables in the fall and indoor snow tables in the winter) allow young toddlers to stand and play with toys in very shallow water.
Fill a bunch of different sized stacking cups with water for kids to pour, dump, or perhaps to mix with rocks, dirt, or leaves.
Simple squirt bottles are great fun. When Dr. Kardos’s twins were little they spent large amounts of time “watering” every plant, bush, flower, and blade of grass in the yard.
Fill small cupcake tins with water and supply your kids with water-color paint to decorate the sidewalk or walkway of your house. Kids become entranced by the colors created as they rinse off the brushes. Warning— make sure the paint is water soluble. Dr. Lai still has the name of one of her children in fluorescent orange written on her driveway.
Wet down your walkway and blow bubbles onto the cement – they will cling onto the walkway for a long period of time.

Grab a towel and enjoy the summer with your children.

May 28, 2014 by twopedsinapod

On our minds: Concussions

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

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

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

How long is recovery?

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

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

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

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

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

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

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

See you up at Brown.

Naline Lai, MD with Julie Kardos, MD

May 22, 2014 by twopedsinapod

Sunscreens and sunburns: your burning questions answered

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

Hot!

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

Treat sunburn the same as you would any burn:

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

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

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

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

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

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

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

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

Which brand of sunscreen is best for babies and kids?

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

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

May 18, 2014 by twopedsinapod

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