Two Peds in a Pod®

When a pet dies

Photo by Lexi Logan

Today we welcome Bereavement Counselor Amy Keiper-Shaw who shares with us how to discuss the death of a pet with your child.

–Drs. Lai and Kardos

When I first graduated from college I worked as a nanny. One day the mom shared with me that their family goldfish recently died. As this was her daughter’s first experience with death, we schemed for nearly 20 minutes to find the best way to talk to her child. The mom and I thought it could be an excellent teaching moment.

We pulled the girl away from her playing to explain that the fish had died. We told the girl we’d help her have a funeral if she wanted, and we would find a box (casket) to bury the fish so she could say her goodbyes. We explained what a casket was and what a funeral was in minute detail. After our monologue we stopped, we asked if she had any questions.

After a slight pause she asked, “Can’t we just flush it?”

The lesson I learned from that experience, and still use to this day, is to keep things simple, and know my audience. Sometimes as parents we overcompensate for our own fears and make situations more challenging than they need to be.

Here are some tips on how to talk to your children about pet loss:

Tell your child about the death, and then pause. Ask her what she thinks death means before moving on with further explanations. This will help you know if she has questions or if she has enough information for the moment. Children often need a small amount of information initially and will later come back to you several times later to ask more questions after they process the information.Remember to express your own grief, and reassure your child that many different feelings are ok. Be sure to allow children to express their feelings. If your child is too young to express herself verbally, give her crayons and paper or modeling clay too help express grief.

Avoid using clichés such as: Fluffy “went to sleep.” Children may develop fears of going to bed and waking up. The phrase “God has taken” the pet could create conflicts in a child and she may become angry at a higher power for making the pet sick, die, or for “taking” the pet from them.

Be honest. Hiding a death from a child can cause increased anxiety. Children are intuitive and can sense is something is wrong. When the death isn’t explained they make up their own explanation of the truth, and this is often much worse than the reality of what occurred.

Children are capable of understanding that life must end for all living things. Support their grief by acknowledging their pain. The death of a pet can be an opportunity for a child to learn that adult caretakers can be relied upon to extend comfort and reassurance through honest communication.

Developmental Understanding of Death

Two and three-year-olds
Often consider death as sleeping, therefore tell them the pet has died and will not return.

Reassure children that the pet’s failure to return is unrelated to anything the child may have said or done (magical thinking).

A child at this age will readily accept another pet in the place of a loved one that died.

Four, five, and six-year-olds

These children have some understanding of death but also a hope for continued living (a pet may continue to eat, play & breathe although deceased).

They can feel that any anger that they had towards the pet may make them responsible for the pet’s death (“I hated feeding him everyday”).

Some children may fear that death is contagious and could begin to fear their own death or worry about the safety of their parents.

Parents may see temporary changes in their child’s bladder/bowels, eating and sleeping.

Several brief discussions about the death are more productive than one or two prolonged discussions.

Seven, eight, and nine-year-olds

These children have an understanding that death is real and irreversible.

Although, to a lesser degree than a four, five or six-year-old, these children may still possibly fear their own death or the death of their parents.

May ask about death and its implications (Will we be able to get another pet?).

Expressions of grief may include: somatic concerns, learning challenges, aggression, and antisocial behavior. Expression may take place weeks or months after the loss.

Adolescents

Reactions are similar to an adult’s reaction.

May experience denial which can take the form of lack of emotional display so they could be experiencing the grief without outwards manifestations.

Resources:
Petloss.com– a gentle and compassionate website for pet lovers who are grieving the death or an illness of a pet- they have a Pet Loss Candle Ceremony every week

Your local veterinarian- often your veterinarian has or knows of a local pet loss group

Handsholdinghearts.org– our group of counselors offer grief support to children, teens, and their families centered in Bucks County Pennsylvania.

Books on pet loss for children:

Badger’s Parting Gifts (children) by Susan Varley

Lifetimes by Brian Mellonie & Robert Ingpen

The Tenth Good Thing About Barney (children) by Judith Viorst

Amy Keiper-Shaw, LCSW, QCSW, GC-C

Amy Keiper-Shaw is a licensed grief counselor who holds a Masters Degree in clinical social work from the University of Pennsylvania. For over a decade she has served as a bereavement counselor to a hospice program and facilitates a bereavement camp for children. She directs Handsholdinghearts, a resource for children who have experienced a significant death in their lives.

December 19, 2013 by twopedsinapod

Prevent colds and flu!

how to prevent cold and flu

We have seen many patients with nasty colds lately, and we know that a few cases of flu recently popped up in our area of the United States. Take a look at “Top Ten Ways to Prevent Colds and Flu,” a post we wrote recently for Mom365, to get your kids through cold and flu season.

To keep yourself updated on the status of the flu, check the Centers for Disease Control flu tracker.

The bad news: thus far three pediatric deaths from flu were reported for this 2013-2014 flu season. The good news: the latest allergy guidelines say that even egg-allergic kids, unless they have a history of anaphylaxis (difficulty breathing) to egg, can safely receive the flu vaccine. Talk to your child’s doctor if your egg-allergic child has never received flu vaccine.

Stay healthy and WASH YOUR HANDS,

Julie Kardos, MD and Naline Lai, MD

December 12, 2013 by

Alleviating indoor allergies

‘Tis the season for indoor allergies. We’re all inside a lot, and the heat is blowing through dry, dusty vents. With our energy-saving windows and doors, we’ve created houses where the allergens that tickle our noses can circulate again and again. But there’s no reason to break out the Kleenex® every year. Here are keys to cutting down on indoor allergens:

If your kids have sensitive noses, consider opting for an artificial Christmas tree instead of a live one. Mold spores love evergreens and storage outside before your purchase can make live trees rather dusty. If you do opt for the live tree, one remedy is to hose off mold and dirt from your tree in your driveway before bringing it indoors.

To keep dust down in general in your home, do your best to mop rather than vacuum. Vacuums can spew dust into the air. When you vacuum, use one with a HEPA filter. Or you could replace dust-trapping carpets with wood floors.

Kids spend nearly half of their days sleeping, so it’s imperative to keep their bedrooms allergen free. Mattress and pillow covers will trap dust mites and their droppings, which trigger allergic reactions, away from your allergic kids’ noses. Unfortunately, these microscopic creatures are ubiquitous.

Also, get the stuffed animals and real animals out of the bedrooms. However, if your child needs to snuggle with his stuffed bunny at night to sleep well, don’t take it away, but at least try to clean it. A good wash and then high heat in the dryer at 130 degrees F for 20 minutes kills dust mites. Alternatively, extreme cold of -17 degrees C to -20 degrees C will also kill mites. While we’ve never heard of anyone putting their child’s “Bun-Bun” into the freezer, we suppose it is an option.

Avoiding allergy triggers is more effective than employing air filtration systems. In fact, many experts argue that filtration makes little difference in air quality in a well-ventilated house. However, we know that some parents will still consider buying a filter. While there are no national standards, the EPA does have guidelines. Since ozone is a known lung irritant, avoid products that specifically claim to generate ozone in order to clean the air.

What to do about the vents in your home? The jury is out. Some experts argue that cleaning vents stirs up decades of dust. On the other hand, less dirt in a ventilation system is less dirt that can spew into the house.

One last word on allergy medication: antihistamines. Some are marketed for indoor allergies. But indoor and outdoor antihistamines all work alike. They all block the action of histamine, which is the substance your body releases when it encounters a substance that you are allergic to. Histamines cause those allergy symptoms of general itching, watery eyes, runny nose, sneezing, wheezing, coughing, etc. So the best antihistamine is simply the one that works for your kids.

Above all, don’t despair. Before you know it, the winter will swirl by, the flowers will bloom … and it will be time for spring allergies!

Naline Lai, MD and Julie Kardos, MD

December 7, 2013 by twopedsinapod

Happy Thanksgiving 2013 from your Two Peds

thanksgiving paper turkey We love being pediatricians because it’s an honor to be a part of your family, it’s intellectually challenging, and it gives us a chance to teach. But mostly, we love to make people feel better.
We love not only when our patients feel better, but also when their parents feel better.

Parents feel better when we say:

Not strep throat. It’s a viral sore throat.
Not pneumonia. It’s a viral cough.
Not a broken foot. It’s an ankle sprain.
Not appendicitis. It’s constipation.
Not an ear infection. It’s fluid behind her ear drum.
Not cancer. It’s a lymph node infection.

In other words, our favorite diagnosis is “Not what you are worried about.”

Parents, including us, fear the worst when their children are ill. Some parents apologize to us when we give the diagnosis of “Not what you are worried about.” They feel they have wasted our time or their time. But this diagnosis is never a waste of time for anyone. It is a stress relieving, sometimes guilt relieving, diagnosis that we are happy to give. Too often we wish with all our hearts that we could give this diagnosis, but instead, we must confirm a parent’s fears.

So this Thanksgiving, we take time to be grateful for the diagnosis “Not what you are worried about.”

May you find lots of Happy in your Thanksgiving.

With gratitude,

Drs. Kardos and Lai
©2013 Two Peds in a Pod®

November 27, 2013 by twopedsinapod

Gift ideas by ages and developmental stages 2013

gift recommendations for kids

A five-year-old boy in the office last week said he planned to go home after his checkup and play “Elf on the Shelf.” In the game, he perches very still in a hiding spot in his house with one leg crossed and both hands on his knee, gazes into the distance, and waits for his sister to find him.

Yup, its that time of the year. Before you know it, a “real” Elf on the Shelf or perhaps a Mensch on a Bench may be visiting your home and you’ll be thinking about holiday gifts. Now that your families are another year older, we brought back our holiday gift idea list arranged by ages and developmental stages.

0-3 months: Babies this age have perfect hearing and enjoy looking at faces and objects with contrasting colors. Music, mobiles, and bright posters are some age appropriate gift ideas. Infants self sooth themselves through sucking- if you can figure out what your nephew’s favorite type of binkie is, wrap up a bunch-they are expensive and mysteriously disappear.

3-6 months: Babies start to reach and grab at objects. They enjoy things big enough to hold onto and safe enough to put in their mouths- try bright colored teething rings and large plastic “keys.” New cloth and vinyl books will likewise be appreciated; gnawed books don’t make great hand-me-downs.

6-12 months: Around six months, babies begin to sit alone or sit propped. Intellectually, they begin to understand “cause and effect.” Good choices of gifts include toys with large buttons that make things happen with light pressure. Toys which make sounds, play music, or cause Elmo to pop up will be a hit. For a nine-month-old old just starting to pull up to standing, a water or sand table will provide hours of entertainment in the upcoming year. Right now you can bring winter inside if you fill the water table with a mound of snow. Buy some inexpensive measuring cups and later in the summer your toddler will enjoy standing outside splashing in the water.

12-18 months: This is the age kids learn to stand and walk. They enjoy things they can push while walking such as shopping carts or plastic lawn mowers. Include gifts which promote joint attention. Joint attention is the kind of attention a child shares with you during moments of mutual discovery. Joint attention starts at two months of age when you smile at your baby and your baby smiles back. Later, around 18 months, if you point at a dog in a book, she will look at the dog then look back at you and smile. Your child not only shows interest in the same object, but she acknowledges that you are both interested. Joint attention is thought to be important for social and emotional growth.

18-24 months: Although kids this age cannot pedal yet, they enjoy riding on toys such as big wheels “Fred Flintstone” style. Dexterous enough to drink out of a cup and use a spoon and fork, toddlers can always use another place setting. Toddlers are also able to manipulate shape sorters and toys where they put a plastic ball into the top and the ball goes down a short maze/slide. They also love containers to collect things, dump out, then collect again.

Yes, older toddlers are also dexterous enough to swipe an ipad, but be aware, electronics can be a double edged sword— the same device which plays karaoke music for your daddy-toddler sing-along can be transformed into a substitute parent. The other day, a toddler was frighted of my stethoscope in the office. Instead of smiling and demonstrating to her toddler how a stethoscope does not hurt, the mother repeatedly tried to give her toddler her phone and told the child to watch a video. Fast forward a few years, and the mother will wonder why her kid fixates on her phone and does not look up at the family at the dinner table. Don’t train an addiction.

2-3 years: To encourage motor skills, offer tricycles, balls, bubbles, and boxes to crawl into and out of. Choose crayons over markers because crayons require a child to exert pressure and therefore develop hand strength. Dolls, cars, and sand boxes all foster imagination. Don’t forget those indestructible board books so kids can “read” to themselves. By now, the plastic squirting fish bath toys you bought your nephew when he was one are probably squirting out black specks of mold instead of water- get him a new set.

3-4 years: Now kids engage in elaborate imaginary play. They enjoy “dress up” clothes to create characters- super heroes, dancers, princesses, kings, queens, animals. They become adept at pedaling tricycles or even riding small training-wheeled bikes. Other gift ideas include crayons, paint, markers, Play-doh®, or side-walk chalk. Children this age understand rules and turn-taking and can be taught simple card games such as “go fish,” “war,” and “matching.” Three-year-olds recognize colors but can’t read- so they can finally play the classic board game Candyland®, and they can rote count in order to play the sequential numbers game Chutes and Ladders®.

5-year-olds: Since 5-year-olds can hop on one foot, games like Twister® will be fun. Kids this age start to understand time. In our world of digital clocks, get your nephew an analog clock with numbers and a minute hand… they are hard to come by. Five-year-olds also begin to understand charts— a calendar will also cause delight. They can also work jigsaw puzzles with somewhat large pieces.

8-year-olds: Kids at this point should be able to perform self help skills such as teeth brushing. Help them out with stocking stuffers such as toothbrushes with timers. They also start to understand the value of money. The kids will appreciate gifts such as a wallet or piggy bank. Eight-year-olds engage in rough and tumble play and can play outdoor games with rules. Think balls, balls, balls- soccer balls, kickballs, baseballs, tennis balls, footballs. Basic sports equipment of any sort will be a hit. Label makers will also appeal to this age group since they start to have a greater sense of ownership.

10-year-olds: Fine motor skills are quite developed and intricate arts and crafts such as weaving kits can be manipulated. Give a “cake making set” (no not the plastic oven with a light bulb) with tubes of frosting and cake mix to bake over the winter break. Buy two plastic recorders- one for you and one for your child to play duets. The instrument is simple enough for a ten year-year-old or a forty-year-old to learn on their own. Ten-year-olds value organization in their world and want to be more independent. Therefore, a watch makes a good gift at this age. And don’t forget about books: reading skills are more advanced at this age. They can read chapter books or books about subjects of interest to them. In particular, kids at this age love a good joke or riddle book.

Tweens: Your child now has a longer attention span (30-40 minutes) so building projects such as K’nex® models will be of interest to her. She can now also understand directions for performing magic tricks or making animal balloons. This is a time when group identity becomes more important. Sleepovers and scouting trips are common at this age so sleeping bags and camping tents make great gifts. Tweens value their privacy – consider a present of a journal with a lock or a doorbell for her room.

Teens: If you look at factors which build a teen into a resilient adult, you will see that adult involvement in a child’s life is important. http://www.search-institute.org/research/developmental-assets

We know parents who jokingly say they renamed their teens “Door 1” and “Door 2,” since they spend more time talking to their kid’s bedroom doors than their kids. Create opportunities for one-on-one interaction by giving gifts such as a day of shopping with her aunt, tickets to a show with her uncle, or two hours at the rock climbing gym with dad.

Encourage physical activity. Sports equipment is always pricey for a teen to purchase- give the fancy sports bag he’s been eying or give a gym membership. Many teens dislike sweating because they fear sweat will promote acne—treat them to moisture wicking shirts and elaborate acne regimes from the high-end department store make-up counter.

Enjoy your holiday shopping!

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

November 19, 2013 by twopedsinapod

Escape from Candy Land

We welcome back health coach Mary McDonald (the mom who overhauled her kids’ sports snack stand), to provide advice on how to survive what Dr. Shifrin referred to last week as Candy Season.
—Drs. Lai and Kardos

If your home is like mine, you have an extraordinary amount of Halloween candy lurking in the most unusual locations: inside an old roasting pan, under a pile of shoes in your daughter’s closet, or tucked in an end table drawer in your living room. It’s an incredibly hard time of the year to eat healthy and to help your children make good food choices when sweets are so abundant from October to January. It is disturbing to think about the bad eating habits that start at the holidays and can lead to an addiction to sugar throughout the rest of the year. In order to combat the inevitable onslaught of sugary treats, here are a few strategies to consider:

Invite the “Switch Fairy” or “Switch Witch” to your home. If you’re tired of telling your children, “Step away from the candy!” then make sure it isn’t easy to access. Your kids will love you if you tell them the Switch Fairy will visit your home tonight to replace the candy with a toy, clothing, or their favorite item. Keeping sweets out of sight will make it easier to replace the candy with a healthier option, such as fruit salad or a yogurt parfait.
So, what can the Switch Fairy do with the extra sweets? Contact your local dentist or do an online search for candy donation sites. Many local organizations will buy back Halloween candy. This becomes a perfect way to subsidize the present that the Switch Fairy purchases.
Drink Water. Staying hydrated is a great way to curb cravings. When you crave sweets, there’s a good chance that you’re actually dehydrated and your brain is craving water. When your kids are tired, instead of reaching for a-little-something-sweet as a pick-me-up, try giving them a drink of water. You may be surprised that their cravings are reduced. Are you looking to make water more enticing? Try purchasing a swirly straw and designate the straw for water only.
Don’t drink soda. Soda is nothing but liquid sugar and void of any nutrition. Each 12-oz. can of Coke contains approximately 10 teaspoons of sugar. An easy way to reduce your sweets during the holiday season is to select water as your drink of choice. If your child must have a soda, suggest splitting the can with your child or with a friend. Pour a few ounces into each cup and throw away the rest. It’s okay.
Increase your carbs! Yes, you heard me correctly. For years, carbs were given a bad rap. Low carb diets promoted the idea that all carbs are created the same. In fact, they are not. Natural carbohydrates (the ones found in fruits and vegetables such as sweet potatoes, carrots, bananas, and oranges) can help reduce your cravings for sweets. Try reaching for one of these options before you go for a cookie. For an added bonus, wash this snack down with a big glass of water. You will be really surprised at how quickly you cure your sugar craving. Make fruit or veggies more exciting by using toothpicks to pick up the food. See how many green peas you can fit on a toothpick. Make it fun – who doesn’t like a pea eating competition?
Chew Gum. According to research from the University of Rhode Island, people who chewed gum consumed 68 fewer calories at lunch and did not compensate by eating more later in the day. Chewing gum also helped the study participants satisfy their cravings and resist fattening treats. And there’s more: Gum chewers actually burned about 5% more calories than non-gum chewers.
Just say no. Social pressure to join in and eat what others are eating can be overwhelming. Most people are very receptive when you say, “No thanks, I’m full.” Tell your children that it’s okay to “Just Say No”, whether you’re talking about food or other temptations.
Cook from scratch. Cooking, especially with your children, is a wonderful way to control the ingredients that are in the food that you eat. There are many wonderful natural substitutions to cane sugar (stevia, agave syrup, maple syrup, dates, raisins, etc.) that provide an equal amount of sweetness to your food. Become a scientist and experiment with alternative sweeteners. Click here for recipe ideas.
Understand your labels. Did you know that every 4 grams of sugar = 1 teaspoon of sugar? Understanding the basics of a nutrition label is critical to understanding what you are eating.

So, as you and your family weave your way through the sweetest months of the year, think of inviting the Switch Fairy to your house for a home cooked meal full of natural carbs and a big cup of water.

Mary McDonald
©2013 Two Peds in a Pod®

Mary McDonald holds a Masters of Education from Arcadia University and completed her health coach certification from Institute of Integrative Nutrition. She is a high school teacher, a mom of four daughters, and an advocate for healthy food choices. For more information on her health coaching services, please contact her at nutrition101withmary@gmail.com or visit her website at nutrition101withmary.com.

November 16, 2013 by twopedsinapod

Beyond Halloween

We enjoyed meeting Pediatric media expert Dr. Don Shifrin, whose interviews have appeared in numerous publications including Good Housekeeping, the Wall Street Journal, and Time blogs. Today he writes about the “fifth season” of the year.
—Drs. Kardos and Lai

Pleading with children not to eat too much candy on Halloween borders on sacrilege. So when a USA Today headline blares, “Scary amount of candy will be consumed on Halloween,” it strikes us as proclaiming the obvious. Or does it? A candy industry analyst states that almost four percent of the yearly total for candy consumption in the US occurs on All Hallows Eve. And that “frightens doctors.”

“Why?” you might ask.

The article then goes on to give parents several parent-tested hints regarding ways to minimize candy gluttony during and after October 31.

But friends, here’s what scares me as a Pediatrician: thanks to the demonic coalition between the candy industry, advertising media, and retailers, Halloween is just the appetizer to a 6-plus month buffet of sugar laden offerings.

The main course closely follows with Thanksgiving and Christmas. Followed closely by the twin desserts of Valentine’s Day and Easter. We can get our M&Ms in all seasonal colors from scary to pastels to match each holiday. That’s over 6 months of intensive and impressive candy packaging, marketing, and buying by our nation’s most vulnerable and vocal customers- our children. I picture the wolf saying to Little Red Riding Hood, “The better to sell you, my dear.”

So parents, good luck trying to avoid the candy aisles from October through April. Here’s my perspective on the real scary part of Halloween. It signals the beginning of a newly created season, lasting from fall through spring: America’s Candy Season.

And the scariest part? It’s not just McDonald’s anymore. Groceries, drug stores, warehouse clubs, and convenience stores now join the list of places YOU can get supersized.

Don Shifrin, MD

©2013 Two Peds in a Pod®

Dr. Shifrin is a Clinical Professor of Pediatrics at the University of Washington School of Medicine in Seattle, and has practiced at Pediatrics Associates, Inc, PS. in Bellevue, Washington, for 35 years. He is past Chair of the American Academy of Pediatrics Committee on Communications—a committee which recognizes and evaluates the physical, mental, and social impact of positive and negative messages communicated to children from the media.

November 11, 2013 by twopedsinapod

The medical meaning of colors

image by Pixabay

“Red and yellow and pink and green, purple and orange and blue…”

Please imagine the “I Can Sing a Rainbow” song playing in the background of this post as you “listen with your eyes.”

In the same order as the song, we proudly present colors with medical meaning:

RED It’s okay to turn red while coughing. Red shows that a person has enough oxygen and is not short of breath. Of course redness of the skin is NOT a good color when it results from sunburn or infection. It is also not a good color in the whites of the eyes. Red eyes are irritated eyes, and red can be a sign of infection, allergies or sleep deprivation.

YELLOW In the “whites of the eyes” or sclera, yellow is a sign of jaundice. Jaundice in only the eyes of newborns is very common and usually does not require treatment. In anyone older than a newborn, jaundice points towards liver disease. So yellow, other than in the newborn period, is a problem color.

PINK Children of all races and ethnicities should have pink inner eyelids, pink lips, and pink nails. Pink in these body areas implies normal blood flow and normal blood count.

GREEN We can see this color in a child’s face before an episode of vomiting or fainting. If you see this color in your child’s face, lie him down on his side to encourage blood flow to his head and to prevent him from hitting his head on the floor if he faints. And get a bucket!

PURPLE A bad rash called “purpura” is purple. It can be seen with a high fever or with leg and belly pain. If you see a purple rash on your ill child, take him to a doctor ASAP.

ORANGE Orange skin in an older baby WHOSE SCLERAE (EYES) ARE STILL WHITE may be seen in kids who love to eat orange fruit and veggies such as carrots, peaches and squash. This condition, called hypercarotinemia, is a result of the build-up of beta carotene from orange foods. We see this often in 9-12 month olds. Hypercarotinemia is not dangerous . An easy way to change the skin color is to feed more green veggies to balance out the orange ones.

BLUE In general, blue is not a good color. Turning blue while coughing means NOT enough air/oxygen is flowing to the body. Low oxygen levels in kids with heart or lung diseases cause a blue coloration in their faces, mouths, and fingernails.

WHITE White inner eyelids, lips, or fingertips implies anemia or poor blood flow in the body. However, white is a normal color for sclera, the “whites of the eyes.”

Speaking of color— kids cannot get a tattoo legally in the USA under age 18 years without parental consent. In case you were thinking of letting your underage child permanently color his or her skin, read this article about an infection caused by one kind of grey tattoo ink.

Hopefully you can now “sing a rainbow too.” If any of our medical colleagues are reading this post, please fill in any color we forgot!

November 6, 2013 by twopedsinapod

Sippy Cups are not a developmental stage, revisited

Ah Ha! Little did we know when we wrote this post back in 2010 that a study of injuries related to sippy cup, bottle, and pacifier use wrapped up that same year. The results, published in the journal Pediatrics in May 2012, showed that sippy cups were a significant source of injury in children. Most commonly they caused mouth lacerations in children who fell while drinking out of the cups.

Drs. Kardos and Lai

At a baby’s six month old check-up I advise parents to have their child start drinking from a cup.

Some respond with surprise,” A cup? So young? How exciting! Do you mean a sippy cup?”

“No,” I explain. “A regular, open-face cup.”

Then I get incredulous looks. “But how will our baby manage that?”

Just like your baby “learns” how to eat food off a spoon, she will have to practice. You will have to help her at first. Just put water in the cup. Who cares if water spills? You see how by this age she naturally puts her hands together and pulls most things to her mouth. With practice, she will learn to drink out of a cup. Just like everyone else did before sippy cups were invented.

“But when,” parents ask me, “should we introduce the sippy cup?”

The reality is, sippy cups satisfy a parent’s desire to be neat and to avoid mess. Sippy cups are not a developmental stage. Did I use sippy cups with my own kids? Yes I did, especially with my twins, because anything I could do to decrease mess in my home I welcomed with open arms. But it is perfectly okay to never introduce sippy cups to your child.

Because sippy cups are spill-proof, it is tempting to leave one out all day for your child. If the cup contains water, this practice is safe. However, many toddlers have ended up with a mouth full of cavities in their brand new baby teeth after sipping milk or juice all day long out of sippy cups. Constant sweet substances on the gums can sink in and affect baby teeth. Just as we advise parents of bottle fed babies to avoid allowing the child graze from the bottle all day and to avoid falling asleep drinking a bottle, young children should not be drinking sugar-containing drinks, including milk, all day from a sippy cup.

“But I only give my kids water mixed with a tiny bit of juice in the sippy cups,” I hear parents say. Yes, kids (and grownups) need water, but watered down juice is not the same as plain water. Watered down juice is sugar water, and it harms teeth just like straight-up juice. In addition, drinking watered down juice teaches kids that all beverages need to be sweet. Sweet drinks do not actually quench thirst; rather, they make kids feel thirstier. Remember that unlike adults, babies and toddlers have not formed unhealthy habits yet, so teach them that water and milk are for drinking. The only exceptions are electrolyte solutions that are used to prevent dehydration during vomiting and juice once a day (prune, pear, or apple) for constipated children. For nutrition, fruit is much healthier than fruit juice.

So put water in the open faced cup and allow your baby to imitate you and drink out of it. Then, around your child’s first birthday when most parents wean their children from breast milk or formula to cow milk, put the “big boy milk” or “big girl milk” into a cup. Aim for all open cups by at least two years of age. If you decide to use sippy cups, as I did, for neatness sake, do not forget practice with a regular cup. Get rid of the sippy cup whenever you are tired of washing those moldy valves and tired of rescuing them from your drain or garbage disposal. You might have a “sippy cups are for car rides” policy and use open cups at home.

What about straw cups? Well, think of it this way. Do you plan to travel around with straws in case your child becomes thirsty? Sure it’s fine to teach your child to drink out of straw. It’s healthier than a sippy cup because most of the milk will bypass most of the teeth. But again, it is easiest in the long run to teach your child to drink out of a regular cup so that in any situation you know you can offer your child a drink.

All kids are messy. The younger you practice with your child, the sooner she will be drinking out of a regular cup like a pro. Just in time for finger feeding which means self-feeding—more mealtime mess!

November 3, 2013 by twopedsinapod

An injured limb: Should I stay or should I go now?

The classic punk rock song lyric “Should I stay or should I go now?” will run through your head many times during parenthood as you wonder when your kid should go to the doctor’s office. Today we turn to pediatric orthopedic surgeon and author Dr. Gleeson Rebello for advice on whether an injured limb needs immediate medical attention – Drs. Lai and Kardos.

You drive home after a tiring day at work and think about all you will do with your family in the next few hours before calling it a day. A visit to the local emergency department or your child’s doctor is definitely not on that list.

Upon arriving home, you find out your six-year-old daughter just fell from the swing in the backyard and complains of a painful elbow.

Do you hug, kiss, comfort her, stop to pour yourself a glass of wine and take it easy on the patio? Or, do you take her to a doctor?

Take her to a doctor as soon as possible if:

• She has a deformed arm

• She cannot move her arm

• She has an open injury with bone visible or with uncontrollable bleeding

• She is screaming with pain that does not seem to get better with rest, comfort and ice packs

• She cannot move the joint (shoulder, elbow, wrist and finger joints) without significant pain

DON’T GIVE HER ANYTHING TO EAT OR DRINK while you assess what is going on…. just in case she needs to undergo surgery once she gets to the hospital.

If she is in some pain with moving the elbow, immobilize her in a home-made sling using a towel and some safety pins. Apply an icepack and give her an anti-inflammatory/pain relief medication like ibuprofen (brand names Motrin, Advil).

Think strongly about going to the doctor if she shows signs of persistent discomfort and you wonder if you will be staying up with her the whole night.

If she appears comfortable, give her a light meal and elevate the elbow on a couple of pillows. Arrange her hand above the elbow, and the elbow above her heart in order for gravity to reduce the swelling.

Call your child’s doctor to set up an appointment if she is still in pain in the morning or has not improved overnight.

Hopefully you will never need to use the knowledge gained from this article!

Gleeson Rebello, MD

Dr. Gleeson Rebello serves as a pediatric orthopedic surgeon at MassGeneral Hospital for Children, and is on the faculty of Harvard Medical School. His new children’s book coauthored with Jamie Harisiades, DareBone’s Big Break , helps children navigate the potentially frightening experience of fixing a broken elbow. Dr. Rebello is dedicated to making everyday medical practice accessible to children in a fun and sophisticated manner through books and media. Applaud his efforts and like his Facebook page at https://www.facebook.com/Darebone

October 23, 2013 by twopedsinapod

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