This drives us crazy: Listed on many pediatric developmental milestone charts, there is the six month milestone, ” can hold their own bottle. ” Unfortunately, this is the last thing we want our patients to do. Babies who feed by holding their own bottle tend to suck for a longer period of time than when they are at the breast or when a parent holds the bottle. Prolonging the time any sweet substance, whether breast milk, cow’s milk, or watered down juice is in the mouth can produce cavities. Even in toothless babies, the sugar can seep through gums and rot the teeth producing cavities called “bottle rot” in the two front teeth. As shown above, sucking on a sippy cup constantly can also produce the characteristic damaging pattern and cause rotten teeth.

Sippy cups are like daytime bottles. In the “old days” if a child wanted a drink, the parent would give him a cup, he would take his drink, and then the cup would be put away so it would not spill. Sippy cups are easier to leave around for kids to grab when they need it. They are easy for kids to carry and graze from while playing. They don’t make a mess in the car. But because kids can nurse a sugar-containing drink all day, it becomes easy for a sweet drink to have constant contact with teeth, thus producing the problem you can see in our photo.

How to prevent rotten teeth:

• Once they are toddlers, give your kids beverages at meal or snack times only. Let them drink and then put the cup away. Otherwise, forward to the future, and imagine your sippy-cup-toting toddler becoming the perpetually-drinking-coffee office coworker down the hall. We’re sure your coworker’s teeth are not pretty. The only exception to giving a beverage only at meal or snack times is the quick after dinner cup of milk when they are very young (toddlers). If your toddler drinks a cup of milk before bed, make sure he brushes his teeth before going to sleep. Brush-book-bed is a good routine to institute.
• Limit juice. Whether 100%, or organic, or watered down, juice contains enough sugar to rot teeth over time. Dr. Kardos remembers a friend lamenting, “I bought only 100% juice for his sippy cup and had no idea it could hurt my son’s teeth like that!” Eventually, her friend’s son underwent a tooth repair under anesthesia.
• Encourage good tooth brushing at least twice a day with fluoride-containing toothpaste, starting when your child gets his first tooth. Before that point, wipe out your baby’s gums with a wet gauze or wash cloth.
• Schedule regular dental visits for your child starting around or soon after his first birthday. Going to the dentist is a vital part of preventing rotting teeth.
• Ask your pediatrician or dentist if supplemental fluoride may be helpful.

Some final food for thought: snacks of pouch-pureed fruits and vegetables are increasing in popularity. We don’t think we need to wait for a scientific study to say that prolonged sucking on a packet of “healthy” fruit puree will probably result in the kind of teeth pictured above .

For more tips check out the American Academy of Pediatrics and the American Academy of Pediatric Dentistry.

Julie Kardos, MD and Naline Lai, MD

©2016 Two Peds in a Pod®

Questions: Why does that child run into the road? Why does that child hit other kids?

Answer: Because no one ever taught him not to.

Toddlers need lots of teaching, so where do you start? To help teach your on-the-move, act-first-and-ignore-the-consequences toddler how to become more civilized, first make sure BOTH parents agree on the rules. Teach your toddler that you mean what you say. When you call your toddler and he does not come right away, GO TO HIM AND  LEAD HIM BY THE HAND OR PICK HIM UP no matter what the situation. Also remember that civilizing a toddler is a work in progress, not an afternoon project.

These are negative behaviors we want to train out of our toddlers: hitting, kicking, biting, pinching, and in any way inflicting pain on others. Excitement and anger are normal reactions in toddlers, but these negative responses to excitement or anger are always unacceptable.

Before we go further let’s review normal toddler behavior. These are things that you just can’t punish a toddler for, but rather you can try to capture on camera and to enjoy the memory later:

• Making a mess.  All toddlers are messy. They can’t help it. They don’t have the fine motor coordination to prevent dropping food or for keeping toys contained to one area. (I am recalling with a smile a home-movie of my twin toddlers double-fisting a spaghetti dinner). Besides, to a toddler (and to many adults for those of you who used to watch Dave Letterman) it’s always fun to watch things splat on the floor. That being said, kids are never too young to teach “clean-up.” Make it fun and light-hearted, not onerous. All kids love to use brooms, so encourage them to help clean up the Cheerios that coat the floor after a meal.
• Touching everything. They will touch  themselves and others- they are just curious.
• Speaking their minds. Toddlers are truthful and literal, not malicious or insinuating. My oldest son at age 3 saw a man with one arm and said very loudly, “Look, Mommy, that man has only one arm!”

How to discipline:

Catch ’em being good. This works wonders if you are consistent about it. Be specific about your praise. Tell your toddler, “I like how you are not hitting your brother right now,” or “Good job playing quietly while your baby sister naps,” or “Great job putting the legos away in the box!” instead of “You are being good now.”

Teach consequences: If he throws a toy, say “NO throwing that toy,” and take the toy away for a minute or two to make your point.

Chastise the behavior, not the child. Say to your child “No hitting,” not “You are bad for hitting.”

First make it clear that a behavior is not acceptable. Toddlers are not mind readers. If you never told her, “Don’t rummage through the garbage can,” she will not know better.

Parents need to be on the same page. Discuss in advance, not in front of your child, what the consequences are for misbehavior. If one parent”gives in” to a tantrum and one does not, your toddler will become confused, then anxious, and then learn how to pit parents against each other. He will throw longer, louder, more destructive tantrums because he knows, if he hangs on long enough, ONE person will give him what he wants.

Have immediate consequences. Avoid “Wait until your mom gets home.” Also avoid “When we get home from the store, you are in trouble.” As determined as they can get, toddlers also paradoxicaly have the attention span and memory of a flea. However, in order to give an appropriate, immediate consequence, plan your consequence before you need it or else you may give out one that you regret.

For example, if you and your toddler are having a fine time at the playground with other parents and their toddlers, you may regret this warning: “Stop hitting Billy with your toy car or we will leave the playground.” If your child ignores you, then you are stuck leaving the playground. And leave, you must! If you fail to heed your own warning, your toddler will learn that you do not mean what you say. He will see you as a wimp and will always try to take advantage of you. A better way to stop your kid is to say, “Stop hitting Billy with your toy car or I take that car away from you.” Then take it away if he continues the behavior. Here are the benefits:

1-Teach your child that you mean what you say.

2- Protect others from your toddler’s dangerous behavior.

3- Preserve your own sanity. Why should you have to miss out on talking to other mommies while enjoying the day with your toddler? Sure, your toddler may tantrum in response to his lost car, but after the tantrum your toddler and you can continue to have fun at the park.

Don’t nag. Toddlers are professionals at ignoring parental nagging. Just follow through on your consequence for failure to obey you.

Ignore whining. Whining is very hard to stop once you allow your toddler to get what he wants when he whines. Instead, ignore his whining and nagging (just as your toddler does so easily and naturally when you do it to him). Only grant him your attention when he uses his regular voice. Tell him once: “I can’t understand when you talk that way. I only understand your Joey (insert your child’s name here) voice.” Then ignore him until he uses his “regular” voice.

Catch teachable moments. If you see another toddler misbehaving OR behaving well, point out the behavior to your toddler. You could say, “Oh, she hit her sister. I am so glad you are not hitting now. You know that our rule is No Hitting!” Also use books to point out desirable behavior. Plenty of books that you read to your children have examples of children having fun together or working toward a goal together without hitting, biting, or kicking each other. Point that out!

Time out and its permutations:

Time-out is a consequence. The goal of time-out is to stop the undesirable behavior and to give negative associations to the bad behavior.

The traditional way of giving a Time-out in response to an aggressive or otherwise inappropriate behavior is to place your child in a chair or stool or on the floor in a corner or other quiet, boring place in the house for one minute per age of the child. Try not to use a spot which is associated with relaxation and sleep such as his crib.

Time-out is more of a mental place than a physical place. Years ago when I was out with Dr. Lai and our kids, her then 18-month-old hit her 3-year-old sister. Dr. Lai firmly told her 18 month old, “NO hitting, Mommy is not talking to you for one minute!” and she turned her back and folded her arms, making it a point of not looking at her daughter (Of course I was there to make sure her 18- month-old didn’t run into trouble). Her 18-month-old had a tantrum but she got the message.

My own twins were a handful- often they would bite or hit each other over a toy that they both wanted. Rather than attempting to put two twins in two Time-Out chairs, I put the TOY in time-out on top of the refrigerator, where they could see it but not reach it, for the number of minutes of my twins’ age. Yes, I had to endure a double tantrum but the undesirable behavior, namely the hitting, stopped. Over time they learned to think twice about hurting each other. Read more about twin toddler discipline tips here.

Teaching self-calming is different from disciplining misbehavior/unsafe activities.

Your kids may throw tantrums often in response to your discipline. This is perfectly fair. Toddlers are allowed to feel frustrated and angry (“If you’re happy and you know it clap your hands; if you’re angry and you know it throw a fit!”). Just ignore the tantrum and remove any breakables from the line of fire. The goal is for your child to have a bad feeling about making a bad choice. If she has a tantrum, she may later remember that if she throws a toy at someone, it will be removed from her and She Will Feel Bad about it. We will give you more tips about helping to stop an endless tantrum in our next post. Remember, though, that once time out is over, it is over. Move on and don’t continue to talk about the incident.

We do not recommend hitting your toddler as punishment or as a way to stop them from some undesirable behavior. Toddlers mirror your behavior. They will pretend to swipe a smart phone. They will blow kisses back to you. Toddlers will suddenly will start spewing inappropriate words because they hear their parents using those words.  So, be on your best behavior. If you hit your child,  you will model hitting as a proper response for anger. Try not to hit your child even in jest. You don’t want to be explaining to other parents on the playground that your hitting child “doesn’t know better.”

Be aware it will feel like you are reiterating the same teaching points endlessly You will often feel you are talking to yourself. Even though you told a toddler once not to rummage through a garbage can, you’ll have to repeat the instructions the next time you see a different garbage can. As my brother-in-law says,”You don’t ever stop. Kinda like practicing layups or free throws in basketball.”

Remember to take a deep breath: It is easy to lose control of yourself when you spend a lot of time with a toddler because toddlers, even though they are all adorable, can be infuriating, unreasonable, and irrational. Remember who is two and who is thirty-two. You NEED to be in control. If not, give yourself a timeout.

If you find a day with your toddler particularly tough, just do what melted my heart when my boys were toddlers. When asked,  “Who will you marry?”  they would always say “YOU, Mom.”

Julie Kardos, MD and Naline Lai, MD

©2015 Two Peds in a Pod®

Based on our original 2009 podcast about toddler discipline- you can listen to it here.

Riding into toddlerhood

When your baby turns one, you’ll realize he has a much stronger will. My oldest threw his first tantrum the day he turned one. At first, we puzzled: why was he suddenly lying face down on the kitchen floor? The indignant crying that followed clued us to his anger. “Oh, it’s a tantrum,” my husband and I laughed, relieved he wasn’t sick.

Parenting toddlers requires the recognition that your child innately desires to become independent of you. Eat, drink, sleep, pee, poop: eventually your child will learn to control these basics of life by himself. We want our children to feed themselves, go to sleep when they feel tired, and pee and poop on the potty. Of course, there’s more to life such as playing, forming relationships, succeeding in school, etc, but we all need the basics. The challenge comes in recognizing when to allow your child more independence and when to reinforce your authority.

Here’s the mantra: Parents provide unconditional love while they simultaneously make rules, enforce rules, and decide when rules need to be changed. Parents are the safety officers  and provide food, clothing, and a safe place to sleep. Parents are teachers. Children are the sponges and the experimenters. Don’t be afraid of spoiling  your child; be afraid of raising a child that acts spoiled. Here are concrete examples of how to provide loving guidance:

Eating: The rules for parents are to provide healthy food choices, calm mealtimes, and to enforce sitting during meals. The child must sit to eat. Walking while eating poses a choking hazard. Children decide how much, if any, food they will eat. The kids choose if they eat only the chicken or only the peas and strawberries. They decide how much of their water or milk they drink. By age one, they should be feeding themselves part or ideally all of their meal. By 18 months they should be able to use a spoon or fork for part of their meal.

If, however, parents continue to completely spoon feed their children, cajole their children into eating “just one more bite,” insist that their child can’t have strawberries until they eat  their chicken, or bribe their children by dangling a cookie as a reward for eating dinner, then the child gets the message that independence is undesirable. They will learn to ignore their internal sensations of hunger and fullness.

For perspective, remember that newborns eat frequently and enthusiastically because they gain an ounce per day on average, or one pound every 2-3 weeks. A typical one-year-old gains about 5 pounds during his entire second year, or one pound every 2-3 months. Normal, healthy toddlers do not always eat every meal of every day, nor do they finish all meals. Just provide the healthy food, sit back, and enjoy meal time with your toddler and the rest of the family.  

A one-year-old child will throw food off of his high chair tray to see how you react. Do you laugh? Do you shout? Do you do a funny dance to try to get him to eat his food? Then he will continue to refuse to eat and throw the food instead. Instead, you can say blandly,” I see you are full. Here, let’s get you down so you can play,” then he will do one of two things:

1)      He will go play. He was not hungry in the first place.

2)      He will think twice about throwing food in the future because whenever he throws food, you put him down to play. He will learn to eat the food when he feels hungry instead of throwing it.

Sleep: The rule is that parents decide on reasonable bedtimes and naptimes. The toddler decides when he actually falls asleep. Singing to oneself or playing in the crib is fine. Even cries of protest are fine. Check to make sure he hasn’t pooped or knocked his binky out of the crib. After you change the poopy diaper/hand back the binky, LEAVE THE ROOM! Many parents tell me , “He just seems like he wants to play at 2:00am or he seems hungry.” Well, this assessment may be correct, but remember who is boss. Unless your family tradition is to play a game and have a snack every morning at 2:00am, then just say “No, time for sleep now,” and ignore his protests.

Pee/poop: The rule is that parents keep bowel movements soft by offering a healthy diet. The toddler who feels pain when he poops will do his best not to have a bowel movement. Going into potty training a year or two from now with a constipated child can lead to many battles. Also the toddler decides when he is brave enough or feels grown up enough to sit on the potty. Never force a toilet training child to sit on the potty. After all, did you force your toddler to learn how to use a remote control for your television? Of course not- he learned to use it by imitating you and wanting to be like you and by being pleased with the result (Cool! I turned on the TV!). The same principle applies to potty training. He will imitate you when he is ready, and will be pleased with the result when you praise him for his result.

Even if your child does not show interest in potty training for another year or two, talk up the advantages of putting pee and poop in the potty as early as age one. Remember, repetition is how kids learn.

Your toddler will test your resolve. He is now able to think to himself, “Is this STILL the rule?” or “What will happen if I do this?” That’s why he goes repeatedly to forbidden territory such as the TV or a standing lamp or plug outlet, stops when you say “No no!”, smiles, and proceeds to reach for the forbidden object.

When you feel exasperated by the number of times you need to redirect your toddler, remember that if toddlers learned everything the first time around, they wouldn’t need parenting. Permit your growing child to develop her emerging independence whenever safely possible. Encourage her to feed herself even if that is messier and slower. Allow her to fall asleep in her crib and resist rocking and giving a bottle to sleep. Everyone deserves to learn how to fall asleep independently (and to brush their teeth before bed). You don’t want to train a future insomniac adult.

And if you are baffled by your child’s running away from you one minute and clinging to you the next, just think how confused your child must feel: she’s driven towards independence on the one hand and on the other hand she knows she’s wholly dependent upon you for basic needs. Above all else, remember the goal of parenthood is to help your child grow into a confident, independent adult.

Julie Kardos, MD with Naline Lai, MD
©2015, revised from 2012
Two Peds in a Pod®

In spite of long TSA lines, rental car challenges and all the howling, the wolf family went to grandmother’s house every year for the holidays.

You don’t appreciate how much your baby has grown until you attempt a diaper change on a plane. For families with young children, any holiday can become stressful when travel is involved. Often families travel great distances to be together and attend parties that run later than children’s usual bedtime. Fancy food and fancy dress are common. Well-meaning relatives who see your children once a year can be too quick to hug and kiss, sending even not-so-shy kids running. Here are some tips for safer and smoother holiday travel:
If you are flying:

• Do not offer Benadryl (diphenhydramine) as a way of “insuring” sleep during a flight. Kids can have paradoxical reactions and become hyper instead of sleepy, and even if they do become sleepy, the added stimulation of flying can combine to produce an ornery, sleepy, tantrum-prone kid. Usually the drone of the plane is enough to sooth kids into a slumber.
• Not all kids develop ear pain on planes as they descend- some sleep right through landing. However, if needed you can offer pacifiers, bottles, drinks, or healthy snacks during take-off and landing because swallowing may help prevent pressure buildup and thus discomfort in the ears. And yes, it is okay to fly with an ear infection.

General tips for visiting:

• Traveling 400 miles away from home to spend a few days with close family and/or friends is not the time to solve your child’s chronic problems. Let’s say you have a child who is a poor sleeper and tries to climb into your bed every night at home. Knowing that even the best of sleepers often have difficulty sleeping in a new environment, just take your “bad sleeper” into your bed at bedtime and avoid your usual home routine of waking up every hour to walk her back into her room. Similarly, if you have a picky eater, pack her favorite portable meal as a backup for fancy dinners.  One exception is when you are trying to say bye-bye to the binkie or pacifier.
• Supervise your child’s eating and do not allow your child to overeat while you catch up with a distant relative or friend. Ginger-bread house vomit is DISGUSTING, as Dr. Kardos found out first-hand when one of her children ate too much of the beautiful and very generously-sized ginger bread house for dessert.
• Speaking of food, a good idea is to give your children a wholesome, healthy meal at home, or at your “home base,” before going to a holiday party that will be filled with food that will be foreign to your children. Hunger fuels tantrums so make sure his appetite needs are met. Then, you also won’t feel guilty letting him eat sweets at a party because he already ate healthy foods earlier in the day.
• If you have a young baby, be careful not to put yourself in a situation where you lose control of your ability to protect the baby from germs. Well-meaning family members love passing infants from person to person, smothering them with kisses along the way. Unfortunately, nose-to-nose kisses may spread cold and flu viruses along with holiday cheer.
• On the flip side, there are some family events, such as having your 95-year-old great-grandfather meet your baby for the first time, that are once-in-a-lifetime. So while you should be cautious on behalf of your child, ultimately, heed your heart. At six weeks old, Dr. Lai’s baby traveled several hours to see her grandfather in a hospital after he had a heart attack. Dr. Lai likes to think it made her father in law’s recovery go more smoothly.
• If you have a shy child, try to arrive early to the family gathering. This avoids the situation of walking into a house full of unfamiliar relatives or friends who can overwhelm him with their enthusiasm. Together, you and your shy child can explore the house, locate the toys, find the bathrooms, and become familiar with the party hosts. Then your child can become a greeter, or can simply play alone first before you introduce him to guests as they arrive. If possible, spend time in the days before the gathering sharing family photos and stories to familiarize your child with relatives or friends he may not see often.
• Sometimes you have to remember that once you have children, their needs come before yours. Although you eagerly anticipated a holiday reunion, your child may be too young to appreciate it for more than a couple of hours . An ill, overtired child makes everyone miserable. If your child has an illness, is tired, won’t use the unfamiliar bathroom, has eaten too many cookies and has a belly ache, or is in general crying, clingy, and miserable, despite your best efforts, just leave the party. You can console yourself that when your child is older his actions at that gathering will be the impetus for family legends, or at least will make for a funny story.
• Enjoy your CHILD’s perspective of holidays: enjoy his pride in learning new customs, his enthusiasm for opening gifts, his joy in playing with cousins he seldom sees, his excitement in reading holiday books, and his happiness as he spends extra time with you, his parents.

We wish you all the best this new year!

Julie Kardos, MD and Naline Lai, MD

©2014, 2015 Two Peds in a Pod®
Updated from our 2009 articles on these topics

Grief counselor Amy Keiper-Shaw joins us today to help families during the difficult time after a miscarriage or still birth occurs. — Drs. Lai and Kardos

If you are reading this, you or someone you love may have had a miscarriage. It is a tragic, often unexpected, experience that many families will encounter. 

Bereaved parents may feel great sadness, regret, shock, confusion, some or all of these emotions. There may be anger directed toward the doctor, a spouse, or other women who have been able to conceive easily and carry their pregnancies to full term. Some women feel guilt, as if there were something that they could have been done to prevent this loss.

What should you tell your children?

When adults experience a traumatic event like a miscarriage, they often are so consumed by their own grief that they fail to see that their children may be struggling with the same emotions. They may wonder what they should tell their children, if anything. Some parents may feel that the children are too young to be told about the miscarriage or believe they would not understand and instead wait until the children is older to explain it to them.

If the surviving children were not aware of the pregnancy, parents may wonder about the need for them to know about the loss. Even though you may not have told them about the pregnancy or the loss, they will likely know something is wrong and may act out. You might have been tearful, in pain, or angry, or you might have been in a hospital and away from home. The children’s routine might have changed, people could be speaking in hushed tones, and other family members may be visiting or bringing meals.   It is difficult to hide changes such as these from children. Often a child feels or sees this change and worries about the parents’ sadness and grief yet he may not have the skills to talk about it. If children are not told what has occurred, they often develop their own ideas of what has happened, such as mom is sick and dying or they must have done something to make everyone act differently.

It is usually best to be honest, to use simple language and to give clear explanations. Avoid euphemisms. If you say “lost” to young children, they may worry that they will get “lost” as well. If you say the baby has fallen asleep, they may become frightened of falling asleep or have nightmares.

You may also need to reassure them that the miscarriage was not anyone’s fault. Children might believe that they are somehow to blame, especially if they weren’t happy about the idea of a new sibling. One of the children who came to my bereavement camp carried the guilt of his baby sister’s death for nearly five years. He believed that because he asked God for a baby brother and not a sister, he had somehow caused her death. It was only by talking about it and processing those feelings in a supportive, safe environment that he came to understand that he had done nothing wrong.

If your children were aware of the pregnancy, they would probably need to be told about the miscarriage promptly. If they are small children, a later time might be more appropriate when they are more able to comprehend what has occurred.

Very young children are likely to pick up on the feelings of the adults around them, but will not fully understand the finality of the loss.   Children under five will have some awareness of death. They may ask questions to try to make sense of what has happened, such as “Where has the baby gone? When will the baby come back?”

By the age of eight or nine, most children will understand that the baby is gone and not returning. As one parent illustrates, “We explained to her that sometimes, for no reason and through nobody’s fault, babies can die.”

Teenagers will think about death like an adult. At any stage, there will most likely be questions about the baby that died as the loss is processed.

Children as well as adults react in their own way to a miscarriage. You may see your children being more “clingy”, acting out at home or school, or having tantrums. They may have disturbed sleep, appetite or concentration. They may have a lot of questions and need to share them with you or someone else they trust. They may also withdraw.

When parents can share their grief with their children openly and honestly, it implies to the child that it is understandable to be sad. This is a family loss that they will get though together. Some suggestions to help acknowledge the death are:

• Read books together
• Plant a tree or bush in memory of the baby
• Make a memory book of special things from the pregnancy
• Write a note to the baby on a string attached to a balloon and release it
• Participate in art/creative activities: painting, music, poetry, writing
• Visit the grave together

If you would like more information on helping children cope with a loss, please view the website for Hands Holding Hearts, a nonprofit organization in Bucks County, Pennsylvania that supports grieving children and their families.

Amy Keiper Shaw

©2015 Two Peds in a Pod®

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.

Why do babies cry? In short, newborns cry to communicate. Remember, newborns cannot talk. They can’t even smile back at you until around six weeks of age.
Ah, but what are they trying to tell us? Babies cry when they…

• Are tired.
• Are hungry.
• Feel too cold.
• Feel too hot.
• Need to be changed –I never really believed this reason before I had my twins. My firstborn couldn’t have cared less if he was wet and could nap right through a really poopy diaper. Then I had my twins.  I was amazed that their crying stopped if I changed the tiniest bit of poop or a wet diaper. Go figure.
• Are bored. Perhaps she is tired of the Mozart you play and prefers some good hard rock music instead. Maybe she wants a car ride or a change of scenery. Try moving her to another room in the house.
• Feel pain. Search for a piece of hair wrapped around a finger or toe and make sure she isn’t out-growing the elastic wrist or ankle band on her clothing.
• Need to be swaddled. Remember a fetus spends the last trimester squished inside of her mom. Discovering her own randomly flailing arms and legs can be disconcerting to a newborn.
• Need to be UN-swaddled. Hey, some like the freedom to flail.
• Need to be rocked/moved. Dr. Lai’s firstborn spent hours tightly wrapped and held by her dad in a nearly upside down position nicknamed “upside-down-hotdog” while he paced all around the living room.
• Need to burp. Lay her down for a minute and bring her up again to see if you can elicit a burp.
• Are gassy. Bicycle his legs while he is on his back. Position him over your shoulder so that his belly presses against you. You’d be gassy too if you couldn’t move very well. The gassy baby is a topic for this entire post– talk to your doctor for other ideas.
• Are sick. Watch for fever, inability to feed normally, labored breathing, diarrhea or vomiting. Check and see if anything is swollen or not moving. Listen to his cry. Is it thin, whimper-like (sick) or is it loud and strong (not so sick)? Do not hesitate to check with your pediatrician. Fever in a baby younger than eight weeks old is considered 100.4 degrees F or higher measured rectally. A feverish newborn needs immediate medical attention.

What if you’re certain that the temperature in the room is moderate, you recently changed his diaper, and he ate less than an hour ago?

• • Walk outside with your baby– this can be a magic “crying be gone” trick. Fresh air seems to improve a newborn’s mood.
  • Offer a pacifier. Try many different shapes of pacifiers. Marinade a pacifier in breast milk or formula to increase the chance your baby will accept it.
    Pick him up, dance with him, or walk around the house with him. You can’t spoil a newborn.
  • Vacuum your house. Weird, but it can work like a charm. Place him in a baby frontal backpack or in a sling while cleaning.
  • Try another feeding, maybe he’s having a growth spurt.
  • When all else fails, try putting him down in his crib in a darkened room. Crying can result from overstimulation. Wait a minute or two. He may self-settle and go to sleep. If not, go get him. The act of rescuing him may stop the wailing.
  • If mommy or daddy is crying at this point, call your own mom or dad or call a close friend. Your baby knows your voice and maybe hearing you speak calmly to another adult will lull him into contentment.
  • Call your child’s health care provider and review signs of illness.

If you feel anger and resentment toward your crying baby, just put him down, walk outside and count to ten. It is impossible to think rationally when you are angry and you may hurt your child in order to stop your frustration. Seek counseling if these feelings continue.

Now for the light at the end of the newborn parenting tunnel: the peak age when babies cry is six weeks old. At that point, infants can cry for up to THREE HOURS per day. Babies with colic cry MORE than three hours per day. (Can you believe people actually studied this? I am amused that Dr. Lai won a prize in medical school for a paper on the history of colic). By three months of age crying time drops dramatically.

While most crying babies are healthy babies and just need to find the perfect upside-down-hot-dog position, an inability to soothe your baby can be a sign that she is sick. Never hesitate to call your baby’s doctor if your baby is inconsolable, and don’t listen to the people who say, “Why do babies cry?…They just do.”

Julie Kardos, MD and Naline Lai, MD
©2015, 2010 Two Peds in a Pod®

For those of you who plan ahead: It’s gift-giving season! We love pop culture, but if you are tired of GameStop gift cards or feeling a bit overwhelmed by  Frozen, Star Wars and Minecraft marketing, here’s another list of ideas 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-soothe 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 often 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 herself up to a standing position, 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.

At 12 months your baby no longer needs to suck from a bottle or the breast for hydration. Although we don’t believe mastery of a  sippy cups is a necessary developmental milestone, Dr. Lai does admire the WOW cup because  your child can drink from it like she does from a regular cup. Alternatively, you can give fun, colored actual traditional plastic cups, which difficult to break and encourage drinking from a real cup.

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. Looking ahead, in the spring a three- year-old may start participating in team sports (although they often go the wrong way down the field) or in other classes such as dance or swimming lessons. Give your relatives the gift of a shin guards and soccer ball with a shirt. Offer to pay for swim lessons and package a gift certificate with a pair of goggles.  

3-4 years: Now kids engage in elaborate imaginary play. They enjoy “dress up” clothes to create characters- super heroes, dancers, wizards, princesses, kings, queens, animals. Kids also enjoy props for their pretend play, such as plastic kitchen gadgets, magic wands, and building blocks. 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.  Preschool kids now understand and execute the process of washing their hands independently… one problem… they can’t reach the faucets on the sink. A personalized, sturdy step stool will be appreciated for years. 

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 (here is one way to teach kids about money). The kids will appreciate gifts such as a real 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. Kids at this age love doodling on the long rolls of paper on our exam table. Get your kid a few rolls of banner paper to duplicate the fun. Buy two plastic recorders, one for you and one for your child, to play duets. The instrument is simple enough for ten-year-olds or forty-year-olds 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 kids’ 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. Cool techy trackers like Fitbit will always appreciated or treat your teen to moisture wicking work-out clothes.

Sleep! Who doesn’t need it, and teens often short change themselves on sleep and fall into poor sleep habits.  Help a teen enjoy a comfortable night of rest and buy  luxurious high thread count pillow cases, foam memory pillows, or even a new mattress. After all,  it been nearly 20 years since you bought your teen a  mattress and he probably wasn’t old enough at the time to tell you if he was comfortable. Since a teen often goes to bed later than you do, a remote light control will be appreciated by all.

Adolescence is the age of abstract thinking and self awareness— Google “wall decals” and find a plethora of inexpensive ways to jazz up his or her room with inspiring quotes.

Enjoy your holiday shopping.

Naline Lai, MD and Julie Kardos, MD
©2012, 2014, 2015 Two Peds in a Pod®

We can tell from this past week at the office that croup season has started. DON’T PANIC! Read on to learn what to look for. Please also listen to our podcast on this same subject. Dr. Lai heard one mom say that she listened to the podcast three times in one night…nights with croup can be very long indeed. 

You wake up in the middle of the night to the sound of a seal barking…inside your house. More specifically, from inside a crib or toddler bed. Unless you actually have a pet seal, that sound is likely the sound of your child with croup.

“Croup” is the lay term for any viral illness causing swelling of the voice box (larynx)  which produces a seal-like cough. The actual medical term is “laryngotracheobronchitis.”  In adults, the same viruses may cause laryngitis and hoarseness, but minimal cough. In children the narrowest part of a child’s airway is his voice box. So not only does the child with croup sound hoarse when he talks and cries, but since he breathes through a much narrower opening, when he forces air out with a cough, he will sound like a barking seal. When a kid with croup breathes in, he may produce a weird guttural noise, called “stridor.”

Many viruses  cause croup, including  flu (influenza) viruses. Therefore, a flu vaccine can protect against croup. While no antibiotic or other medicine can kill the croup causing viruses, here are some ways to help your child feel better.

What to do when your child has croup:

Stay calm. The noisy breathing and barky cough frighten children and their parents alike. It’s easier for the child to breathe when he is calm rather than anxious and crying. So, even if you are scared, try to act calmly since children take their cues from their parents.

Try steam. Run the shower high and hot, close the bathroom door and sit down on the bathroom rug with your child and sing a song or read a book or just rock him gently. The steam in the bathroom can help shrink the swelling in your child’s voice box and calm his breathing.

Go outside. For some reason, cool air also helps croup. The more misty the better. In fact, many a parent in the middle of the night has herded their barking, noisy breathing  child outside and into the cold car (with windows slightly cracked open) to drive to the hospital. Once in the emergency room, the parents are surprised to find a happily sleeping, or  wide awake, chatty child, “cured” by the cold night ride.

Run a humidifier. A cool-mist humidifier running in your child’s room will also help. Make her room feel like a rain forest, or the weather on a  really bad hair day, and often the croupy cough will subside. Cool-mist humidifiers in the child’s room are safer than hot air vaporizers because vaporizers pose a burn risk. It’s the mist that helps, not the temperature of the mist.

Offer ibuprofen or acetaminophen. Your child may cough, and then cry, because her throat is sore. Pain relief will make her more comfortable and allow her to get back to sleep.

Who needs further treatment?

Most kids, more than 95%, who come down with croup, get better on their own at home. Typically, croup causes up to three nights of misery punctuated by trips into the cold night air or steam treatments. During the day, kids can seem quite well, with perhaps a slightly hoarse voice as the only reminder of the night’s tribulations. Why croup is worse at night and much better during the daytime hours remains a medical mystery. One theory is, just like ankles swell after one is upright all day, swelling in the voice box increases when people lie down. After the three nights, your child usually just exhibits typical cold symptoms with runny nose, a regular sounding cough, watery eyes, and a possible ear infection at the end. Then brace yourself for next time—kids predisposed to croup tend to get croup the next time a croup causing virus blows into town. But take heart, most kids outgrow the disposition for croup around six years of age.

Some kids do develop severe breathing difficulties. If your child shows any of these symptoms, get emergency medical care:

Turns pale or blue with coughing. Turning red in the face with coughing is not as dangerous.

Seems unable to swallow/unable to stop drooling.

Breathing fails to improve after steam, cool air, humidity, or breathing seems labored– nostrils flare with every breath or chest heaves with every breath—pull up their night shirts to check for this. See this link for an example of labored breathing.

Mental state is altered: your child does not recognize you or becomes inconsolable.

Child is unimmunized and has a high fever and drooling along with his croup symptoms: he may not have croup but rather epiglottitis, most commonly caused by a vaccine-preventable bacteria. This is a different, more severe illness that can be fatal and requires airway management as well as antibiotics in a hospital.

We searched the internet for a good example of what the “seal bark” cough of croup. The best imitation we found is actually the sound of a sea lion. We will have to ask a veterinarian sometime if seals and sea lions get croup. If so, what do they sound like?

Julie Kardos, MD and Naline Lai, MD
©2012, 2015 Two Peds in a Pod®

I always tell new moms that if you can breastfeed for two weeks, then you can breastfeed for two years. The point is, while our species has been breastfeeding for millions of years, sometimes it’s not intuitive. Getting to the two week point isn’t always easy, but once you’re there, you’ll be able to continue “forever.”

So, how to get through those first two weeks? Practice. Fortunately, your newborn will become hungry for a meal every two hours, on average, giving you many opportunities to practice. For the first few meals, a newborn can feel full after eating only one teaspoon of colostrum (the initial clear milk). The size of a person’s stomach is the size of his fist. For a baby, that’s pretty small. So relax about not making a lot of milk those first few days. But remember, your baby’s needs will change and she will start to require more milk. A nursing baby tells the mom’s body to produce more milk by stimulating the breast. Nurse more often and production will increase. Traditionally, moms are told to attempt a feeding every 2-3 hours. But babies do not come with timers, and Dr. Lai tells moms the interval of time between feeds is not as important as the number of times the breast is stimulated. Around 8-12 feedings a day is usually enough to get a mom’s milk to “come in.”

Some lactation consultants advocate allowing the baby to feed on one breast as long as she wants before switching sides. I am more of a proponent of efficiency (I had twins, after all). What works well for many of my patients for the first few days is to allow the baby to nurse for 5-8 minutes on one breast, then break suction and put the baby on the other breast for the same amount of time. If your baby still seems hungry, you can always put her back on the first breast for another five minutes, followed by the other breast again for five minutes. Work your way up to 10-15 minutes on each side once your milk is in, which can take up to one week for some women. Nursing the baby until a breast is empty gives the baby the rich hind milk as well as the initial, but less fatty fore milk. Close mom’s kitchen for at least an hour after feedings. Beware of being used as a human pacifier.

Advantages for this feeding practice:

1. Prevents your newborn from falling asleep before finishing a feeding because of the activity of changing sides
2. Stimulates both breasts to produce milk at every feeding
3. Prevents mom from feeling lopsided
4. Prevents mom from getting too sore
5. Allows time in between feedings for mom to eat, drink, nap, use the bathroom, shower (remember, these are essentials of life)
6. Teaches baby to eat in 30 minutes or less.

I have seen improved weight gain in babies whose moms breast feed in this way. However, if your baby gains weight well after feeding from one breast alone each feeding, or if you are not sore or dangerously fatigued from allowing your baby to feed for a longer time, then carry on!

How do you know if your baby is getting enough milk? While all babies lose weight after birth, babies should not lose more than 10% of their birth weight, and they should regain their birth weight by 2-3 weeks of life. Young babies should also pee and poop a lot (some poop after EVERY feeding) which is a reflection of getting enough breast milk.  Count on about one pee diaper for each day of life and one poop diaper for each day of life (three days old = 3 poop diapers and 3 urine diapers). Yellow poop is a sign that milk in going through your baby. Good urine output shows that your baby is well hydrated. Your child’s doctor will weigh your baby by two weeks of life to make sure he “makes weight.”

Many good sources can show you different suggestions for feeding positions. Experiment to see which is most comfortable for you and your baby. If you notice one spot on a breast is particularly full and tender, position your baby so that his chin points towards that spot. This may make for  awkward positions, but in this way, he drains milk more efficiently from the full spot.

When you first get home with your newborn, if the visitors in your house aren’t willing to do your dishes, then kick them out. It’s time to practice feeding.

Helpful websites:

To find a  lactation consultant near you see the International Lactation Consultant Association

For our moms across the world and the States- La Leche League International and The Children’s Hospital of Philadelphia- breastfeeding tips for beginners

For moms in Bucks, Mongomery and Philadelphia Counties, Pennsylvania- Nursing Mother’s Advisory Council

Julie Kardos, MD with Naline Lai, MD

©2012, 2015 Two Peds in a Pod®

Ouch! Stung on the scalp.

Ouch! Stung on the hand.

Ouch! Stung on the leg.

Ouch! Ouch! Stung TWICE on the lips.

Those nasty, nasty wasps. During the hot days of August, they become more and more territorial and attack anything near their nests. Today, in my yard, wasps mercilessly chased and attacked a fourth grader named Dan.

As everyone knows, you’d rather have something happen to yourself than have something negative happen to a child who is under your watch. As I had rolled out the Slip and Slide, I was relieved not to see any wasps hovering above nests buried in the lawn. I was also falsely reassured by the fact that our lawn had been recently mowed. I reasoned that anything lurking would have already attacked a lawn mower. Unfortunately, I failed to see the basketball sized grey wasp nest dangling insidiously above our heads in a tree. So, when a wayward ball shook the tree, the wasps found Dan.

What will you do in the same situation?

Assess the airway– signs of impending airway compromise include hoarseness, wheezing (whistle like sounds on inhalation or expiration), difficulty swallowing, and inability to talk. Ask if the child feels swelling, itchiness or burning (like hot peppers) in his or her mouth/throat. Watch for labored breathing. If you see the child’s ribs jut out with each breath, the child is struggling to pull air into his/her body. If you have Epinephrine (Epi-Pen or Auvi-Q) inject immediately- if you have to, you can inject through clothing. Call 911 immediately.

Calm the panic– being chased by a wasp is frightening and the child is more agitated over the disruption to his/her sense of security than over the pain of the sting. Use pain control /self calming techniques such as having the child breath slowly in through the nose and out through the mouth. Distract the child by having them “squeeze out” the pain out by squeezing your hand.

If the child was stung by a honey bee, if seen, scrape the stinger out with your fingernail or a credit card. Removal of the stinger prevents any venom left in the stinger from entering the site. Some feel scraping, rather than squeezing or pulling a stinger with tweezers lessen the amount of poison excreted. However, one study suggests otherwise. Wasps do not leave their stingers behind. Hence the reason they can sting multiple times. (Confused about the difference between wasps, hornets and yellow jackets? Wasps are members of the family Vespidae, which includes yellow jackets, hornets and paper wasps.) Relieve pain by administering Ibuprofen (trade names Motrin or Advil) or Acetaminophen (trade name Tylenol).

As you would with any break in the skin, to prevent infection, wash the affected areas with mild soap and water.

Decrease the swelling and itch. Histamine produces redness, swelling and itch. Counter any histamine release with an oral antihistamine such as Diphenhydramine (trade name Benadryl). Any antihistamine will be helpful, but generally the older ones like Diphenhydramine tend to work the best in these instances. Just be aware that sleepiness is a common side effect.

To decrease overall swelling elevate the affected area.

Soothe the area by spreading on calamine lotion or by applying a topical steroid like hydrocortisone 1%.

And don’t forget, ice, ice and more ice. Fifteen minutes of indirect ice (wrap in a towel, for example) on and fifteen minutes off helps relieve both pain and itching.

Even if the child’s airway is okay, if the child is particularly swollen, or has numerous bites, a pediatrician may elect to add oral steroids to a child’s treatment

It is almost midnight as I write this blog post. Now that I know all of my kids are safely tucked in their beds, and I know that Dan is fine, I turn my mind to one final matter: Wasps beware – I know that at night you return to your nest. My husband is going outside now with a can of insecticide. Never, never mess with the mother bear…at least on my watch.

Naline Lai, MD with Julie Kardos, MD

2015, updated from 2009, Two Peds in a Pod®