Remember Elmer Fudd from the Bug Bunny cartoons? He was the hunter who would say “Where’s the wascally wabbit?” instead of “Where’s the rascally rabbit?” Think how frustrated Elmer was as a kid when his parents and teachers didn’t understand him.   

Unclear speech or lack of speech development can be a sign of hearing loss or an inability to communicate (autism, retardation or developmental delay).  Amy King, MA, CCC-SLP with over 12 years as a speech therapist outlines important speech and language milestones to watch for: 

Receptive Language Milestones- what your child understands (children should be doing these things by the time they reach the year marker)

By the time they are

1 year:  shakes head to respond to simple questions such as “Want milk?” and identifies some body parts

2 years:  Follows 1 step directions- “Go get the ball.”

3 years:  Follows 2 step directions- “Go get the ball and give it to daddy.” 

4 years:  Understands if/then- “If you pick up your toys, then you can help Mommy make a cake.”

5 years:  Follows 3 step directions- “After you wash your hands, get the napkins and put them on the table.” 

Expressive Language Milestones- what your child is able to say

1 year: 1 word

2 years: 2 word sentences- two words with one meaning such as “thank you” does not count. Expect phrases such as “mommy up” for “mommy, pick me up.”

3 years: 3 to 5 words—Dr. Kardos tells parents think Cookie Monster from Sesame Street: “me want cookie”

4 years: 4 to 7 word sentences with consistent correct use of parts of speech (nouns, verbs, adjectives, pronouns, prepositions, etc.): “I want to go to the park.” 

Speech Milestones- phonetics (sounds should be produced accurately and consistently in words and phrases)

By the time they are:   

3 Years:  sounds of the letters:  m, b, p, h, w, n, f,

 4 Years:  t, k, g, ng, s, r, sh

5 Years:  z, l, v, y, th, wh, ch

6 Years:  j, st, br, cl, r (by now if not before) 

Speech Intelligibility -how well strangers understand your child

         2 Years:     at least 25%-50% of what your two year old is saying

         2 ½ Years:  at least 60%-75% of what your two and a half year old is saying

         3 Years:      at least 75%-90% of what your three year old is saying

         4 Years:      at least 95% of what your four year old is saying 

Fluency- stuttering

         Stuttering is normal in the preschool years.  Be sure to give the child time to say what she is trying to say. Dr. Lai likes to think of a preschool stutterer as a child whose mind is thinking faster than he can move his mouth. If stuttering lasts more than 6 months and is accompanied by facial contortions, grimaces, or repetitive body movements, speak to a medical professional. 

Red flags that always need further workup:

o  Does not coo by 4 months of age

o  Does not babble by 9 months of age

o  Child does not respond to his/her name by 9 months of age

o  Child does not look at you, others or objects upon request by 9 months of age

o  Does not gesture (point, wave, grasp, etc.) by 12 months of age

o  Child does not respond to your simple verbal requests (e.g., “Look!”, “Wave bye-bye”, “Come here”, “Give a kiss,” etc.) by 12 months of age

o  Does not say single words by 16 months of age

o  Does not say two-word phrases on his or her own (rather than just repeating what someone says to him or her) by 24 months of age

o  Loss of any language or social skill at any age

 Amy King, MA, CCC-SLP

©2010 Two Peds In a Pod


Dr. Dave, a friend of Dr. Kardos, is a physician in a Student Health Center at a respectable college in a large city. Here is an alarming, yet typical, scenario involving binge drinking that Dr. Dave encounters on a too-frequent basis.


A 19 year old young man comes in to the Student Health Center very concerned because he had woken up that morning in an apartment in bed with a woman he did not know. He had been out with friends drinking at a bar (a frequent occurrence), vaguely recalls meeting a woman, but had so much to drink that he cannot even recall leaving the bar, let alone what happened afterward. His greatest concern is that he has no idea if he used a condom (he left before she woke up), and thus could have been exposed to HIV and other sexually transmitted infections.

Ironically, this student is worried about exposure to sexually transmitted diseases but not about the root of his problem: binge drinking. In other words, he is worried about sexually transmitted diseases but not about his drinking which caused his potential exposure to dangerous diseases.

Here is what Dr. Dave, a career student health doctor, wants parents of college students to know about binge drinking in college students:

Although alcohol use is often considered a rite of passage for college students, it is also one of the major health risks for this age group.  Alcohol-related health problems can present in a variety of ways and do not have to involve any signs of dependency.  Among college-aged students, the most common manifestation of alcohol abuse comes from the consequences of binge drinking.  

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) reports the following sobering statistics regarding annual health risks directly attributed to alcohol use among college students between the ages of 18 and 24.  These statistics also serve as an important reminder that a person does not have to be drinking to be adversely affected by alcohol abuse.

·         1,400 student deaths from alcohol-related unintentional injuries (including motor vehicle accidents)

·         500,000 unintentional student injuries 

·         More than 600,000 cases of student-on-student assault 

·         More than 70,000 cases of sexual assault or date rape

·         400,000 students having unprotected sex and more than 100,000 students too intoxicated to remember if sex was consensual.

The first 6 weeks of the first semester of college is an important predictor of first year academic performance and is an important window period to monitor for any significant changes in a new student’s behavior and lifestyle habits.  Parents can help by being aware of these issues and by being open to speaking with their children about the potential risks of alcohol use both before and during the college experience.  A simple rule of thumb for parents is to stay involved, while still allowing their children the space necessary for learning, exploring, and maturing into adulthood. 

If your child begins to exhibit unusual behavior, such as lower grades, mood changes, or a new unwillingness to talk to you, this behavior should prompt you to find out more. 

Additional information is available at

Dr. Dave, MD is a physician who has been working in college health since 2000.

© 2010 Two Peds in a Pod



Three little kittensthey lost their mittens, and they began to cry. 

Oh, mother dear,  we sadly fear That we have lost our mittens. 

What! Lost your mittens, you naughty kittens! 

Then you shall have no Nintendo   DS 

    -the modern version of a traditional poem



It’s only January and pictured here is a photo of my three kittens’ mittens (gloves) which are already missing mates.


Prolonged exposure to cold can lead to injury in body parts with relatively less blood flow such as the ears, fingers and toes. In frostbite, injury occurs secondary to ice crystals which form within or between the cells in your body. Injury can be so severe that the tissue dies and infection sets in.


Early signs of frostbite include tingling or achiness. Without treatment, the area will become pale and lose all sensation.


If you suspect your child’s hands are starting to become frostbitten, first remove all wet clothing. Rewarm the area by placing immediately in warm water.  Think opposite of a burn- where you use cold water. Do not massage the hand as this may cause further injury, but do encourage your child to move his hands. As very cold hands warm up, they will become blotchy and painful or itchy. Ibuprofen (brand names Motrin and Advil)or acetaminophen (Tylenol) will be helpful.  Warm for at least half an hour even if it is painful.


Signs of actual frostbite are blistering, numbness, or color changes. As my sister, an emergency room doctor says, red is good. Black and white are not.


Head over to the emergency room if you think your child has frostbite. To avoid the risk of over-heating and to manage the pain of treating frost bite, thawing for frost bite should be medically supervised. Just as you would seek care for a burn, seek medical care for a cold induced injury. To rewarm properly, the frostbitten part of the body should be submerged in warm 37-to-40 C (98 -to-104 F) water.  No higher because then it’s like trying to defrost a chicken. You will end up cooking rather than thawing the tissue, says my sister. Also a big no-no: starting to thaw but then not completing the thaw. Thaw-refreeze-thaw will injure tissue, same as it ruins a defrosting chicken. So again, seek medical attention for your child if you suspect frost bite has set in.

For a recent interesting, but somewhat technical article with photographs on a case of frostbite, check out the New England Journal of Medicine, N Engl J Med 2009;361:2654-62


Naline Lai, MD

Two Peds in a Pod © 2010.




Haiti, one of the poorest countries in theWestern Hemisphere, was struck by a devastating earthquake last week.

If you are looking for a way to help the children, consider donating to the American Academy of Pediatrics Friends of Children Disaster Relief Fund. The American Academy of Pediatrics has used this fund in the past to respond to disasters that affect children in the US, such as hurricanes Katrina and Ike, and worldwide, such as recent earthquakes in China.

 The fund provides emergency relief to pediatricians and the children they treat by:

 Addressing primary health care needs ofchildren;

 Supporting medical services (example: power generators for medical facilities, replacement of medical equipment damaged by the disaster);

 Supporting future disaster preparedness and response programs with a special focus on children.

 Naline Lai, MD and Julie Kardos, MD
© 2010 Two Peds In a Pod 


How can I tell if my child has strep throat?

The definitive way to diagnose strep throat is for a health care provider to get a sample of the sore throat germs from your child by using a long cotton swab to gently swipe the sore throat and send the germs to a laboratory for culture. The laboratory lets the germs grow to determine if the Strep Throat bacteria grows from your child’s throat.

Thus, strep throat cannot be diagnosed over the telephone. Nor can health care providers rely solely on physical exam findings, because while there is a “classic” look to strep throat, some kids have normal appearing throats yet the test reveals strep, while others have yucky looking throats but in fact have some other viral infection causing their sore throat and thus do not need antibiotic treatment since antibiotics do not cure viruses. Health care providers ask questions about your child’s symptoms and perform a thorough physical exam and then do a “strep test” if they are suspicious that your child may have strep throat.

Many pediatric offices use rapid strep tests to help make a quick decision about treatment because the strep culture takes  about 48 hours or so to finalize. These tests are fairly reliable, but sometimes the quick test is negative (shows NO strep) even if strep is present, so most offices will send a culture back-up if the rapid test is negative (no strep germs found). The other problem with the quick test is that once your child has strep, the quick test stays positive for about a month, even if your child no longer has strep disease. So if a child is treated for strep throat and then develops another sore throat within a month of treatment, that child needs a strep culture back up if the office quick test is positive.

To further complicate matters, some kids “carry” the strep germ in their throats but never develop the disease (no sore throat or illness symptoms). These kids will test positive for strep but do not require treatment. This is why we do not routinely check kids for strep throat unless they have symptoms of strep throat.

My child was treated for strep throat. We used all of the antibiotic. Three days later his sore throat is back. Why did this happen?

The most common reason for getting two episodes of strep throat close together is that your child contracted the germ again, usually from a classmate in school. If your child gets strep throat again, it is usually not because the antibiotic didn’t work but rather it is from bad luck. Most doctors treat a second episode of strep with the same medicine used the first time around.

Luckily, strep throat has not shown much, if any, resistance to standard antibiotic therapy. The reason that children (and adults) are treated for a full course of antibiotic is that this duration is known to prevent some of the complications of strep throat. You should give your child the complete course of antibiotic her health care provider prescribes, even if she “feels better” part way through the treatment. In addition to treating with antibiotic, be sure to provide pain medicine such as acetaminophen (brand name Tylenol) or ibuprofen (Motrin or Advil) to treat sore throat pain as needed.

Reasons to contact your child’s health care provider during treatment would be increasing pain, inability to swallow, or looking worse instead of better during the course of treatment.



Julie Kardos, MD
© 2010 Two Peds in a Pod




You just got the call from the school nurse, who tells you: “I have your child here with me and she has a sore throat. I think you need to take her to the doctor to see if it’s strep throat.”

What exactly IS Strep Throat?

Strep throat is a throat infection caused by Group A streptococcus bacteria. Symptoms can include sore throat, fever, pain with swallowing, enlarged lymph nodes (glands) in the neck, headache, belly pain, vomiting, and rash. Not all symptoms are present in all kids with strep throat.

Symptoms do NOT include cough, profuse runny nose, or diarrhea. Only about 15 percent of all kids coming to our offices with a main concern of “sore throat” are going to actually have strep throat. That means that MOST kids with sore throats will turn out to have something other than strep throat, usually some form of virus causing pain or post-nasal drip.

Who gets Strep Throat?

The most common age for kids to get strep throat is between ages 5 to 12 years old. For some reason, kids younger than 3 years are not as prone to strep throat. Also strep throat is seen less often in adults than school aged kids.  Some children appear really ill with strep throat and other kids just have a bad sore throat, but with pain medicine can look quite well.

So why do we care about strep throat?

Most children’s immune systems are really good at fighting the strep germ off and in fact most kids will get better from strep throat even if they are not treated. However, some kids’ immune systems get a little haywire when fighting the strep germ, and in addition to making antibodies (germ-fighting cells) to fight the strep, they make antibodies against their own heart valves (immune system gets confused) which causes rheumatic fever. It has been shown that treating strep throat with antibiotics shortens the duration of strep throat only by about one day, but more importantly prevents the body from making the wrong kind of immune cells, or antibodies, against the heart valves thus lowering the risk of rheumatic heart disease.

Strep throat can also lead to other complications such as scarlet fever (strep throat plus sandpaper-feeling rash on the skin), peritonsilar abscesses (pus pocket in the tonsils) and kidney inflammation (first symptom can be cola-colored urine).

Stay tuned for Part 2 about Strep Throat: how it is diagnosed and treated.

Julie Kardos, MD
© 2010 Two Peds in a Pod      


Ode to the Binkie

Bed time when toddlers start to shout,

It is you, dear binkie, who knocks them out.

Those thumb suckers look so snide,

But haven’t been without you on a long car ride.

None in the diaper bag, none in the crib?

Take one from our infant sib.

If you touch the ground, I’ll give you a quick blow,

Back into the mouth you’ll just go.

But now my child can run and jump with both feet off the ground,

Two to three word sentences she can sound.

If old enough to politely ask for you,

Then old enough to make permanent teeth go askew.

Oh dear binkie, you once had your place,

Now let’s take the cork from the face.

Once you were our beloved binkie,

But right now… you are just stinky.


Whether you love or hate the pacifier, at some point, to avoid the possibility of dental and speech articulation impairment, your child needs to wean. Besides, it’s nice to see your child’s entire face. The easiest time to wean is usually around two to three years old. At that point, your child’s dependence on sucking for self-comfort begins to lessen and he begins to want to dissociate himself from being a “baby.”

Now that it’s the New Year, here are some ways to say bye-bye to the binkie, if this is on your child’s (or your) resolution list.

  • Throw the pacifier across the room and entice your child to say with you, “Yucky, binkies are for babies.”
  • Restrict pacifiers to specific places such as your home, crib, or bed
  • Take a  “Binkie finding hunt” with your child and gather all the binkies into a basket. Have the binkie fairy come overnight, take the basket, and leave a present in the morning. Alternatively, one set of parents told me that they told their child that they were gathering binkies for babies who didn’t have any.
  • If giving your child a pacifier is part of your bedtime routine, start to introduce something else such as a special blanket or stuffed animal.
  • Sometimes as parents, we are the ones who have to be weaned. When your child is upset, do not automatically pop a binkie into your child’s mouth. Seek other ways to help your child calm himself
  • Vow to yourself not to buy new pacifiers at the grocery store. Gradually the pacifiers left in the house will disappear or the mold on them will prompt you to throw them away.
  • Cut a small hole in the tip of the nipple- the binkie will not “be the same.” Tell your child that the binkie is broken and throw it away.
  • Vacations disrupt schedules. Therefor, sometimes in an unfamiliar bed, children wean habits. Conveniently forget the binkie while going on vacation and do not introduce it on return home.
  • By age three, most kids appreciate the value of a good bribe. Offer them a reward for going a whole week (or at least 3 days) without the binkie. One night doesn’t count because often the second night is more difficult for the child than the first when he is giving up the binkie. Once you have gone a week, the child will have no desire to go back. Just make sure you have disposed of every last binkie in your home so they will not have reminders of the “good old days.”

Naline Lai, MD with Julie Kardos, MD

Poem by Dr. Lai

©2010 Two Peds in a Pod®

Special note: all of Dr. Lai’s and Dr. Kardos’s children are former binkie users. You could call us “binkie specialists.” Leave a comment about how your child weaned.



 We are thrilled to release our first podcast recorded from a podcast party!

We recorded with GNO, a  group of dynamic moms with young school aged children (pictured above).  GNO stands for Girls Night Out. That evening, Two Peds in a Pod was “the night out.” The recording you hear below is a distillation (with a few later additions) of the conversation we had on three topics: tantrums, anxiety and tics.  We found the discussion reflected the concerns of parents of kindergarteners and first and second graders whom we see in the office.

In photo: Dr. Kardos on left and Dr. Lai on right.

Live in the greater Philadelphia area? Give a Two Peds in a Pod podcast party as a gift or host one yourself.  Email us at

(If you subscribe via Atom feed or do not see a podcast player displayed, please go to our website

 Happy New Year

Naline Lai, MD and Julie Kardos, MD
© 2009 Two Peds in a Pod


Mothers and fathers of twins know that parenting twins is not “twice the work” of singletons. Parenting twins is “EXPONENTIALLY the work” of parenting singletons. Think “singleton, squared.” I know. Not only do I care for twins (and triplets!) in the office, but also I have a set at home.

Discipline is tough. Twins squabble just like other siblings. The difficulty lies in that twins are at the exact same developmental stage as each other. In contrast, when you have a two-year-old and a four-year-old child, for example, you expect the two-year-old to not understand sharing or turn taking and you expect the four-year-old to understand both. Then, you can patiently explain to a four-year-old, “Well, if your younger sister has the doll, and you want it, you can make her very interested in another toy. Then, trade her the toy for the doll.”

When you have two-year-olds fighting over the same toy, you have few options. You can force turn taking, which always involves crying (for the one who is waiting for her turn). You can put the toy in time out which causes both twins to cry. Or you can put both twins in time out which, to help you visualize, can be like putting two angry Houdini octopi into a net together.

Turn taking can be taught using the “count to ten” method. Take this scenario: both twins “need” the same red car at the exact same time. You know that the only reason twin B wants the car is because twin A has the car (this is the same logic as for any sibling: “I covet what you have because you have it.”) You give the car to twin A and stay with twin B, hold his hand, and say, “When we get to ten, your brother will give the car to you.” Then you slowly count out loud to ten. If twin A does not give up the car, then gently take the car from him and say, “Now your brother gets the car until we get to ten.” Stay with twin A while twin B plays with the car and you count out loud to ten. Keep switching off until one brother says “I don’t want it” or simply gives the car away by the time you get to 3 or 4 in your count.

Using the “count to ten” method teaches several lessons: 1) how to count to ten, 2) how to wait your turn, and 3) that fairness matters in your home.  You also convey to your child that you will not abandon a crying, frustrated two-year-old. The textbooks say that two-year-olds are young to learn to share.  However, twins must learn how to share. And you know what? This method works.

When my twins started preschool at two-and-one-half years old, I warned their teacher that if she saw either of my twins standing next to a classmate and counting to ten slowly, loudly, and deliberately, that my child would expect that child to hand over whatever toy she had when my child got to ten! I had to prep my twins that home rules may differ from classroom rules.

What about time out? Time out doesn’t work as well with toddler twins. If one twin is in time out, the other twin will sabotage the time out by making a raucous.  One time, I put one of my twins in time out for biting the other one.  Because the biter was crying, the victim startled me when he also started crying and yelling “Let him out of Time Out, Mommy!”  One way around this is to put the toy that precipitated the squabble in time out instead of the child (one minute per year of the twin’s age). 

Even at the end of the day, discipline for twins differs. For twins who share a bedroom, every night is a slumber party. When my twins became old enough to talk to each other before falling asleep, I moved their bedtime earlier to allow them extra time to talk.  I found their conversations too cute to interrupt and didn’t have the heart to enforce sleep time. Plus I like to think that it made up for any bickering (ok, fighting and tears) that occurred during that day and allowed for extra bonding time. Like so many other aspects of parenting, sometimes you just have to go with the flow.

Julie Kardos, MD with Naline Lai, MD
© 2009 Two Peds in a Pod
With special thanks to my psychology-major lawyer-friend Karen for passing on the “count to ten” stroke of genius method of teaching “twin sharing.”


The American Academy of Pediatrics has increased the recommended daily requirement for Vitamin D in children and adolescents to 400 IU (international units), based on studies of decreasing bone density in kids. This is equivalent to 32 ounces of milk per day. This is TOO MUCH milk for anyone other than an older formula-fed baby who has not yet started solids foods. All breastfed babies, babies on formula AND solid foods, and all other children and teens should be given a vitamin D supplement such as Tri-Vi-Sol or a chewable children’s vitamin. Read the labels: look for “Vitamin D—400 IU.” The goal is to prevent rickets (a bone disease that results in brittle bones) and to make sure growing bones reach their maximum potential for strength. Vitamin D is also important for other body systems such as the immune system.

Interestingly, 15 to 30 minutes of direct sunlight per week is all kids need to absorb enough vitamin D through skin. However, concern for increased risk of skin cancer from cumulative sun exposure means that kids are absorbing less vitamin D from sunlight because we parents are so good at applying sunscreen. Also, especially in winter months, children spend more time playing inside than playing outside.

Calcium requirements vary somewhat by age but generally can be met with 16 to 24 ounces (2-3 cups) of milk, or less if kids consume other calcium containing foods such as cheese, yogurt, broccoli, sweet potatoes, fortified cereals, or a supplement. The milligram (mg) requirements are around 500mg for toddlers, 800mg for children and 1200-1500mg for kids 11-18 years. To give you an idea of how to visualize this amount, one cup of milk contains 300mg of calcium. When you read food labels that report calcium as a percent of daily requirement, know that the “standard” for food labels is set as 1000mg. So if a yogurt container reports “25% of daily calcium requirement” you assume that the yogurt contains 250mg of calcium (25% of 1000mg).

So continue to have your kids Drink Milk! But remember to give them a Vitamin D supplement as well.

For more interesting tidbits about milk, please refer to our blog post: “Got Milk? Dispelling Myths About Milk

Julie Kardos, MD
©2009 Two Peds in a Pod