Two Peds in a Pod®

Quick flu vaccine update: what’s new in 2010 for kids

Vaccine protection against flu (influenza) is coming soon. Thankfully, last year’s confusion caused by two separate vaccines is eliminated. This year’s flu vaccine, both the injectable and the nasal forms, protects against both novel H1N1 and the season strains of flu. Not only from a confusion standpoint, but also from a health benefit standpoint, this is good news. Unlike seasonal flu, which causes severe disease in both the elderly and youngsters, 90 percent of deaths from H1N1 were in people younger than age 65 years.

The current recommendation of the US Center for Disease Control (http://www.cdc.gov/flu ) is to immunize ALL children against flu starting at six months of age (if local supplies are limited, the highest risk groups will be targeted). All household members and caregivers of babies too young to receive the immunization should also be vaccinated, as well as all caregivers of children of any age.

As always, children nine years old and older need only ONE dose of flu vaccine this year. Children below nine (eight years old and younger) will receive one dose of flu vaccine this year as long as they received at least two doses of seasonal flu and one dose of H1N1 vaccine in the past.

The children who need two doses of flu vaccine this year are the ones younger than nine years old who received zero or one seasonalflu vaccine in the past or who have never received H1N1 vaccine.

With school start comes illness season, so remember to schedule your children for their flu vaccines early this fall. Speak with your child’s health care provider about which form of flu vaccine is appropriate for him or her. Then schedule your own flu vaccine.

Remember the artwork from last year? The picture is a rendition of H1N1 from the perspective of a kindergartener. Note the large boogie to nose ratio. The red represents “boss germs” and the purple shows the “just plain mean ones.”

Ah-CHOO! Banish FLU!

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

Sept 16, 2010 a quick add- if your child actually had H1N1 last year (confirmed by a test) you can consider it the same as getting the H1N1 vaccine in the 2009 season (just building up immunity the hard way)

August 15, 2010 by twopedsinapod

Tips on caring for your son’s circumcision

Ok, so now you are in charge of caring for a newly circumcised penis. As a mom who’s never had a penis or as a dad who has no memory of his pre-circumcised days, you may have questions after you leave the hospital about how to care for this “wound.”

Unlike most infants in the world, in the United States, most boys are circumcised. Parents choose to circumcise their sons for various reasons including medical and cultural beliefs. In this blog post I will not address any debates about circumcision. I will only address care of the recently circumcised penis.

It takes about one week for a circumcised penis to fully heal. This is not long in the scheme of things. While there are no absolute standards of circumcision care, most providers recommend putting a walnut size amount of either petroleum ointment or antibiotic ointment directly onto the head of the penis at every diaper change for the first 3 or 4 days. Some find it easier to dollop the ointment onto a gauze pad and then tuck the ointment covered pad into the diaper.

Be sure to clean any stool on the penis using mild soap and water. Some white, gray, or yellow material will accumulate on the head of the penis around the third or fourth day. This material, called granulation tissue, is a normal part of the healing process. (You may remember a similar healing process occured when you skinned your knee as a child). Go ahead and wash the goo with warm water, the secretions will disappear over the next few days.

Infection is rare, but does occur. Watch for an increase in swelling, an increase in redness, redness extending down the shaft of the penis, an increase in pain, pus discharge from the wound site, and fever of 100.4 F or higher. With any of these symptoms, take your child to be evaluated by your child’s health care provider.

Sometimes extra, or redundant, foreskin remains around the head of the penis. Over time, this extra tissue does retract back. Scar tissue rarely forms permanently because with each erection (yes, infants have erections) the head of the penis pulls away from the shaft. As the baby gets older, parents can gently pull back redundant skin with their hands when they give the baby a bath. If you are concerned about the appearance of your child’s penis, ask his health care provider to take a look.

One last tip: remember to point the penis DOWN when putting a new diaper on your son; otherwise he will urinate “up” through the diaper and all over his shirt. Trust me on this one.

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

August 13, 2010 by twopedsinapod

The Heart Ache of Heart Break-how to help your teen through a break-up

As summer dwindles, unfortunately so do the summer romances. Psychologist John Gannon guest blogs today on how to help your teen when a first love goes sour…

It happens to almost every adolescent. At some point or another, we all experienced our first love. In the early stages, it was the greatest feeling we had ever felt. When it ended, it was the largest and most powerful feeling of hurt that we had ever experienced. Each moment felt like 10 years. Days went by and life went on for everyone else. Yet, for us, life stopped and we felt lost and paralyzed.

Your child will not be the exception either. They will feel their feelings the same way we felt ours. Your response to their heart break might offer them comfort. It may also infuriate them. They might claim that you just don’t understand. They might sob inconsolably. In practicality, your life will also suffer! Nothing can take their pain away except the passage of time. I always speak about the scar that occurs from first love. I believe it is a necessary scar, so that we do not become lost without emotional boundaries. The price of the scar though, is the loss of emotional love with another person.

There are things you may want to consider when this occurs for your child. For instance, some teenagers have more than just a traditional break up syndrome. They enter a state of significant sadness or anxiety. It can be difficult to distinguish what is a break up and what is something else. Sometimes, they will try to self medicate with drugs or alcohol. They may be more likely to have poorer judgment than they typically would have. It’s good to try and be as emotionally available as they will let you. Don’t take it personally if they shut you away.

Fortunately, time does heal most of these feelings. One day, you will see they look brighter. They may start to smile. Luckily, first love happens only once in a lifetime for most of us. (Some people live life with every relationship as a first love.) Keep in touch with your kids during this time. Even if it appears they are being overly dramatic, they are inexperienced when it comes to affairs of the heart. The pain is real for them. First love can teach how to balance love. Sometimes, they may need to have several breakups to figure this out. Most of the time, we ultimately learn how love is kept in perspective and by doing so we do not lose our emotional well-being.

Finally, this is a passage of your child’s becoming an adult. Enjoy the ride!

John Gannon, MS, licensed psychologist

Gannon has over 25 years experience as a marriage and family therapist in the Philadelphia area. He has spoken both locally and nationally on family matters. He has addressed numerous teacher and parent groups, given advice on radio, and has appeared on The Montel Williams Show.

August 10, 2010 by twopedsinapod

Avoid back strain- what to look for in a school backpack

Just in time for the fall sales, physical therapist Dr. Deborah Stack returns to give us the low-down on backpacks.

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Believe it or not, there are only a few weeks left before school starts for the fall. As I look at last year’s first day of school photo, I notice my not-quite-100-pound child bending in half under the weight of a backpack, trombone, lunchbox and art portfolio. This year, I quietly decree, that scenario will not happen again. To make sure it does not happen at your house either, consider a few tidbits as you plan your back-to-school purchases:

-A traditional backpack with two shoulder straps distributes the weight more evenly than a pack or messenger bag with a single strap.

-Look for wide, padded straps. Narrow straps can dig in and limit circulation.

-A chest or waist strap can distribute weight more evenly.

-Look for a padded back to protect your child from pointy pencils etc.

-Look for a lightweight pack that does not add much overall weight.

–Multiple compartments can help distribute weight.

–Compression straps on the sides or bottom of a backpack can compress and stabilize the contents.

–Reflective material allows your child to be more visible on those rainy mornings.

–A well fitting backpack should match the size of the child. Shoulder straps should fit comfortably on the shoulder and under the arms, so that the arms can move freely. The bottom of the pack should rest in the contour of the lower back. The pack should “sit” evenly in the middle of the back, not “sag down” toward the buttocks.

How much should your tike tote? Experts, including the American Academy of Pediatrics and the American Physical Therapy Association, recommend kids should not carry backpacks weighing more than 15-20% of the kid’s weight.

Here’s a chart to give you an idea of the absolute maximum a child should carry in a properly worn backpack:

Child’s Weight (pounds)	Maximum Backpack Weight (pounds)
50	7.5-10
60	9-12
70	10.5-14
80	12-16
90	13.5-18
100	15-20
110	16.5-22
120	18-24
130	19.5-26

Here are some ideas to help lighten the load, especially for those middle school kids who have a plethora of textbooks:

-Find out if your child’s textbook can be accessed on the internet. Many schools are purchasing access so the students can log on rather than lug home.

-Consider buying an extra set of books for home. Used textbooks are available inexpensively online.

-Limit the “extras” in the backpack such as one free reading book instead of five. I am not exaggerating; one day I found five free reading books in my child’s backpack!

-Encourage your child to use free periods to actually study, and leave the extra books in his locker.

-Remind your child to stop by her locker between classes to switch books rather than carrying them all at once.

-Consider individual folders or pockets for each class rather than a bulky 3-ring notebook that holds every subject.

You may need to limit the load even further if your child is still:

-Struggling to get the backpack on by herself

-Complaining of back, neck or shoulder pain

-Leaning forward to carry the backpack

If your child complains of back pain or numbness or weakness in the arms or legs, talk to your doctor or physical therapist.

When used correctly, backpacks are supported by some of the strongest muscles in the body: the back and abdominal muscles. These muscle groups work together to stabilize the trunk and hold the body in proper postural alignment. However, backpacks that are worn incorrectly or are too heavy can lead to neck, shoulder and back pain as well as postural problems. So choose wisely and lighten the load. Happy shopping!

Deborah Stack, PT, DPT, PCS

Dr. Stack has been a physical therapist for over 15 years and heads The Pediatric Therapy Center of Bucks County in Pennsylvania www.buckscountypeds.com. She holds both masters and doctoral degrees in physical therapy from Thomas Jefferson University.

August 5, 2010 by

It’s a tough pill to swallow

In the wake of liquid Tylenol and Motrin recalls, some parents are facing empty shelves of liquid medications in the stores. Check to see if your child weighs enough to take the dose in pill form. If so, it’s time to learn to swallow pills! Here are some of our favorite helpful ideas:

-Don’t wait until your child is ill. She may not feel up to learning a new skill.

-Practice swallowing peas, tic-tacs or watermelon seeds. You can start with a cake sprinkle and move up to something larger.

-Demonstrate for your child the process of swallowing.

-Thick liquid will carry down a pill better than thin liquid. Try orange juice or milk instead of water.

-Try having your child tilt her head forward as she drinks so that she is “upside down.”

-Use mind over matter, for a nervous kid, tell him to first take three breaths, sit-down, gulp and quickly swallow.

-Take a pill while simultaneously eating apple sauce, yogurt, or pudding.

-Put a pill in his mouth and have him suck liquid quickly up through a straw. This action will push back the pill before it dissolves in the liquid.

-Remind your child: if you can swallow food, you can swallow a pill.

What if nothing works? Some pills can be chewed, and the contents of some capsules can be sprinkled on food; check with the pharmacist first. Then teach your child the song “I know an old lady who swallowed a fly…”

Naline Lai, MD and Julie Kardos, MD

August 2, 2010 by twopedsinapod

The Ins and Outs of Baby Proofing

A mom once told me about a time when she left their toddler in the care of her husband who worked from home.

“Are you sure you can concentrate on your work and watch him?” she asked quizzically.

“No problem,” he said reassuringly.

Hours later, the mom was delighted to come home to a quiet house. She found her husband busy working at his desk. Everything seemed calm. That is, until the mom glanced in the dining room and saw her toddler. Somehow he had scampered to the top of the table and now dangled from the chandelier.

A kid hanging from the chandelier is a parent’s baby proofing nightmare. Out there are an overwhelming number of baby proofing checklists and catalogs of safety devices. But you don’t need to read reams on how to baby proof or spend a fortune on equipment. To baby proof, just roll back to 5^th grade and remember your prepositions… those little placement words such as “IN, OUT, ON and OVER.” Remember those words? Then you are ready to baby proof. Let’s go.

Drop DOWN on your hands and knees and look at your home from your child’s perspective. Start when your child is about six months old, before he can crawl. Because baby proofing is time consuming and it’s tough to take time out of your sleep deprived life, you need to start early, or you may not be done before your child is ready for high school.

Clear play areas of anything which may go IN your baby’s mouth and choke or poison him. Anything small enough to fit inside of a toilet paper tube is a potential choking hazard. Don’t leave loose change lying around on a counter top. Lock caustic and poisonous substances UP and OUT of reach. Have the Poison Control Center’s phone number BY the phone in case of accidental ingestion (United States 1-800-222-1222). The clinicians at the Center will instruct you whether or not to go to the emergency room. Do not induce vomiting because the emergency room has more effective ways to detoxify your child and if the ingested substance is caustic, vomit will cause a chemical burn both going DOWN and coming back UP.

Brain death can occur within five minutes of oxygen deprivation, so anything a child can pull OVER or AROUND his airway passages is hazardous. Dangling drapery cords, plastic bags, crib bumpers, and loose crib sheets fall into this category. To avoid neck strangulation, bars ON cribs and on banisters should be less than 2 3/8 inches apart (the width of a soda can) to prevent a child from trapping his head between them. Do not allow more than two fingerbreadths between the crib frame and the mattress.

All standing water is a potential drowning hazard. Even a large ice bucket at a party poses a risk. Several years ago, one of my neighbor’s children toddled up to an ice bucket at a party and right UNDER my nose flipped head first INTO the icy water.

What goes UP must come DOWN. An unsteady kid who climbs UP the stairs may come tumbling DOWN. Gate the top and the bottom of the stairs. Make sure to bolt the top gate into the wall. An angry toddler can break THROUGH any pressure secured gate. Walkers are also associated with an increased injury from falls DOWN steps. Since walkers do not actually teach your baby to walk any sooner than he would have anyway, just avoid them altogether.

Look also INSIDE his crib. Too much soft bedding (crib bumpers and large blankets) are not only suffocation risks but older babies can use the material as a step ladder and climb out. Also ensure that your five month old cannot reach UP and pull the mobile OVER the crib down ON himself.

Outside the crib, your child can still fall DOWN, so cushion and move sharp edges (end tables) out of the way. Not just children fall. Furniture which is UP may tumble DOWN ONTO a child’s head. Make sure your excited child reaching for a dancing dinosaur does not pull the television DOWN.

Don’t allow children to get their hands ON a burn hazard. Secure electrical outlets and cords. Set the temperature of hot water to no more than 120 degrees and protect children from the stove and open heating units.

Beware of other people’s homes and hotels. Grandparents tend to leave pills within reach of little hands ON end tables or NEAR bathroom sinks. Once when my family stayed AT a hotel, one of my children proudly showed me a pill she found ON the floor. “Look mommy at what I found,” she said and handed me a pill of Viagra!

Sooner or later children will need to identify potential hazards on their own. Help them understand what is safe. For instance, watch and teach your two year old to “bite then chew” a grape. Practice going UP and DOWN a few steps at a time and have her always hold the rail.

Of course, nothing is a substitute for adult supervision. But not everything can be anticipated. Sometimes you just have to cross your fingers. When my oldest was 15 months old, my husband was eating an open faced toasted bagel. My daughter toddled up, looked at daddy and scraped her forehead on the hard edge of the bagel.

Maybe we should just cushion children WITH pillows and keep helmets ON their heads until they go AWAY from home.

Naline Lai, MD with Julie Kardos, MD

July 29, 2010 by twopedsinapod

Oy! Soy! Will it girlify your boy?

Debunking myths about soy, our guest blogger today is esteemed pediatrician Dr. Roy Benaroch. In practice near Atlanta, Georgia, he is an assistant clinical professor of pediatrics at Emory University, a father of three, and the author of The Guide to Getting the Best Health Care for your Child and Solving Health and Behavioral Problems from Birth through Preschool . We enjoy his blog The Pediatric Insider and we think you will enjoy the except below.

Drs. Lai and Kardos

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From LeeAnn: “Are soybeans (edamame) safe for my 11 year old daughter to eat? I have heard that they can ‘mess with’ her hormones?”

You want to see a freakshow? Try googling this topic. I found one essay, on a “news” site, that blamed soy products for everything from stroke to vision loss to homosexuality. On the other hand, other authors love soy: it will apparently prevent heart attacks, improve the symptoms of menopause, and help flush the toxins out of your body while improving your sex drive (women) and fracture healing (men.) On one site, in two adjacent paragraphs, I found a breathless author worrying that soy could cause breast cancer, followed by a second paragraph extolling its virtues in preventing breast cancer.

Please.

Soybeans contain a group of chemicals called “phytoestrogens” (sometimes called “isoflavones”) that are chemically somewhat similar to human estrogen hormones. In the 1970’s and 1980’s, some research showed that in the laboratory, these compounds could activate human estrogen receptors, presumably causing estrogen-like effects. So that’s the germ of truth.

But these phytoestrogens activate human estrogen receptors very, very weakly. They’re also easily broken down by cooking and processing, and by enzymes in the human body. It would take a tremendous amount of soy, eaten every day, to have anything close to a genuine hormonal effect. No human study has shown anything close to a measurable effect of consuming soy, at least not in ordinary amounts.

So: enjoy your edamame, tofu, and soy burgers. If you want to be super-careful, just don’t do all of this on the same day.

The Pediatric Insider

July 27, 2010 by twopedsinapod

Acne, an unwelcome bump on the road to adulthood

Why does that big pimple always appear the night before prom, picture day, her sweet sixteenth birthday party or any other important event in your teen’s life?

A rite of passage, acne is caused by a combination of genetics and bad luck. The perception of acne as a problem depends on the eye of the beholder. When I see a teenaged patient in my office for acne, the first question I ask is, “Who is more concerned about the acne? The parent or the patient?” Some kids have very mild acne, yet those kids perceive their pimples are the size of golf balls. Other kids are oblivious, and the parents are more upset than the teen.

Even if your teen starts to break out with what she perceives are huge blemishes but are really the size of pin pricks, do take her seriously. Many effective, safe products can diminish mild acne and thus greatly help self-esteem in a self conscious teen. Also, make sure to probe to see if a negative perception of her appearance extends to an overall poor body image. Sometimes distress over minimal acne can be an early sign of body image disorders such as anorexia nervosa or bulimia.

The categories of acne medicines are:

-Topical antibiotics such as benzoyl peroxide or clindamycin, applied directly to skin- works to kill the bacteria that lead to acne

-Other topical medications such as tretinoin (Retin A) and adapalene (Differin) stop acne formation mainly by penetrating into the deep layers of the skin to loosen acne causing pores

-Oral antibiotics, such as minocin, clindamycin or erythromycin also kill the bacteria that lead to acne formation

-Accutane, an oral medical reserved for severe, scarring acne. Can cause significant birth defects and so girls who take it must also take birth control pills and have periodic pregnancy tests. Chemical imbalances may occur, so blood work is required for both sexes.

-Hormonal therapy (birth control pills)- works best for females who break out near their periods, smooths out the hormonal fluctuations which fire up acne.

I always remind my patients that most treatments take six weeks to work. For kids who experience dry skin with the topical medications, use noncomedogenic (non acne forming) moisturizer liberally.Dermatologists and pediatricians schedule follow up visits for acne at 4-6 week intervals. If your teen has mild acne but truly doesn’t want to bother with treatment, just encourage washing with a mild cleanser (for example Dove soap) once daily. Tell him also to use a clean washcloth or soft paper towel to dry off after each washing. Applaud his self-confidence and lack of obsession with a skin condition which almost always improves with time.

Myth buster: eating chocolate does not cause acne. The chocoholic in me is greatly relieved by this knowledge.

Truth: arranging hair to hide the face tends to make acne worse. Avoid oily hair gels and sprays. In addition, touching and picking at the skin also causes irritation in an already irritated area.

Finally, what to do on prom night? Cosmetics work wonders, and parental reassurance, even if your teen waves it aside, can take care of the rest.

July 23, 2010 by twopedsinapod

What could be lurking in your pool-Cryptosporidium

We welcome guest blogger Dr. Alissa Packer who informs us about Cryptosporidium.

-Drs. Kardos and Lai

Here in the state of Utah we are starting to see cases of Cryptosporidium crop up. “Crypto” is a nasty bug that hides in water (both drinking and recreational), is resistant to chlorine, and caused a massive diarrhea outbreak in 2007. Crypto is present throughout the United States and originates in the stool of an infected human or animal. The little germs then hunker down in the closest water, soil, or food, just waiting for their next host.

If your little one becomes that next host you can look forward to diarrhea, vomiting, stomach cramps, fever, nausea and weight loss. Symptoms occur 2 to 10 days after becoming infected. These symptoms typically last, on and off, for 1 to 2 weeks. Not everyone exposed will develop symptoms–some lucky ones will be just fine.

So, does that mean you need to ditch your summer pass to the pool? Give up your fresh raspberries? Skip that trip to the lake? Probably not. Find out how your local pool treats for crypto and what their policies are regarding swim diapers. Ultraviolet (UV) treatment is better than chlorine, and requiring swim diapers is probably a good thing. Thoroughly wash all fresh fruits and vegetables. Use common sense with good hand washing. And make sure the lake water is adequately treated before drinking it—or better yet, bring your own drinking water.

If you think your child may have crypto, visit your pediatrician so he or she can test your child’s stool. The test is a little tricky and may require a few different stool samples over several days. If it turns out to be crypto there is a medication called nitazoxanide that can help. Also try to keep your child tanked up on fluids. A hydrated child is a happy child.

Hopefully we won’t see the same kind of outbreak we did in 2007…but if we do, you’ll be prepared.

Alissa Packer, MD
Dr. Packer is a pediatrician and mom in West Jordan, Utah. She loves kids- both the snotty nosed and the well kind, the outdoors, and good books. The above post was expanded from her original post in her wonderful blog at: southpointpediatrics.blogspot.com .

July 19, 2010 by twopedsinapod

Podcast Party Potpourri-milk and more milk, daycare guilt and thumb sucking

Join us as we talk with moms from Building the Family, part of Child, Home and Community, a Pennsylvania based organization dedicated to empowering young parents. We share with you a few tidbits on milk, daycare and thumb sucking – topics gathered from a podcast recording party held this summer. Here we are pictured with the fabulous moms and some of their children (listen carefully and you will hear the pitter-patter of little feet in the background).

Play the podcast here!

Naline Lai, MD and Julie Kardos, MD

July 16, 2010 by twopedsinapod

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