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®

Baby spew doesn’t always require reflux medications

In our office, two-month-old Max smiles ear to ear, naked except for a diaper and a bib. His worried mom asks me about the large amounts of spit up Max spews forth daily. “He spits up after every feeding. It seems like everything he eats just comes back up. It even comes out of his nose!” she says. Max gained the expected amount of weight, an average of one ounce per day, since his one-month check-up. He breastfeeds well and accepts an occasional bottle from his dad. Even after spitting up and drenching everything around him, he remains comfortable and cheerful. He is well hydrated, urinates often, and poops normally.

In short, Max is a “happy spitter” Other than creating piles of laundry, he acts like any healthy baby.

This sign now sits on my friend’s lawn. I still remember four years ago when I pulled my big blue minivan up in front of their house after the moving van left. A mommy sat on the stoop with her children. “How old are they? I hollered out. The ages of the children matched my children’s and I was delighted. Indeed they became good friends. And now, there’s the “For Sale” sign.

It’s  the end of the school year, and “For Sale” signs dot lawns all over the United States. Chances are, one of them belongs to your child’s friend. Just as the child who moves will have to adjust to a new environment, your child will have to adjust to a world without a friend who was part of his daily routine.

Much has been written about how to transition the child who moves into a new environment, but how can you help your child when his close friend moves away?

Your child may experience a sense of loss and feel that he was “left behind.” Some children perseverate over the new hole in their world. Others take the change in stride.

In the late 1960’s, psychiatrist Elisabeth Kubler-Ross described “the five stages of grief.” The stages were initially applied to people suffering from terminal illness, but later they were applied to any type of deep loss such as your child’s friend moving. The first stage is denial: “I don’t believe he moved.” Anger follows in the second stage: “Why me? That’s not fair!” Your child may then transition into the third stage and bargain: “If I’m good maybe he will hate it there and come back.” The fourth stage is sadness: “ I really miss my friend,” or, “Why make friends when they end up moving away?” The final stage is acceptance: “Everything is going to be okay. We will remain friends even if he doesn’t live here.”

Some pass through all stages quickly and some skip stages altogether. The process is personal and chastising your child to “just get over it” will not expedite the process. However, there are ways to smooth the journey:

· Reassure your child that feeling sad or angry is common. Parents need to know that sad children may not show obvious signs of sadness such as crying. Instead, rocky sleep patterns, alterations in eating, disinterest in activities or a drop in the quality of school work can be signs that a child feels sad. If feelings of depression in your child last more than a month or if your child shows a desire to hurt himself, consult your child’s health care provider.

· When you discuss the move with your child, keep in mind your child’s developmental stage. For instance, preschool children are concrete and tend to be okay with things being “out of sight, out of mind.” Talking endlessly about the move only conveys to the child that something is wrong. Children around third or fourth grade can take the move hard. They are old enough to feel loss, yet not old enough to understand that friendships can transcend distance. For teens, who are heavily influenced by their peers, a friend’s moving away can cause a great deal of disruption. Acknowledge the negative emotions and reassure your child that each day will get better. Reassure him that despite the distance, he is still friends with the child who moved.

· Prior to the move, don’t be surprised if arguments break out between the friends. Anger can be a self defense mechanism employed subconsciously to substitute for sadness.

· Set a reunion time. Plan a vacation with the family who moved or plan a trip to their new home.

· After the move, send a care package and write/ help write a letter with your child.

· Answer a question with a question when you are not sure what a child wants to know. For example if he asks,” Will we always be friends?” Counter with “What do you think will happen?”

· Share stories about how you coped with a best friend moving when you were a child.

Social media and texting can be ways for older kids to stay in touch with a friend who moves away. Be sure to monitor your child, however, because too much time texting, skyping, and posting takes away from time your child needs to spend acclimating to a new routine.

As for my children, when I told one of my kids that I will sign her up for soccer, she squealed with delight, “Oh, that’s the league Kelly belongs to.”

My heart sank. I said as gently as I could, “She’s moving- she won’t be here for soccer season.”

And so we begin the process…

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

Recently we’ve had a parade of itchy children troop through our office.  The culprit: poison ivy.

Myth buster: Fortunately, poison ivy is NOT contagious. You can catch poison ivy ONLY from the plant, not from another person.

Also, contrary to popular belief, you can not spread poison ivy on yourself through scratching.  However, where  the poison (oil) has touched  your skin, your skin can show a delayed reaction- sometimes up to two weeks later.  Different  areas of skin can react at different times, thus giving the illusion of a spreading rash.

Some home remedies for the itch :

• Hopping into the shower and rinsing off within fifteen minutes of exposure can curtail the reaction.  Warning, a bath immediately after exposure may cause the oils to simply swirl around the bathtub and touch new places on your child.
• Hydrocortisone 1%.  This is a mild topical steroid which decreases inflammation.  We suggest the ointment- more staying power and unlike the cream will not sting on open areas, use up to four times a day
• Calamine lotion – a.k.a. the pink stuff. This is an active ingredient in many of the combination creams.  Apply as many times as you like.
• Diphenhydramine (brand name Benadryl)- take orally up to every six hours. If this makes your child too sleepy, once a day Cetirizine (brand name Zyrtec) also has very good anti itch properties.
• Oatmeal baths – Crush oatmeal, place in old hosiery, tie it off and float in the bathtub- this will prevent oat meal from clogging up your bath tub. Alternatively buy the commercial ones (e.g. Aveeno)
• Do not use alcohol or bleach– these items will irritate the rash more than help

The biggest worry with poison ivy rashes is not the itch, but the chance of infection.  With each scratch, your child is possibly introducing  infection into an open wound.  Unfortunately, it is sometimes difficult to tell the difference between an allergic reaction to poison ivy and an infection.  Both are red, both can be warm, both can be swollen.  However, infections cause pain – if there is pain associated with a poison ivy rash, think infection.  Allergic reactions cause itchiness– if there is itchiness associated with a rash, think allergic reaction.  Because it usually takes time for an infection to “settle in,” an infection will not occur immediately after an exposure.  Infection usually occurs on the 2nd or 3rd days.  If you have any concerns take your child to her doctor.

Generally, any poison ivy rash which is in the area of the eye or genitals (difficult to apply topical remedies), appears infected, or is just plain making your child miserable needs medical attention.

When all else fails, comfort yourself with this statistic: up to 85% of people are allergic to poison ivy.  If misery loves company, your child certainly has company.

Naline Lai, MD and Julie Kardos, MD

©2015 Two Peds in a Pod®, updated from 2012

Gepetto always said his son had allergies, but the villagers knew better

Recently, Dr. Lai was so excited to see Flonase in the local pharmacy that she texted all of the providers in our practice with the news. Flonase (fluticasone),  a nose spray allergy treatment, is the  latest allergy medication to go over-the-counter. Now, nearly every allergy medication that we wrote prescriptions for a decade ago is now available to kids over-the-counter.

As you and your child peer around the pharmacy through itchy blurry eyes, the  displays for allergy medications can be overwhelming. Should you chose the medication whose ads feature a bubbly seven-year-old girl kicking a soccer ball in a field of grass, or the medication whose ads feature a bubbly ten-year-old boy roller blading? Its it better to buy a “fast” acting medication or medication that promises your child “relief?”

A guide to sorting out your medication choices:

Oral antihistamines: Oral antihistamines differ mostly by how long they last, how well they help itchiness, and their side effect profile. During an allergic reaction, antihistamines block one of the agents responsible for producing swelling and secretions in your child’s body, called histamine. Prescription antihistamines are not necessarily “stronger.” In fact, at this point there are very few prescription antihistamines. The “best” choice is the one that alleviates your child’s symptoms the best. As a good first choice, if another family member has had success with one antihistamine, then genetics suggest that your child may respond as well to the same medicine. Be sure to check the label for age range and proper dosing.

• First generation antihistamines work well at drying up nasal secretions and stopping itchiness but don’t tend to last as long and often make kids very sleepy:
  Diphenhydramine (brand name Benadryl) is the best known medicine in this category. It lasts only about six hours and can make people so tired that it is the main ingredient for many over-the-counter adult sleep aids. Occasionally, kids become “hyper” and are unable to sleep after taking this medicine. Opinion from Dr. Lai: dye-free formulations of diphenhydramine are poor tasting. Other first generation antihistamines include Brompheniramine (eg. brand names Bromfed and Dimetapp) and Clemastine (eg. brand name Tavist).
• The newer second and third generation antihistamines cause less sedation and are conveniently dosed only once a day:
  Cetirizine (eg. brand Zyrtec) causes less sleepiness and it helps itching fairly well. Give the dose to your child at bedtime to further decrease the chance of sleepiness during the day. Loratadine (brand name Alavert, Claritin) causes less sleepiness than cetirizine. Fexofenadine (brand name Allegra) causes the least amount of sedation. The liquid formulations in this category tend to be rather sticky, the chewables and dissolvables are favorites among kids. For older children, the pills are a reasonable size for easy swallowing.

Allergy eye drops: Your choices for over-the-counter antihistamine drops include ketotifen fumarate (eg. Zatidor and Alaway). For eyes, drops tend to work better than oral medication. Avoid products that contain vasoconstrictors (look on the label or ask the pharmacist) because these can cause rebound redness after 2-3 days and do not treat the actual cause of the allergy symptoms. Contact lenses can be worn with some allergy eye drops- check the package insert, and avoid wearing contacts when the eyes look red.

Allergy nose sprays: Simple nasal saline helps flush out allergens and relieves nasal congestion from allergies. As we mentioned above, Flonase, which used to be available by prescription only, is a steroid allergy nose spray that is quite effective at eliminating symptoms. It takes about a week until your child will notice the benefits of this medicine. Even though this medicine is over-the-counter, check with your child’s pediatrician if you find that your child needs to continue with this spray for more than one allergy season of the year. Day in and day out use can lead to thinning of the nasal septum. Avoid the use of nasal decongestants (e.g., Afrin, Neo-Synephrine) for more than 2-3 days because a rebound runny nose called rhinitis medicamentosa may occur.

Oral Decongestants such as phenylephrine or pseudoephedrine can help decrease nasal stuffiness. This is the “D” in “Claritin D” or “Allegra D.” However, their use is not recommended in children under age 6 years because of potential side effects such as rapid heart rate, increased blood pressure, and sleep disturbances.

Some of the above mentioned medicines can be taken together and some cannot. Read labels carefully for the active ingredient. Do not give more than one oral antihistamine at a time. In contrast, most antihistamine eye drops and nose sprays can be given together along with an oral antihistamine.

If you are still lost, call your child’s pediatrician to  tailor an allergy plan specific to her needs.

The best medication? Get the irritating pollen off your child. Have your allergic child wash her hands and face as soon as she comes in from playing outside so she does not rub pollen into her eyes and nose. Rinse  outdoor particles off your child’s body with nightly showers. Filter the air when driving in the car and at home by running the air conditioner and closing the windows to prevent the “great” outdoors from entering your child’s nose.

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

It is never easy to break bad news, and it can be especially difficult to break bad news to our children. Bereavement counselor Amy Keiper-Shaw helps parents give advice on how to talk to your children if  someone they love is dying.

While we all try to live our best and happiest lives, one day, something bad will invariably happen to us and/or our families. Maybe a grandparent or a pet is so ill they have been told they are going to die, or a family member has been diagnosed with a terminal illness. Are you and your child prepared to communicate effectively during these tough times?  Here are some suggestions to help you talk to your child when death is a possibility.

“One must talk little and listen much.”—African proverb

• First, try to distinguish your emotions about the news from what to tell your kids. It’s always harder to talk about bad news when it’s an emotional issue for you.  Allow yourself to “sit with” the feelings you have about it before sharing it with a child.  Try to be calm—even if the news is upsetting to you. If you’re overly emotional, your child may feel like he or she needs to take care of you instead of having his or her own reaction.

• Mentally rehearse how you will deliver the news. You may wish to practice out loud, as you would prepare for public speaking. Script specific words and phrases to use or avoid. Be open and prepared for your kids’ reactions. Some may cry. Others may get angry. Some may not seem to react at all. Don’t read too much into your child’s initial reaction. For some kids, it takes a while for the news to sink in.

• Arrange to talk to the child in a private, comfortable location. For example, have your child sit on your lap, or talk to your child on his or her bed. Having your child’s favorite comfort item available (a blanket, a stuffed animal or favorite toy) can also help.  Turn off your cell phone, TV, or other background distractions.

• Long before we realize it, children become aware of death and when bad news is approaching.  It may be tempting to withhold bad news. It’s important to be honest with your kids and not to be afraid of their reactions. When we aren’t honest about what is going on, children make up their own explanation for the tense environment.  What they imagine is often worse than the truth.  Foreshadow the bad news, “I’m sorry, but I have bad news.”

• When you meet with the child ask what they already know and understand. Be prepared to provide basic information about prognosis and treatment options if there are any available.  Give information according to your child’s age. Younger children will require less information than older teenagers.

• Speak frankly but compassionately. Avoid euphemisms and medical jargon. Use the words cancer or death rather than “going to sleep” or giving false hope.  Offer realistic hope. Even if a cure is not realistic, offer hope and encouragement about what options are available such as hospice or medications which will help the person or pet have the best quality of life as possible until they die.

• Have the child tell you his or her understanding of what you have said, use repetition and corrections as needed. Encourage them to ask questions if they have any now or in the future and be sure to follow up often to see if any new questions have arose.

• Allow silence and tears, and avoid the urge to talk to overcome your own discomfort. Proceed at the child’s pace. Be empathetic; it is appropriate to say “I’m sorry” or “I don’t know.”

• Talk about what the bad news means for them personally. Be as clear as possible about how the bad news will make their life change—or not change. “Mom won’t be able to take you to school anymore so our neighbor will bring you instead.”  Older kids will want to know more details about this than younger kids.

• Reassure your kids. When bad things happen, they need to hear that you love them and that you’re there for them. If you’re uncertain how long you can be there for your children (such as when you receive a terminal prognosis), make sure they know of other caring, trusted adults who will also be there for them.

• Don’t be surprised if your child tries to blame you or someone else for the bad news. It’s hard for children and teens to understand that sometimes bad things just happen.

• Do something special with your child. You can say that when bad things happen, it often helps to do something you enjoy to try to feel better. For example, ask your child what he or she would like to do with you. Maybe your child will want to go the playground or play a board game.  It is important that children know it is okay to still want to have fun and to enjoy life.  They should not feel guilty about wanting to be happy.

• Model the grief process.  It helps children and teens to see that there are hard times and that people can get through these tough situations by making positive coping choices. For example, even if you don’t feel like exercising, you notice that exercise helps you feel a bit better. Explain that even though you may be tempted to eat badly, you notice that you feel better when you eat healthy. Talking about the ups and downs (while modeling positive coping strategies) will help your child be more intentional about the choices he or she makes and they are grieving.

• Keep in mind, although older teenagers may seem like they can take on more hardship than younger kids, remember that they still don’t have the life experience that you have. Hearing bad news can be extremely difficult on a teenager, and it can sometimes trigger risky behaviors, particularly if they were struggling before the bad news hit or they’re feeling extremely vulnerable.

• Talk to other significant adults in your child’s life. For example, talk to your child’s teacher, coach, or club leader. Sometimes a child will talk to another adult, and it helps if everyone knows the same information.

Parents, remember this:

• Attend to your own needs during and following the delivery of bad news.  Find a few people who are good listeners and can help with practical things such as taking kids to after school activities.

• Allow yourself to accept help.

It can be challenging to be the bearer of bad news, but keep in mind that there are others who can assist with this.  Asking for help from a social worker, counselor, a trusted friend, or spiritual adviser can help to facilitate this conversation, as well as connect families to resources in the community.

Amy Keiper-Shaw, LCSW

©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.com, a resource  for children who have experienced a significant death in their lives.

Let’s face it, it’s hard to move when it’s cold , and it’s freezing at my home.  I believe today’s high is 20 degrees Fahrenheit.  Now while this may not deter younger children from bundling up and going sledding, teen couch potatoes are busy whining that it’s “too cold.”  So there they sit.

What’s the secret to keeping them active in the winter months?  Have them schedule an activity, and be an example yourself.

Ideas for teens (and you) to do when it’s cold outside:

• Have a 15-minute dance party
• Have a Wii contest
• Try swimming (indoors please!)
• Dust off the treadmill or stationary bike in the basement and GET ON IT
• Play ping-pong
• Do a few chores
• Jump rope
• Jog during T.V. commercials
• Pull out some “little kid games” such as hopscotch, hula-hoop or Twister
• Let each child in your house choose an activity for everyone to try

Teens, like everyone else, need exercise to stay healthy.  Staff from the Mayo Clinic recommend kids ages 6-17 years should have one hour of moderate exercise each day.  Exercise can help improve mood (through the release of endorphins), improve sleep and therefore attention (critical with finals coming up), and improve cardiovascular endurance. Those spring sports really ARE just around the corner.

Here are some numbers to get the kids moving:  All activities are based on 20 minutes and a teen who weighs 110 pounds.  The number of calories burned depends on weight.  If your teen weighs more, he will burn a few more calories, if he weighs less, he’ll burn a few less.  Below the table are links to some free and quick calorie calculators on the web so your teen can check it out for him self.  For those attached to their phones, there are web apps too.

What’s the worst that can happen?  You’ll have a more fit, better rested, and happier teen!  Or at least you’ll have a cleaner home!

Try these activity calculators:

http://primusweb.com/fitnesspartner/calculat.htm

www.caloriesperhour.com/index_burn.php

http://www.caloriecontrol.org/healthy-weight-tool-kit/lighten-up-and-get-moving

Deborah Stack, PT, DPT, PCS

With nearly 20 years of experience as a physical therapist, guest blogger Dr. Stack 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.

© 2011, 2013, updated 2015 Two Peds in a Pod®