Two Peds in a Pod®

What’s up with Acetaminophen (Tylenol)?

Acetaminophen, brand name Tylenol, has been in the news recently, and parents are asking me if it is safe.

This medication, used as a pain reliever and as a fever reducer, is safe to give to babies older than two months, but you must be very careful about the dose that you give. Medicine doses are based on the weight, not the age, of a child. So when checking the label on the bottle that tells how much acetaminophen to give, look at the weight recommendations if there is a discrepancy between your child’s weight and age. If you are not sure, then ask your child’s health care provider. I cannot stress proper dosing enough because of how dangerous an overdose can be.

Here are some facts you need to know in order to avoid over-dosing your child with Tylenol:

1) Always measure the medicine in the dropper or cup provided by the manufacturer of that particular medicine bottle.

2) Be aware that Tylenol infant drops are more concentrated than the children’s suspension liquid. This means that if you were to pour out equal amounts of infant drops and children’s suspension, the amount of drug is actually HIGHER in the measurement of infant drops than in the same measurement of children’s suspension. For example, one full infant dropper of Infant Tylenol Drops, measured to the 0.8ml line of the dropper, is 80mg of Tylenol. The same 0.8ml of Children’s Tylenol Suspension Liquid is only 25mg.

Another way to look at this medicine math: if you intended to give 80mg = 2.5ml = 1/2 teaspoon of Children’s Tylenol Suspension Liquid but you actually gave your child 2.5ml = ½ teaspoon of Infant Tylenol instead of Children’s Tylenol, you would be giving them over 240 mg of Tylenol, which is THREE TIMES the amount that you wanted to give. Again, use the dropper provided to give Infant Tylenol drops and use the cup provided when dosing the Children’s Tylenol Suspension Liquid.

3) Note that other medications have acetaminophen (Tylenol) in them. I advise my patients’ parents to avoid combination cold and flu medicines for two reasons. First, there is little evidence that shows that they actually provide symptom relief. Second, from a safety perspective, parents can accidentally overdose their child with acetaminophen because many contain acetaminophen in them. For example, as of this writing, the following medications all contain acetaminophen as stated in the ingredient list:

Benadryl Allergy and Cold Tablets, Sudafed PE nighttime Cold Maximum Strength Tablets, Theraflu Nighttime Severe Cold and Cough Powder, Tylenol Plus Children’s Cold and Allergy Suspension, Tylenol Sore throat Nighttime liquid, Tylenol Chest Congestion Liquid, and Nyquil.

4) Be aware that “APAP” in the ingredient list means acetaminophen.

Tylenol overdoses can be fatal by causing liver failure. If your child has a chronic liver disease, it is likely that she should avoid Tylenol altogether.

Because of the risk of overdose, I also avoid advising my patients to “alternate Tylenol (acetaminophen) with Motrin (ibuprofen).” I discourage this practice because I am afraid of parents forgetting which medicine they gave last and possibly over-dosing by mistake. Tylenol is meant to be dosed every 4 to 6 hours unless otherwise specified on the label or by your child’s health care provider.

If you ever have questions about possible overdose, call the national US Poison Control Center at 1-800-222-1222.

Julie Kardos, MD
©2009 Two Peds in a Pod

Addendum 10/11/2011: The manufacturers of Tylenol (acetaminophen) responded to the hazard of parents and caregivers accidentally giving the wrong dose of infant drops ( see point #2 above) and stopped making the “concentrated infant drops.” Instead, they now manufacture the “infant drops” and “children’s liquid” using the same concentration as each other. Continue to use the measuring dropper or cup provided with the medication for proper measuring.

December 1, 2009 by twopedsinapod

We Give Thanks

“Three things we know for certain: a child is a gift, being a good parent is a blessing, and being a pediatrician is a privilege.” –author unknown

This Thanksgiving, we want to thank you, our readers, for allowing us to help you help your children. We are grateful to you for telling other families about Two Peds In A Pod because when you get right down to it, our information is only good if it reaches people. Thank you for your comments and questions. Keep them coming!

From both of our families, we wish you all a Happy Thanksgiving.

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

November 26, 2009 by twopedsinapod

Worry Wart : Getting rid of warts

Emma’s dad and I both peered at the filamentous growth dangling from his nine year old’s right nostril. “Yes,” I said, “it’s definitely a wart.”

Emma’s dad replied, “When I was a kid, I heard the way to get rid of a wart was to cut a potato in half, rub it on the wart, and bury it in the backyard.Legend had it, by the time the potato disintegrates, the wart will begone.”

“I wish it were so easy,” I replied.

Warts are caused by skin-dwelling viruses. On the feet, warts can sometimes be mistaken for calluses. One distinguishing feature is that warts sit in the skin like this:

Fine “feeder” blood vessels extend from the wart into the skin. Therefore, if you scrape off the top layer of a wart, a dotted pattern usually appears from above. The dots will not appear in a callus. View from above:

There are simply no glamorous ways to get rid of warts. Most treatment modalities destroy warts by pulverizing the home they live in, a.k.a. your skin. Your doctor maybe armed with various agents such as liquid nitrogen, or dimethyl ether propane,which produces a chemical “freeze” and dries up the wart. Another agent called cantharidin (otherwise known as “beetle juice”) is a caustic liquid derived from the blister beetle (pictured here.)

Application of beetle juice causes the warts to blister. Some doctors will even manually take a scalpel and cut out the warts. Like I said, there are no glamorous treatments. However, more gentle creams which stimulate the immune system, such as Imiquimod (Aldara) are showing promise.

Over the counter remedies exist in a milder form. Commonly used wart removers such as Compound W, Dr Scholl’s Clear Away Wart and Duofilm all contain salicylic acid. The acid slowly dries up the warts. When applying salicylic acid, after a few applications make sure you peel the dead crusty top layer off the wart. Without peeling, future medicine will not reach the wart. These methods can take weeks to months to work, but they do work.

And don’t forget the duct tape. Duct tape, the great all-purpose household item, has also been shown to speed up the resolution of warts.Scientists hypothesize the constant presence of the adhesive somehow stimulates a natural immune response. If you try duct tape, have your child wear the duct tape over the wart for several days in a row and then give a day off. Effects should be seen within a couple of months if not sooner.

The prevention of warts is tricky. Some people just seem genetically predisposed. However, your best bet for keeping warts away is to keep your child’s skin as healthy as possible. Warts tend to gravitate towards areas of skin broken down by friction such as feet or fingers. Liberally apply moisturizing creams daily to prone areas. After a summer of wearing flip-flops and walking on the rough cement by the side of a swimming pool in bare feet, many children end up with warts on the bottom of their feet. I know a teen whose warts on the tips of her fingers stemmed from months of guitar strumming.

Turns out that even without treatment, 60% percent or more of all warts will disappear spontaneously within two years.

Coincidentally, I think that’s also the time it takes for a potato half to disintegrate.

Naline Lai , MD

Addendum, January 14, 2010

Here is a wart I saw recently in the office. The mom of this sweet girl had been applying salicylic acid (Compound W). Now it is nice and crusty – close to falling off.

November 26, 2009 by

Next steps: your toddler’s gait after he starts to walk

The moment is here, your web cam is on and you beam your toddler’s first steps to hundreds of relatives. But what comes after this highly anticipated moment? Your toddler’s walking gait looks more like Frankenstein’s than that of an Olympic athlete. Deborah Stack, who holds Masters and Doctoral Degrees in Physical Therapy from Thomas Jefferson University, joins us today to tell us what to expect next from your little Frankenstein.

Naline Lai, MD and Julie Kardos, MD

_____________________________________________________________

I remember looking at my 16-month-old son and telling him, “You need to learn to walk before your new brother or sister is born.” I did not relish the idea of simultaneously carrying two children. But even after my second was born, I still did a lot of carrying. We all focus on our children’s first steps, but mature walking does not occur immediately.

Toddlerhood officially begins when a child takes his first steps, around 12-15 months, and ends with a mature walking pattern around age three years. But what happens in between? Look for your child to begin taking steps with his feet closer together. His hands progress from being held out to the side near the shoulders to a relaxed position lowered at his sides as he moves. Children will also begin to be able to walk on a wider variety of surfaces such carpet, grass, sand and inclines. They will learn to walk sideways and backwards as well as maneuver around and over toys in their path. Initially your child will probably walk on his toes or with his whole foot hitting the ground at the same time and his feet as wide apart as his shoulders or even more. By age three, most children will walk with their feet just a few inches apart and a “heel-toe” gait, meaning their heel will hit first and then they will shift their weight forward to the big toe before lifting it for the next step. Skills such as running and jumping occur at varying times during toddlerhood.

Taking a walk is a great way to help your child develop his gait. But don’t restrict him to staying on the path! Try walking on grass, playground surfaces, sand boxes, and snow. Once your child can walk on level surfaces, try walking up and down hills and then across them. Decrease your support as he gains confidence. At the playground, climbing is a great way for toddlers to strengthen their muscles, as well as to develop balance and spatial awareness.

This holiday season, save the shipping boxes. Stepping in and out of low boxes is a great way to practice balance and will provide hours of fun during the upcoming holiday festivities.

These tips will help you enjoy your child’s “next steps” as much as his first ones.

Deborah Stack, PT, DPT, PCS

www.buckscountypeds.com
© 2009 Two Peds in a Pod

November 18, 2009 by twopedsinapod

How Sick is Sick? When to Worry about Your Child’s Illness

A friend of mine who has no children commented to me that many people tell him, “You just can’t know happiness until you have children of your own.” However, I know several adults who are very happy people and who have made a conscious decision to not have children. So I would actually amend the above adage to: “You just can’t know WORRY until you have children of your own.”

Especially in winter, many illnesses circulate. All these sick kids make for many worried parents. Some questions that I answer many times a day in the office are: “Okay, Doc, you just told me that my child is handling her illness right now, but how will I know if she is getting worse? When do I need to worry?”

Here is what I tell my patients’ parents:

First and foremost, trust your parent instincts that something is wrong.

Think about these THREE MAIN SYSTEMS: breathing, thinking, and drinking/peeing.

Breathing:

Normally, breathing is easy to do. It is so easy, in fact, that if you take off your child’s shirt and watch her breathe, it can be hard to see that she is breathing. You should try this while your child is healthy. Normal breathing does not involve effort. It does not involve the chest muscles.

If your child has pneumonia, bad asthma, bronchitis, or any other condition that causes respiratory distress, breathing becomes hard. It becomes faster than baseline. It involves chest muscles moving so it looks like ribs are sticking out with every breath. The chest itself moves a lot. Kids’ bellies may also move in and out. Nostrils flare in attempt to get more oxygen. Sometimes kids make a grunting sound at the end of each breath because they are having difficulty pushing the air out of their lungs before taking another breath in. Also, instead of a normal pink color, your child’s lips can have a blue or pale color. Pink is good, blue or pale is bad. Children old enough to talk may actually have difficulty talking because they are short of breath. Any of the above signs tell you that your child needs medical attention.

Thinking:

This refers to mental or emotional state. Normally, children recognize their parents and are comforted by their presence. They are easy to console by being held, rocked, massaged, etc. They know where they are, and they make sense when they talk.

Change in mental state, whether it comes from lack of oxygen/shortness of breath, pain, or severe infection, results in a child who is inconsolable. She may not recognize her parents or know where she is. Instead of calming, she may scream louder when rocked. She may seem disoriented or just too lethargic/difficult to arouse. Being very combative can also be a sign of not getting enough oxygen. In a baby, extreme pain can cause all these signs as well.

Drinking/peeing:

While this varies somewhat depending on the age of the child, most kids urinate every 3-6 hours or so. Young babies may urinate more frequently than this and some older kids urinate perhaps 2-3 times daily. You should know your child’s baseline. Normal urine reflects a normal state of hydration. If you don’t drink enough, you will urinate less.

If your child has fever, coughing, vomiting, or diarrhea, she will use up fluid in her body faster than her baseline. In order to compensate, she needs to drink more than her baseline amount of liquid to urinate normally. A child will refuse to drink because of severe pain, shortness of breath, or change in mental state, and may go for hours without urinating. This is a problem that needs medical attention. Occasionally a child will urinate much more than usual and this can also be a problem (this can be a sign of new diabetes as well as other problems). Basically any change from baseline urine output is a problem.

A note about fever: any infant 8 weeks of age or younger with fever of 100.4 F or higher, measured rectally, requires immediate medical attention, even if all other systems are good. Babies this young can have fever before any other signs of serious illness such as meningitis, pneumonia, blood infections, etc. and they can fool us by initially appearing well.

In older babies and children, fever is defined as 101 F or higher. Some kids can look quite well even at 104 and others can look quite ill at 101. Fever is a sign that your body’s immune system is working to fight off illness. In addition to fever, it is important to look at breathing, thinking, and hydration state because this will help you determine how quickly your child needs medical attention. A child with a mild runny nose and fever of 103 who can play still play a game with you while drinking her apple juice is less ill than a child with a 101 fever who doesn’t recognize her parents.

To summarize, any deviation from normal breathing, thinking, or drinking/urinating (peeing) is a problem that needs medical attention, even if no fever is present. In addition, any change in the wrong direction (getting worse instead of getting better) is a problem that needs medical attention.

Finally, all parents have PARENT INSTINCT. Trust yourself. Ultimately, if you are wondering if you should seek medical advice, just do it. If parents could just worry every problem away, no one would ever be sick.

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

November 12, 2009 by twopedsinapod

Dry chapped hands – home remedies

I wash my hands about sixty times a day, maybe more. This in combination with cold Pennsylvania fall air leads to chapped hands. It’s a sure sign winter is approaching when patients start to show me their raw hands. Here are the hands of a girl I saw a couple days ago.

To prevent dry hands:
• Don’t stop washing your hands, but do use a moisturizer afterwards.

• Whenever possible, use water and soap rather than hand sanitizers. Hand sanitizers are at minimum 60% alcohol- very drying.

• Wear gloves as much as possible even if the temperature is above freezing. Remember chemistry class, cold air holds less moisture than warm air and therefore is unkind to skin. Gloves will prevent some moisture loss.

• Before exposure to any possible irritants such as the chlorine in a swimming pool, protect the hands by layering heavy lotion (Eucerin cream) or petroleum based product (i.e. Vaseline or Aquaphor) over the skin.

To rescue dry hands:
• Prior to bed smother hands in 1% hydrocortisone ointment. Avoid the cream formulation. Creams tend to sting if there are any open cracks. Take old socks, cut out thumb holes and have your child sleep at night with the sock on his hands. Repeat nightly for a week or so. Alternatively, for mildly chapped hands, use a petroleum oil based product such as Vaseline or Aquaphor in place of the hydrocortisone.

• If your child has underlying eczema, prevent your child from scratching his hands. An antihistamine such as diphenhydramine (Benadryl) or cetirizine (Zyrtec) will take the edge off the itch.

• For extremely raw hands, your child’s doctor may prescribe a stronger cream and if there are signs of a bacterial skin infection, your child’s doctor may prescribe an antibiotic.

Happy moisturizing. Remember how much fun it was to smear glue on your hands and then peel off the dried glue? It’s not so fun when your skin really is peeling.

Naline Lai, MD and Julie Kardos, MD

November 9, 2009 by twopedsinapod

Sleep Safety: How to decrease your baby’s risk of Sudden Infant Death Syndrome (SIDS)

Sudden Infant Death Syndrome, or SIDS, refers to the sudden unexplained death of an infant between the ages of 1-12 months and seems to occur during sleep. We (meaning pediatricians and the rest of the scientific community) still don’t know exactly what causes SIDS, although we do know that some babies seem to be more at risk, such as premature infants and infants of multiple births (twins, triplets, etc).While parents cannot control prematurity and multiple births, parents CAN control other risk factors.

Here is a summary of ways to reduce the risk of Sudden Infant Death Syndrome (SIDS) as recommended by the American Academy of Pediatrics:

· Place babies on their backs (supine) to sleep. Do not waste money buying positioners or wedges for the crib because they are not proven to prevent SIDS and are not endorsed by the American Academy of Pediatrics. A newborn cannot roll from back to stomach. If you start out always placing your infant down on his back to sleep, he will stay this way and learn to like to sleep this way. Side sleeping is not as safe as back sleeping.

· Do not sleep with your baby in a chair, couch, or adult bed. You can take your infant into your bed to nurse/feed but then put him back in his own sleep space.

· Do not let your infant sleep in a bed with older siblings. Put your baby in his own crib.

· Put nothing in the crib other than your baby. No stuffed animals, blankets, pillows, etc. Even bumpers are not recommended.

· Do not smoke in the room where your baby sleeps.

· Offer a pacifier. This has a protective effect.

· Breastfeeding has a protective effect.

Some parents admit to us that they place their babies stomach down (prone) to sleep because “the baby sleeps better that way.” Unfortunately, what seems to be easier in the short run isn’t always the best for children in the long run. For the same reason that you should insist your children wear bike helmets and seatbelts, even if they protest at times, you should put your children down on their backs (supine) to sleep as infants. The rate of SIDS in the USA has dropped by over 50% since 1994 after the start of a “Back to Sleep” campaign. This sleep position change has been the single most effective way, to date, of reducing the rate of SIDS. Of course if your child has any rare medical condition that may prevent supine sleep, your child’s doctor should advise you on the safest sleep position for your child.

The best way to form good habits is to use them from the beginning. It is perfectly safe to position your newborn on his belly during awake time/ playtime while you are with him. However, if you are putting your baby down to sleep, or if you are putting your baby down and walking away and during this time he might fall asleep, just put your baby down on his back. And remember to tell anyone else who cares for your baby the same instructions, including daycare workers, nannies, and even well-meaning grandparents, because safe sleep advice has changed over the generations.

November 5, 2009 by twopedsinapod

Technical talk

We noticed Atom 1.0 readers did not pick up the podcast. Try the RSS 2 feed instead.

Let us know about any technical glitches. We are still very new to cyberspace and appreciate your feedback. We say in our podcasts, “Right now our recording studio is our kitchen table”…. you should see our computer help desk

Naline Lai, MD and Julie Kardos, MD

November 5, 2009 by twopedsinapod

Podcast- The tired teen

Drs. Kardos and Lai advise parents on what they can do for their tired teen. Although we all enjoyed an hour’s extra sleep this past weekend with the resetting of the clocks, many teens are back to their “usual” sleep deprived state. Listen here to find out how to help reset your teen’s internal clock, and what to consider when you have a tired teen.

Julie Kardos, MD and Naline Lai, MD

November 4, 2009 by twopedsinapod

H1N1 as a source of artistic inspiration

Boo (boo-hoo)

A lot of Halloween festivities in our area have been dampened by H1N1 flu. For all the parents of the boys and ghouls in a similar situation, this picture will make you smile. It was sent to me by Ben’s mom. It is flu from the perspective of a kindergarten boy. The arrow points to Ben’s nose. Note the huge boogie to nose ratio. The red represents “boss germs” and the purple ones are the “just plain mean” ones.

Don’t let the “Boogie” man get your family this Halloween

October 31, 2009 by twopedsinapod

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