Does your kid spit out all medicine? Clamp her jaws shut at the sight of the antibiotic bottle? Refuse to take pain medicine when she clearly has a bad headache or sore throat?

Sometimes medicine is optional but sometimes it’s not. Here are some ways to help the medicine go down:

Don’t make a fuss. We mean PARENTS: don’t make a fuss. Stay calm. Explain that you are giving your child medicine for … fill in the blank… reason, calmly give her the pill to swallow or the medicine cup or syringe filled and have her suck it down, then offer water to drink. If you make a BIG DEAL or warn about the taste or try to hurry your child along, she may become suspicious,  stubborn or flustered herself. Calmness begets calm.

What if she hates the taste?

• Most medication can be given with a little chocolate syrup or applesauce (yes, Mary Poppins had the right idea). Check with your child’s pharmacist if your child’s particular prescription can be given this way.
• Often, your pharmacist can add flavor to your child’s prescription.
• Check if your child’s medicine comes in pill form so she doesn’t have to taste it at all.
• Try “chasing” the medicine down with chocolate milk instead of water to wash away a bad taste quicker.
• Use a syringe (no needle of course) to slowly put tiny bits of liquid medicine in the pocket between her outer teeth and her cheek. Sooner or later she will swallow. After all, she swallows her own saliva. ( A factoid: an adult swallows up to 1.5 liters of saliva a day.)

DON’T MIX the medication in a full bottle of liquid if you are administering medication to a baby. There is a good chance that the baby will not finish the bottle and therefore the baby will not finish the medication. Also, some medications will no longer work if they are dissolved in a liquid.

WHAT IF SHE THROWS UP THE MEDICATION? Call your child’s doctor, if the medication was not in the stomach for more than 15 minutes, we will often not count it as a dose and may instruct you give another dose.

WHAT IF SHE CAN’T SWALLOW PILLS?  If your child can swallow food, she can swallow a pill.  Dense liquids such as milk carry pills down the food pipe more smoothly than water. Start with swallowing a grain of rice or a tic-tac. For many kids, it is hard to shake the sequence of biting then swallowing. Face it. You spent a lot of time when she was toddler hovering over her as she stuffed Cheerios in her mouth, muttering “bite-chew-chew-swallow.” Now that you want her to swallow in one gulp, she is balking. Luckily, most medication in pills, although bitter tasting, will still work if you tell your child to take one quick bite and then swallow. The exception is a capsule. The gnashing of little teeth will deactivate the  microbeads in a capsule release system. If you are not sure, ask your pharmacist.  For more ideas, read our prior post on How to swallow pills.

WHAT IF ALL ATTEMPTS AT ORAL MEDICINE FAIL? Talk to your child’s doctor. Some liquid antibiotics come in shot form and your pediatrician can inject the medicine (such as penicillin), and some come in suppository form; Tylenol (generic name acetaminophen) is an example. You can buy rectal Tylenol if sore throat pain or mouth sores prevent swallowing or if your child simply is stubborn. Sometimes you just have to have one adult hold the child and another to pry open her mouth, insert medicine, then close her mouth again.
HAVE AN EAR DROP HATER? First walk around with the bottle in your pocket to warm the drops up. Cold drops in an ear are very annoying. (In fact, if cold liquid is poured into the ear a reflex occurs that causes the eyes beat rapidly back and forth). Use distraction. Turn on a movie or age-appropriate TV show, have your child lie down on the couch on her side with the affected ear facing up. Pull the outside of her ear up and outward to make the ear opening more accessible, then insert the drops and let her stay lying down watching her show for about 10 minutes. If you need to treat both ears, have her flip to the other side of the couch, affected ear up, and repeat. Another option: treat your child while she sleeps.

AFRAID OF EYE DROPS? If your child is like Dr. Kardos who is STILL eye-drop phobic as a grown-up, try one of two ways to instill eye drops. Have your child lie down, have one person distract and cause your child to look to one side, insert the drop into the side of the eye that your child is looking AWAY from. She will blink and distribute the medicine throughout the eye.
ALTERNATIVELY, have your child close her eyes and turn her head slightly TOWARD the eye you need to treat. Instill 2 drops, rather than one, into the corner of her eye nearest her nose. Then have her open her eyes and turn her head slowly back to midline: the drops should drop right into her eye. Repeat for the second eye if needed.

HATE CREAM? Some kids need medicated cream applied to various skin conditions. And some kids hate the feeling of goop on their skin. These are often the same kids who hate sunscreen. Again, distraction can help. Take a hairbrush and “brush” the opposite arm or some other area of the body far away from the area that needs the cream. Alternatively, apply the cream during sleep. Another option- let your child apply his own cream- this gives back a feeling of control which can lead to better compliance with medicine. It also will help him to feel better faster. IF your child is complaining about stinging, try an ointment instead. Ointments tend to sting less than creams.

Of course, as last resort, you can always explain to your child in a logical, systematic fashion the mechanism of action of the medication and the future implications on your child’s health outcome.

If you choose this last method, you should probably have some Hershey’s syrup nearby. Just in case.

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

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

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

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

General tips for visiting:

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

We wish you all the best this Thanksgiving!

Julie Kardos, MD and Naline Lai, MD

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

It’s gift-giving season! Now that your families are another year older, it’s time to update our sometimes-you-just-want-to-buy-something holiday gift idea list 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 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. 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. A running watch is always appreciated or treat them to moisture wicking work-out clothes or a gift card to a sports equipment store.

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.

Enjoy your holiday shopping!

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

Modified from our original November 2012 post

As we said to Robin Young on NPR’s Here and Now, “a lot of life’s issues all boil down to the essentials of life…eat, sleep, drink, pee, poop and love.” Continuing our ideas and updates on all of those baby essentials, here’s the scoop on poop :

Okay, admit it.

Before you became a parent, you never really gave much thought to poop.

Now you are captivated and can even discuss it over meal time: your child’s poop with its changing colors and consistency. Your vocabulary for poop has likely also changed as you are now parents. Before your baby’s birth, you probably used some grown-up word like “bowel movement” or “stool” or perhaps some “R” rated term not appropriate to this pediatric site. But now, all that has changed.

As pediatricians, we have many conversations with new parents, and some not-so-new parents, about poop. Mostly this topic is of real interest to parents with newborns, but poop issues come out at other milestones in a child’s life, namely starting solid foods and potty training. So we present to you the scoop on poop.

Poop comes in three basic colors that are all equal signs of normal health: brown, yellow, and green. Newborn poop, while typically yellow and mustard like, can occasionally come out in the two other colors, even if what goes in, namely breast milk or formula, stays the same. The color change is more a reflection of how long the milk takes to pass through the intestines and how much bile acid gets mixed in with the developing poop.

Bad colors of poop are: red (blood), white (complete absence of color), and tarry black. Only the first poop that babies pass on the first day of life, called meconium, is always tarry black and is normal. At any other time of life, black tarry stools are abnormal and are a sign of potential internal bleeding and should always be discussed with your child’s health care provider, as should blood in poop (also not normal) and white poop (which could indicate a liver problem).

Normal pooping behavior for a newborn can be grunting, turning red, crying, and generally appearing as if an explosion is about to occur. As long as what comes out after all this effort is a soft poop (and normal poop should always be soft), then this behavior is normal. Other babies poop effortlessly and this, too, is normal.

Besides its color, another topic of intense fascination to many parents is the frequency and consistency of poop. This aspect is often tied in with questions about diarrhea and constipation. Here is the scoop:

It is normal for newborns to poop during or after every feeding, although not all babies poop this often. This means that if your baby feeds 8-12 times a day, then she can have 8-12 poops a day. One reason that newborns are seen every few weeks in the pediatric office is to check that they are gaining weight normally: that calories taken in are enough for growth and are not just being pooped out. While normal poop can be very soft and mushy, diarrhea is watery and prevents normal weight gain.

After the first few weeks of life, a change in pooping frequency can occur. Some formula fed babies will continue their frequent pooping while others decrease to once a day or even once every 2-3 days. Some breastfed babies actually decrease their poop frequency to once a week! It turns out that breast milk can be very efficiently digested with little waste product. Again, as long as these babies are feeding well, not vomiting, acting well, have soft bellies rather than hard, distended bellies, and are growing normally, then you as parents can enjoy the less frequent diaper changes. Urine frequency should remain the same (at least 6 wet diapers every 24 hours, on average) and is a sign that your baby is adequately hydrated. Again, as long as what comes out in the end is soft, then your baby is not “constipated” but rather has “decreased poop frequency.”

True constipation is poop that is hard and comes out as either small hard pellets or a large hard poop mass. These poops are often painful to pass and can even cause small tears in the anus. You should discuss true constipation with your child’s health care provider. A typical remedy, assuming that everything else about your baby is normal, is adding a bit of prune or apple juice, generally ½ to 1 ounce, to the formula bottle once or twice daily. True constipation in general is more common in formula fed babies than breastfed babies.

Adding solid foods generally causes poop to become more firm or formed, but not always. It DOES always cause more odor and can also add color to poop. Dr. Kardos still remembers her surprise over her eldest’s first “sweet potato poop” as she and her husband asked each other, “Will you look at that? Isn’t this exactly how it looked when it went IN?” If constipation, again meaning hard poop that is painful to pass, occurs during solid food introductions, you can usually help by giving more prunes and oatmeal and less rice and bananas to help poop become softer and easier to pass.

Potty training can trigger constipation resulting from poop withholding. This poop withholding can result in backup of poop in the intestines which leads to pain and poor eating. Children withhold poop for one of three main reasons.

They are afraid of the toilet or potty seat.

They had one painful poop and they resolve never to repeat the experience by trying to never poop again.

They are locked into a control issue with their parents. Recall the truism “You can lead a horse to water but you can’t make him drink.” This applies to potty training as well.

Treatment for stool withholding is to QUIT potty training for at least a few weeks and to ADD as much stool softening foods and drinks as possible. Good-for-poop drinks and foods include prune juice, apple juice, pear juice, water, fiber-rich breads and cereals, beans, fresh fruits and vegetables. Sometimes, under the guidance of your child’s health care provider, medical stool softeners are needed until your child overcomes his fear of pooping and resolves his control issue. For more information about potty training we refer you to our post with podcast on this subject.

Our goal with this blog post was to highlight some frequently-asked-about poop topics and to reassure that most things come out okay in the end. And that’s the real scoop.

Julie Kardos, MD and Naline Lai, MD

©2014 Two Peds in a Pod®

modified from original 2009 post

Photo by Lexi Logan

Today we welcome Bereavement Counselor Amy Keiper-Shaw who shares with us how to discuss the death of a pet with your child.

–Drs. Lai and Kardos

When I first graduated from college I worked as a nanny. One day the mom shared with me that their family goldfish recently died. As this was her daughter’s first experience with death, we schemed for nearly 20 minutes to find the best way to talk to her child. The mom and I thought it could be an excellent teaching moment.

We pulled the girl away from her playing to explain that the fish had died. We told the girl we’d help her have a funeral if she wanted, and we would find a box (casket) to bury the fish so she could say her goodbyes. We explained what a casket was and what a funeral was in minute detail. After our monologue we stopped, we asked if she had any questions.

After a slight pause she asked, “Can’t we just flush it?”

The lesson I learned from that experience, and still use to this day, is to keep things simple, and know my audience. Sometimes as parents we overcompensate for our own fears and make situations more challenging than they need to be.

Here are some tips on how to talk to your children about pet loss:

Tell your child about the death, and then pause. Ask her what she thinks death means before moving on with further explanations. This will help you know if she has questions or if she has enough information for the moment. Children often need a small amount of information initially and will later come back to you several times later to ask more questions after they process the information.Remember to express your own grief, and reassure your child that many different feelings are ok. Be sure to allow children to express their feelings. If your child is too young to express herself verbally, give her crayons and paper or modeling clay too help express grief.

Avoid using clichés such as: Fluffy “went to sleep.” Children may develop fears of going to bed and waking up. The phrase “God has taken” the pet could create conflicts in a child and she may become angry at a higher power for making the pet sick, die, or for “taking” the pet from them.

Be honest. Hiding a death from a child can cause increased anxiety. Children are intuitive and can sense is something is wrong. When the death isn’t explained they make up their own explanation of the truth, and this is often much worse than the reality of what occurred.

Children are capable of understanding that life must end for all living things. Support their grief by acknowledging their pain. The death of a pet can be an opportunity for a child to learn that adult caretakers can be relied upon to extend comfort and reassurance through honest communication.

Developmental Understanding of Death

Two and three-year-olds
Often consider death as sleeping, therefore tell them the pet has died and will not return.

Reassure children that the pet’s failure to return is unrelated to anything the child may have said or done (magical thinking).

A child at this age will readily accept another pet in the place of a loved one that died.

Four, five, and six-year-olds

These children have some understanding of death but also a hope for continued living (a pet may continue to eat, play & breathe although deceased).

They can feel that any anger that they had towards the pet may make them responsible for the pet’s death (“I hated feeding him everyday”).

Some children may fear that death is contagious and could begin to fear their own death or worry about the safety of their parents.

Parents may see temporary changes in their child’s bladder/bowels, eating and sleeping.

Several brief discussions about the death are more productive than one or two prolonged discussions.

Seven, eight, and nine-year-olds

These children have an understanding that death is real and irreversible.

Although, to a lesser degree than a four, five or six-year-old, these children may still possibly fear their own death or the death of their parents.

May ask about death and its implications (Will we be able to get another pet?).

Expressions of grief may include: somatic concerns, learning challenges, aggression, and antisocial behavior. Expression may take place weeks or months after the loss.

Adolescents

Reactions are similar to an adult’s reaction.

May experience denial which can take the form of lack of emotional display so they could be experiencing the grief without outwards manifestations.

Resources:
Petloss.com– a gentle and compassionate website for pet lovers who are grieving the death or an illness of a pet- they have a Pet Loss Candle Ceremony every week

Your local veterinarian- often your veterinarian has or knows of a local pet loss group

Handsholdinghearts.org– our group of counselors offer grief support to children, teens, and their families centered in Bucks County Pennsylvania.

Books on pet loss for children:

Badger’s Parting Gifts (children) by Susan Varley

Lifetimes by Brian Mellonie & Robert Ingpen

The Tenth Good Thing About Barney (children) by Judith Viorst

Amy Keiper-Shaw, LCSW, QCSW, GC-C

©2013 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, a resource for children who have experienced a significant death in their lives.

‘Tis the season for indoor allergies. We’re all inside a lot, and the heat is blowing through dry, dusty vents. With our energy-saving windows and doors, we’ve created houses where the allergens that tickle our noses can circulate again and again. But there’s no reason to break out the Kleenex® every year. Here are keys to cutting down on indoor allergens:

If your kids have sensitive noses, consider opting for an artificial Christmas tree instead of a live one. Mold spores love evergreens and storage outside before your purchase can make live trees rather dusty. If you do opt for the live tree, one remedy is to hose off mold and dirt from your tree in your driveway before bringing it indoors.

To keep dust down in general in your home, do your best to mop rather than vacuum. Vacuums can spew dust into the air. When you vacuum, use one with a HEPA filter. Or you could replace dust-trapping carpets with wood floors.

Kids spend nearly half of their days sleeping, so it’s imperative to keep their bedrooms allergen free. Mattress and pillow covers will trap dust mites and their droppings, which trigger allergic reactions, away from your allergic kids’ noses. Unfortunately, these microscopic creatures are ubiquitous. 

Also, get the stuffed animals and real animals out of the bedrooms. However, if your child needs to snuggle with his stuffed bunny at night to sleep well, don’t take it away, but at least try to clean it. A good wash and then high heat in the dryer at 130 degrees F for 20 minutes kills dust mites. Alternatively, extreme cold of -17 degrees C to -20 degrees C will also kill mites. While we’ve never heard of anyone putting their child’s “Bun-Bun” into the freezer, we suppose it is an option.

Avoiding allergy triggers is more effective than employing air filtration systems. In fact, many experts argue that filtration makes little difference in air quality in a well-ventilated house. However, we know that some parents will still consider buying a filter. While there are no national standards, the EPA does have guidelines. Since ozone is a known lung irritant, avoid products that specifically claim to generate ozone in order to clean the air.

What to do about the vents in your home? The jury is out. Some experts argue that cleaning vents stirs up decades of dust. On the other hand, less dirt in a ventilation system is less dirt that can spew into the house.

One last word on allergy medication: antihistamines. Some are marketed for indoor allergies. But indoor and outdoor antihistamines all work alike. They all block the action of histamine, which is the substance your body releases when it encounters a substance that you are allergic to. Histamines cause those allergy symptoms of general itching, watery eyes, runny nose, sneezing, wheezing, coughing, etc. So the best antihistamine is simply the one that works for your kids.

Above all, don’t despair. Before you know it, the winter will swirl by, the flowers will bloom … and it will be time for spring allergies!

Naline Lai, MD and Julie Kardos, MD

©2013 Two Peds in a Pod®

A five-year-old boy in the office last week said he planned to go home after his checkup and play “Elf on the Shelf.” In the game, he perches very still in a hiding spot in his house with one leg crossed and both hands on his knee, gazes into the distance, and waits for his sister to find him.

Yup, its that time of the year. Before you know it, a “real” Elf on the Shelf or perhaps a Mensch on a Bench may be visiting your home and you’ll be thinking about holiday gifts. Now that your families are another year older, we brought back our holiday gift idea list 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 sooth 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 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 up to standing, 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.

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.

3-4 years: Now kids engage in elaborate imaginary play. They enjoy “dress up” clothes to create characters- super heroes, dancers, princesses, kings, queens, animals. 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®.

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. The kids will appreciate gifts such as a 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. Buy two plastic recorders- one for you and one for your child to play duets. The instrument is simple enough for a ten year-year-old or a forty-year-old 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 kid’s 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. Many teens dislike sweating because they fear sweat will promote acne—treat them to moisture wicking shirts and elaborate acne regimes from the high-end department store make-up counter.

Enjoy your holiday shopping!

Naline Lai, MD and Julie Kardos, MD
©2013 Two Peds in a Pod®

The antihistamine quandry
 Junior’s nose is starting to twitch
His nose and his eyes are starting to itch.
 As those boogies flow
You ask oh why, oh why can’t he learn to blow? 
 It’s nice to finally see the sun
But the influx of pollen is no fun. 
Up at night, he’s had no rest,
But which antihistamine is the best?

It’s a riddle with a straight forward answer. The best antihistamine, or “allergy medicine” is the one which works best for your child with the fewest side effects. Overall, I don’t find much of a difference between how well one antihistamine works versus another for my patients. However, I do find a big difference in side effects.

Oral antihistamines differ mostly by how long they last, how well they help the 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. Most of what you see over-the-counter was by prescription only just a few years ago. And unlike some medications, the recommended dosage over-the-counter is the same as what we used to give when we wrote prescriptions for them.

The oldest category, the 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.  Diphendydramine (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. Other first generation antihistamines include Brompheniramine (eg. brand names Bromfed and  Dimetapp) and Clemastine (eg.brand name Tavist).

The newer second generation antihistamines cause less sedation and are conveniently dosed only once a day. Loratadine (eg. brand name Alavert, Claritin) is biochemically more removed from diphenhydramine than Cetirizine (eg. brand Zyrtec) and runs a slightly less risk of sleepiness. However, Cetirizine tends to be a better at stopping itchiness.
Now over-the-counter, fexofenadine (eg brand name Allegra) is a third generation antihistamine.  Theoretically, because a third generation antihistamine is chemically the farthest removed from a first generation antihistamine, it causes the least amount of sedation. The jury is still out.

If you find your child’s allergies are breaking through oral antihistamines, discuss adding a different category of oral allergy medication, eye drops or nasal sprays with your pediatrician.
Because of decongestant side effects in children, avoid using an antihistamine and decongestant mix.

Back to our antihistamine poem:
Too many choices, some make kids tired,
While some, paradoxically, make them wired. 
Maybe while watering flowers with a hose,
Just turn the nozzle onto his runny nose. 

Naline Lai, MD with Julie Kardos, MD

©2013 Two Peds in a Pod®

Updated  from the original  post April 10, 2011

“Potty training—will it ever end?” many parents ask. Time moves in slow motion for parents teaching their kids to use the potty. For those trapped in a training time warp, take heart. It’s been almost four years since our podcast on potty training and we’re proud to report that the  parents who listened to the podcast have moved onto new parenting challenges like helping with homework. For those in the midst of training, and those who are contemplating training, this post is for you.

Children master potty training typically between the ages of two and four years. Be patient, not everyone is “typical.”  More important than your child’s age,  is whether she shows she is developmentally ready to train. These signs include:

– is generally agreeable/ can follow directions

– gets a funny expression before passing urine or poop, or runs and hides, then produces a wet or soiled diaper

-asks to be changed/ pulls on her diaper when it becomes wet or soiled- remains dry during the day time for at least two hours

-NOT because grandparents are pressuring you to start training their grandchild

– NOT if the child is  constipated—the last thing you want to do is to teach withholding to a kid who already withholds

-NOT if a newborn sibling has just joined the family. A new baby in the house is often a time of REGRESSION, not progression. However, if your toddler  begs to use the potty at this time, then by all means, allow him to try. 

Make the potty a friendly place. Have a supply of books to occupy your child while she sits. Make sure her feet are secure on the floor if using a potty chair or on a stool if using the actual toilet. If using the real toilet for training, consider placing a potty training rim on the toilet seat to prevent your child from jack-knifing into the toilet. If your child is afraid of the bathroom, go ahead and put the potty chair in the hall just OUTSIDE of the bathroom.

Have reasonable expectations based on age. A two year old’s attention span is two minutes. Never force your child to sit on the potty. If he doesn’t want to sit, then he isn’t ready to train.

Your can lead a horse to water… reward the child for sitting on the potty, even if she does not “produce.” Reward by giving a high-five, verbal praise, or a small, cheap trinket such as a sticker. Do NOT promise your child a trip to Disney for potty training—otherwise, what will you do when she learns to ride a bike or tie her shoes? Accept that she may simply enjoy sitting fully clothing on the potty singing at the top of her lungs for a few weeks. 

Let your child learn by imitation  At home, have an open door bathroom policy so she can imitate you and her older siblings. At school, she will imitate her potty-trained classmates.

Initially, kids rarely tell their parents  they “have to use the potty.” For these kids, schedule potty visits every 2-3 hours throughout the day. Do potty checks at key times such as first waking upright before nap and bed. Be sure to spend extra time a half an hour after meals or after a warm bath. Both meals and warmth stimulate poop!

A child is potty trained when she can do the whole deal: use the potty, help wipe, help un-dress and re-dress, and wash hands.
If the child refuses to wash hands after using the potty, she is not trained. Ultimately, the goal is for her to gain independent  toileting skills.  However, she will need your supervision for a while.

Important note for parents of BOYS: First potty train your son to sit for ALL business. Teach him to gently press his penis downward so pee lands in the toilet and not all over the room. Once your son stands up to urinate, he may become so excited that he may never sit down again. Better to wait until he uses the potty consistently with few accidents before teaching him to stand up. Even after he begins to stands to pee, have him sit on the potty daily to allow him time to poop.

Don‘t be surprised if your child trains for pee before poop. In fact, many kids go through a phase when they ask for a diaper to poop in. After all, it’s frightening to see/feel a chunk of your body fall into an abyss.  Dump the poop from the diaper into the potty and practice waving bye-bye.

A note about night time and naps: Potty train for when your child is awake. Your child will spontaneously, without any training, stay dry at night and during naps. Some kids sleep more soundly than others and some kids (see our post on this subject)  are not genetically programmed to stay dry overnight until they are elementary school aged. No amount of daytime training will affect what happens during sleep. Moderate fluids right before bed and  keep putting on the diapers at night until you notice that the diapers are dry when your child wakes up. After a week of dry mornings, try your child in underwear overnight. Occasional accidents are normal for years after potty training, so you might want to put a water proof liner under your child’s sheets when first graduating to sleep underwear.

Disposable training pants: We like sticking to underwear while potty trainers are awake and diapers while asleep.  A reluctant trainer tends to find training pants just absorbent enough that he does not care if he is wet. However, the pants are not absorbent enough to prevent rashes from stool or urine. Plus they are more expensive than underwear AND diapers. Explain to your child  “sleep diapers” are perfectly acceptable until their “pee pee learns to wake them up.” Use the training pants when your child is older and is  mortified by the idea of a diaper or if your family is going on a long car ride and you don’t want to risk urine on a car seat.

Above all: avoid power struggles. If potty training causes tears, tantrums, or confusion then STOP TRAINING, put those diapers back on, and try again a few weeks later. 

After the training, keep an eye on how often he pees and poops. Older kids get “too busy” to go to the potty. Make sure he is in the habit of  emptying his bladder four to six times a day and having a soft bowel movement every day or every other day.

Ultimately… you just have to go with the flow. And remember, everything eventually comes out right in the end.

Julie Kardos, MD and Naline Lai, MD
©2013 Two Peds in a Pod®

Thanks to the Families With Young Children parenting group at Congregation Rodeph Shalom  in Philadelphia, PA for inviting us out to a last week to talk about potty training. The discussion inspired today’s post. Special thanks to Lauren Rose and Rabbi Jill Maderer pictured on the right for organizing the talk and for blessing such an important topic.

The grand finale… the music blares, a giant grey mouse dances on the stage, and six full tables of kids look on a
s six children wearing sparkling birthday hats simultaneously lean over, puff out their cheeks and blow out candles on six birthday cakes.  Immediately after blowing out the candles, your five-year-old birthday boy (at table number three) runs over and says, “Mommy, I have to go to the potty.” You break off your applause to run him to the bathroom where he tinkles a few drops into the toilet. Five minutes later he asks to go again. Fifteen minutes he asks again. By the time you leave, he has asked to pee three more times.

This potty scenario repeats itself later at his older sister’s soccer game and you spend the entire game running him back and forth across two soccer fields in order reach the bathroom. Oddly, he later sits through a movie without interruptions. And despite his urge to urinate frequently during the day, he sleeps through the night and does not wet the bed.

Welcome to urinary frequency syndrome. A couple years after a child potty trains, some kids “over sense” the need to pee and need to be re-taught. In other words, you are back to potty training. But don’t panic, retraining can take only a few days. After your child’s doctor rules out other causes of frequent urination such as urinary tract infections (usually associated with other symptoms such as pain on urination and sometimes fever) or diabetes (symptoms don’t stop overnight and the amount of urine produced is greater than normal), start retraining.

You probably restricted your child’s liquid intake in order to prevent him from urinating too often. Now do the opposite: hydrate him so well that he re-learns the sensation of a full bladder. Have your child fill up his bladder and hold the urine in for half an hour. Just like when he was younger, start by walking him to the potty at the half hour mark and have him try to urinate whether he needs to or not. Fill up his bladder after each void and continue to increase increments between potty visits until he is voiding a healthy 4-6 times a day.

Sometimes stress triggers urinary frequency. Common times for urinary frequency include the beginning of a school year, a change in teachers part way through the school year, a birthday party or vacation. Stress magnifies the worry in a child’s mind that he will have an accident. We have written many school notes asking teachers to allow a child unrestricted access to the bathroom. The child’s need for “potty checking” will dissipate if his bathroom trips are ignored and the child gains confidence that he will not have an accident. Be patient – it can take a few weeks for your child to regain confidence.

Make sure he is not constipated. A distended colon full of stool will sit on top of the bladder causing the bladder to send confusing messages to the brain.

Now, the next time you visit the big grey mouse, maybe you’ll spend more time in the restaurant rather than in the bathroom.

Naline Lai, MD with Julie Kardos, MD

©2013 Two Peds in a Pod®