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.

® 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®

Last week we all sat on the couch watching the Super Bowl. If your kids are still on the couch, this post on indoor exercises by Dr. Deborah Stack is for you:

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

References:

www.mayoclinic.com/health/fitness/FL00030.   
www.caloriesperhour.com/index.burn.php

Deborah Stack, PT, DPT, PCS

With over 15 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.

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 and what to worry about. Please also listen to our podcast on this same subject.

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 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 separate 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 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 of breastfeeding?

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.”

How many minutes should your baby breastfeed at each feeding?

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. Babies should also pee and poop a lot (some poop after EVERY feeding) which is a reflection of getting enough breast milk. Your child’s doctor should 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.

Stay tuned for our next post where we address breastfeeding beyond two weeks.

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, Montgomery, and Philadelphia Counties, Pennsylvania- Nursing Mother’s Advisory Council

Julie Kardos, MD and Naline Lai, MD

©2012 Two Peds in a Pod®