Two Peds In a Pod ®
We love being pediatricians because it’s an honor to be a part of your family, it’s intellectually challenging, and it gives us a chance to teach. But mostly, we love to make people feel better.
We love not only when our patients feel better, but also when their parents feel better.
Parents feel better when we say:
Not strep throat. It’s a viral sore throat.
Not pneumonia. It’s a viral cough.
Not a broken foot. It’s an ankle sprain.
Not appendicitis. It’s constipation.
Not an ear infection. It’s fluid behind her ear drum.
Not cancer. It’s a lymph node infection.
In other words, our favorite diagnosis is “Not what you are worried about.”
Parents, including us, fear the worst when their children are ill. Some parents apologize to us when we give the diagnosis of “Not what you are worried about.” They feel they have wasted our time or their time. But this diagnosis is never a waste of time for anyone. It is a stress relieving, sometimes guilt relieving, diagnosis that we are happy to give. Too often we wish with all our hearts that we could give this diagnosis, but instead, we must confirm a parent’s fears.
So this Thanksgiving, we take time to be grateful for the diagnosis “Not what you are worried about.”
May you find lots of Happy in your Thanksgiving.
Drs. Kardos and Lai
©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®
We welcome back health coach Mary McDonald (the mom who overhauled her kids' sports snack stand), to provide advice on how to survive what Dr. Shifrin referred to last week as Candy Season.
—Drs. Lai and Kardos
If your home is like mine, you have an extraordinary amount of Halloween candy lurking in the most unusual locations: inside an old roasting pan, under a pile of shoes in your daughter’s closet, or tucked in an end table drawer in your living room. It’s an incredibly hard time of the year to eat healthy and to help your children make good food choices when sweets are so abundant from October to January. It is disturbing to think about the bad eating habits that start at the holidays and can lead to an addiction to sugar throughout the rest of the year. In order to combat the inevitable onslaught of sugary treats, here are a few strategies to consider:
So, as you and your family weave your way through the sweetest months of the year, think of inviting the Switch Fairy to your house for a home cooked meal full of natural carbs and a big cup of water.
©2013 Two Peds in a Pod®
Mary McDonald holds a Masters of Education from Arcadia University and completed her health coach certification from Institute of Integrative Nutrition. She is a high school teacher, a mom of four daughters, and an advocate for healthy food choices. For more information on her health coaching services, please contact her at firstname.lastname@example.org or visit her website at nutrition101withmary.com.
We enjoyed meeting Pediatric media expert Dr. Don Shifrin, whose interviews have appeared in numerous publications including Good Housekeeping, the Wall Street Journal, and Time blogs. Today he writes about the "fifth season" of the year.
—Drs. Kardos and Lai
Pleading with children not to eat too much candy on Halloween borders on sacrilege. So when a USA Today headline blares, "Scary amount of candy will be consumed on Halloween," it strikes us as proclaiming the obvious. Or does it? A candy industry analyst states that almost four percent of the yearly total for candy consumption in the US occurs on All Hallows Eve. And that "frightens doctors."
“Why?” you might ask.
The article then goes on to give parents several parent-tested hints regarding ways to minimize candy gluttony during and after October 31.
But friends, here's what scares me as a Pediatrician: thanks to the demonic coalition between the candy industry, advertising media, and retailers, Halloween is just the appetizer to a 6-plus month buffet of sugar laden offerings.
The main course closely follows with Thanksgiving and Christmas. Followed closely by the twin desserts of Valentine's Day and Easter. We can get our M&Ms in all seasonal colors from scary to pastels to match each holiday. That's over 6 months of intensive and impressive candy packaging, marketing, and buying by our nation’s most vulnerable and vocal customers- our children. I picture the wolf saying to Little Red Riding Hood, "The better to sell you, my dear."
So parents, good luck trying to avoid the candy aisles from October through April. Here's my perspective on the real scary part of Halloween. It signals the beginning of a newly created season, lasting from fall through spring: America's Candy Season.
And the scariest part? It's not just McDonald's anymore. Groceries, drug stores, warehouse clubs, and convenience stores now join the list of places YOU can get supersized.
Don Shifrin, MD
©2013 Two Peds in a Pod®
Dr. Shifrin is a Clinical Professor of Pediatrics at the University of Washington School of Medicine in Seattle, and has practiced at Pediatrics Associates, Inc, PS. in Bellevue, Washington, for 35 years. He is past Chair of the American Academy of Pediatrics Committee on Communications—a committee which recognizes and evaluates the physical, mental, and social impact of positive and negative messages communicated to children from the media.
“Red and yellow and pink and green, purple and orange and blue…”
Please imagine the “I Can Sing a Rainbow” song playing in the background of this post as you “listen with your eyes.”
In the same order as the song, we proudly present colors with medical meaning:
YELLOW In the “whites of the eyes” or sclera, yellow is a sign of jaundice. Jaundice in only the eyes of newborns is very common and usually does not require treatment. In anyone older than a newborn, jaundice points towards liver disease. So yellow, other than in the newborn period, is a problem color.
PINK Children of all races and ethnicities should have pink inner eyelids, pink lips, and pink nails. Pink in these body areas implies normal blood flow and normal blood count.
GREEN We can see this color in a child’s face before an episode of vomiting or fainting. If you see this color in your child’s face, lie him down on his side to encourage blood flow to his head and to prevent him from hitting his head on the floor if he faints. And get a bucket!
PURPLE A bad rash called "purpura" is purple. It can be seen with a high fever or with leg and belly pain. If you see a purple rash on your ill child, take him to a doctor ASAP.
ORANGE Orange skin in an older baby WHOSE SCLERAE (EYES) ARE STILL WHITE may be seen in kids who love to eat orange fruit and veggies such as carrots, peaches and squash. This condition, called hypercarotinemia, is a result of the build-up of beta carotene from orange foods. We see this often in 9-12 month olds. Hypercarotinemia is not dangerous . An easy way to change the skin color is to feed more green veggies to balance out the orange ones.
BLUE In general, blue is not a good color. Turning blue while coughing means NOT enough air/oxygen is flowing to the body. Low oxygen levels in kids with heart or lung diseases cause a blue coloration in their faces, mouths, and fingernails.
WHITE White inner eyelids, lips, or fingertips implies anemia or poor blood flow in the body. However, white is a normal color for sclera, the “whites of the eyes.”
Speaking of color— kids cannot get a tattoo legally in the USA under age 18 years without parental consent. In case you were thinking of letting your underage child permanently color his or her skin, read this article about an infection caused by one kind of grey tattoo ink.
Hopefully you can now “sing a rainbow too.” If any of our medical colleagues are reading this post, please fill in any color we forgot!
Julie Kardos, MD with Naline Lai, MD
©2013 Two Peds in a Pod®
Ah Ha! Little did we know when we wrote this post back in 2010 that a study of injuries related to sippy cup, bottle, and pacifier use wrapped up that same year. The results, published in the journal Pediatrics in May 2012, showed that sippy cups were a significant source of injury in children. Most commonly they caused mouth lacerations in children who fell while drinking out of the cups.
Drs. Kardos and Lai
At a baby's six month old check-up I advise parents to have their child start drinking from a cup.
Some respond with surprise," A cup? So young? How exciting! Do you mean a sippy cup?”
“No,” I explain. “A regular, open-face cup.”
Then I get incredulous looks. “But how will our baby manage that?”
Just like your baby “learns” how to eat food off a spoon, she will have to practice. You will have to help her at first. Just put water in the cup. Who cares if water spills? You see how by this age she naturally puts her hands together and pulls most things to her mouth. With practice, she will learn to drink out of a cup. Just like everyone else did before sippy cups were invented.
“But when,” parents ask me, “should we introduce the sippy cup?”
The reality is, sippy cups satisfy a parent’s desire to be neat and to avoid mess. Sippy cups are not a developmental stage. Did I use sippy cups with my own kids? Yes I did, especially with my twins, because anything I could do to decrease mess in my home I welcomed with open arms. But it is perfectly okay to never introduce sippy cups to your child.
Because sippy cups are spill-proof, it is tempting to leave one out all day for your child. If the cup contains water, this practice is safe. However, many toddlers have ended up with a mouth full of cavities in their brand new baby teeth after sipping milk or juice all day long out of sippy cups. Constant sweet substances on the gums can sink in and affect baby teeth. Just as we advise parents of bottle fed babies to avoid allowing the child graze from the bottle all day and to avoid falling asleep drinking a bottle, young children should not be drinking sugar-containing drinks, including milk, all day from a sippy cup.
"But I only give my kids water mixed with a tiny bit of juice in the sippy cups," I hear parents say. Yes, kids (and grownups) need water, but watered down juice is not the same as plain water. Watered down juice is sugar water, and it harms teeth just like straight-up juice. In addition, drinking watered down juice teaches kids that all beverages need to be sweet. Sweet drinks do not actually quench thirst; rather, they make kids feel thirstier. Remember that unlike adults, babies and toddlers have not formed unhealthy habits yet, so teach them that water and milk are for drinking. The only exceptions are electrolyte solutions that are used to prevent dehydration during vomiting and juice once a day (prune, pear, or apple) for constipated children. For nutrition, fruit is much healthier than fruit juice.
So put water in the open faced cup and allow your baby to imitate you and drink out of it. Then, around your child’s first birthday when most parents wean their children from breast milk or formula to cow milk, put the “big boy milk” or “big girl milk” into a cup. Aim for all open cups by at least two years of age. If you decide to use sippy cups, as I did, for neatness sake, do not forget practice with a regular cup. Get rid of the sippy cup whenever you are tired of washing those moldy valves and tired of rescuing them from your drain or garbage disposal. You might have a “sippy cups are for car rides” policy and use open cups at home.
What about straw cups? Well, think of it this way. Do you plan to travel around with straws in case your child becomes thirsty? Sure it’s fine to teach your child to drink out of straw. It’s healthier than a sippy cup because most of the milk will bypass most of the teeth. But again, it is easiest in the long run to teach your child to drink out of a regular cup so that in any situation you know you can offer your child a drink.
All kids are messy. The younger you practice with your child, the sooner she will be drinking out of a regular cup like a pro. Just in time for finger feeding which means self-feeding—more mealtime mess!
Julie Kardos, MD with Naline Lai, MD
©2013 Two Peds in a Pod®
Originally posted November, 2010
“When the moon hits your eye like a big pizza pie…”
Actually, that’s not amore, but that's a stye on this child’s upper eyelid.
A stye (medical term = hordeolum) pops up seemingly overnight, although sometimes the child feels some tenderness at the eyelashes a day or two before it appears. Styes are tiny infections of eyelid glands that are self-limited and easily treated with warm wet compresses. We instruct patients to apply a clean, warm, wet cloth to the stye for 5-10 minutes four times per day.
Styes tend to improve after a few days but can take up to two weeks to completely resolve.
Persistent styes may actually be chalazions. Chalazions, the result of a dysfunctional eyelid gland, are firm and are not tender. They tend to “point” toward the inside of the eyelid rather than outward.
Insect bites may also masquerade as styes. However, insect bites are itchy rather than painful.
Reasons to call your child’s doctor:
-the entire eyelid is red, painful, and swollen
-pain is felt inside the eye itself
-child is sensitive to light
-child has vision changes
-the inside white part of your child’s eye becomes red
-stye lasts more than two weeks despite treatment with warm compresses
Julie Kardos, MD and Naline Lai, MD
©2013 Two Peds in a Pod®
With special thanks to Dean Martin
Got a baby starting on table foods and out of ideas? You don't have to go broke over buying toddler Puffs®.
Babies and young toddlers don't have a lot of teeth. In fact, a full set of teeth does not come in until around two years of age. In the meantime, to help your new eater avoid choking, cut up food into tiny pieces. Now, sawing at food with a knife is not easy. Meet your new friend: the kitchen shears! Use shears to snip food into perfect toddler bite-sized pieces.
Cut table food into bite-sized pieces smaller than a grape, or approximately Cheerio® sized, and place on a clean surface, such as the high chair tray. Plates are not necessary and often end up on the floor. Go ahead and give your toddler a fork but don't expect him to use it- most toddlers are eighteen months before they can master a fork or spoon. Always be present when he is eating in case he starts to choke. Toddlers tend to put a handful of food in their mouth at one time, so teach your child to eat pieces of food "one at a time."
Forget the toddler-food aisle, just grab your shears and cut away. Below are finger-food ideas to help you get started. These foods are appropriate for babies who are able to finger-feed, starting anywhere between 7 to 9 months of age, even without teeth:
canned mandarin oranges
fruit cocktail (in juice, not syrup)
diced berries, cut blueberries in half at first
diced cooked apples
raw tomato pieces
liverwurst cut into small pieces
diced cooked meat
Cooked, diced chicken
Diced cooked salmon, tilapia, mahi-mahi, flounder (careful to discard any bones)
tofu (extra-firm is easiest to cut)
black beans, cooked or canned (rinse off the salty sauce they come in)
egg salad or hard-boiled egg pieces
bits of scrambled egg
soft cheese- such as American or Munster
vegetable soup (just scoop out the veggies and give them to your child. You can put the broth into a cup for him to drink)
diced cooked veggies such as peas, carrots, corn, broccoli, zucchini, etc.
cooked diced squash
cooked diced potatoes, sweet potatoes, or yams
macaroni and cheese
crackers with cream cheese
toast with jelly
toast with nut-butter (soy, peanut, almond, sunflower, etc.)
Naline Lai, MD with Julie Kardos, MD
©2013 Two Peds in a Pod®
We've heard some interesting things about cow's milk over the years. I am going to share with you four myths about milk that I continue to hear from my patients’ parents. Spoiler: reading myth #4 can save you lots of money.
Myth #1: Don’t give milk to a child with a fever, the milk will curdle (or some other variant).
Truth: As long as your child is not vomiting, milk is a perfectly acceptable fluid to give your febrile child. In fact it is superior to plain water if your child is refusing to eat, which is very typical of a child with a fever. Fevers take away appetites. So if your child stops eating while she is sick, at least she can drink some nutrition. Milk has energy and nutrition, which help fight infection (germs). Take milk, add a banana and a little honey (if your child is older than one year), and maybe some peanut butter for added protein, pour it into a blender, and make a nourishing milk shake for your febrile child. Children with fevers need extra hydration anyway. Even febrile infants need formula or breast milk, NOT plain water. The milk will not curdle or upset them in any way. If, on the other hand, your child is vomiting, then stick to clear fluids until her stomach settles.
Myth #2: Don’t give children milk when they have a cold because the milk will give them more mucus.
Truth: There is NOTHING mucus-inducing about milk. Milk will not make your child’s nose run thicker or make his chest more congested. Let your runny-nosed child have his milk! Yet my own mother cringes when I give my children milk when they have colds. Never mind my medical degree; my mom is simply passing on the wisdom of HER mother which is that you should not give your child milk with a cold. Then again, my grandmother also believed that your body only digests vitamin C in the morning which is why you have to drink your orange juice at breakfast time. But that’s a myth I’ll tackle in the future.
Myth #3: You can’t over- dose a child on milk.
Truth: Actually, while milk is healthy and provides necessary calcium and vitamin D, too much milk CAN be a bad thing. To get enough calcium from milk, your child’s body needs somewhere between 16 to 24 ounces of milk per day. Of course, if your child eats cheese, yogurt, and other calcium-containing foods, she does not need this much milk. New recommendations for healthy Vitamin D requirements have been increased recently to 400 IU (international units) daily which translates into 32 ounces of milk daily. BUT we pediatricians know from experience that over 24 ounces of milk daily leads to iron-deficiency anemia: calcium competes with iron absorption. You’re better off giving an over-the-counter vitamin such as Tri-Vi-Sol or letting older children chew a multivitamin that contains 400 IU of vitamin D. In addition to iron-deficiency anemia, drinking all that extra milk is bad for teeth (all milk contains sugar) and can also lead to obesity from excessive calories or can in fact lead to poor weight gain in children who are picky eaters to begin with: the milk fills them up too much for them to have any appetite left for food.
Myth #4: Organic milk is healthier than non-organic milk.
Truth: If you compare organic milk to non-organic milk, the nutrients on the label of the milk carton are the SAME. “But what about the growth hormones in milk,” you may wonder. First of all, cows may be supplemented with growth hormone, but their milk is not. In addition, let me explain about growth hormone. Some children are actually born without growth hormone, and other kids develop growth hormone deficiency because of kidney failure, or cancer treatment, or other medical problems. These children need supplemental growth hormone. Unfortunately for these kids, the only way that we have to give growth hormone to these kids is by injection (a shot) every day. Do you know why? Growth hormone gets DIGESTED in the stomach and is not active if a child eats/drinks it. SO, even if non-organic milk contained growth hormone (which it doesn’t) then your child would have no effects of it anyway because their guts would break it down before it could act on their bodies. WHEW! So unless you just like the taste better, you do NOT have to spend twice as much money on organic milk. Just buy regular milk. Put that extra money away in your college funds.
In summary, you can safely continue serving your children milk in sickness and in health, in moderation, at a lower cost than organic, every day. Now, all this talk about milk really puts me in the mood to bake cookies…
Julie Kardos, MD with Naline Lai, MD
©2013 Two Peds in a Pod®
Update: Please read this article , by the American Academy of Pediatrics in 2012, for a comprehensive, unbiased review of the data comparing health benefits of conventional vs organic milk and other foods--Drs. Kardos and Lai, October 6, 2013.
Revised from the original post from 10/5/2009