Two Peds in a Pod

Podcast: The barky cough of croup

2012-02-06T04:25:19Z

You wake up in the middle of the night to the sound of a seal barking inside your house. More specifically, from inside the crib or toddler bed. Unless you actually have a pet seal, that bark is the sound of your child with croup.

What is happening and what to do? Press play here to listen to our latest podcast:

Julie Kardos, MD and Naline Lai, MD

Make every bite count: how to increase calories for underweight children

2012-01-30T18:07:55Z

Although the United States is in the midst of an obesity epidemic, some children are underweight. Your child's pediatrician charts your child's height and weight in order to determine whether he is growing appropriately. Just as obesity has many causes, kids can be underweight for many reasons. Regardless of whether the cause of your child’s poor weight gain is medical or behavioral, the bottom line is that underweight kids use more calories than they take in.

Here are ways to increase calories. Remember, you cannot force children to eat if they are not hungry. For example, you can’t just demand that your child eat more noodles. Instead of trying to stuff more food into your child, increase the caloric umph behind a meal. Make every bite count:

Mix baby cereal with formula, not juice or water.
After weaning formula, give whole milk until two years, longer if child is still underweight.
Add Carnation Instant Breakfast or Ovaltine to milk.
Add Smart Balance, butter, or olive oil to cooked vegetables, pasta, rice, and hot cereal.
Dip fruit into whole milk yogurt
Dip vegetables into cheese sauce or ranch dressing
Offer avocado and banana over less caloric fruits such as grapes (which contain only one calorie per grape).
Cream cheese is full of calories and flavor: smear some on raw veggies, whole wheat crackers, or add some to a jelly sandwich
Peanut butter and other nut-butters are great ways to add calories as well as protein to crackers, sandwiches, and cereal.
If your child is old enough to eat nuts without choking (as least 3 years), a snack of nuts provides more calories and nutrition than goldfish crackers or graham crackers.
For your older child feed hardy "home style foods." Give mac 'n cheese instead of pasta with a splash of tomato sauce or serve meatloaf with gravy instead of chicken breast
Try granola mixed into yogurt or as a bar.
Give milkshakes in place of milk (no raw eggs!)
Choose a muffin over a piece of toast at breakfast.

Some causes of poor weight gain are medical. Have your child’s doctor exclude medical reasons of poor weight gain with a thorough history and physical exam before you assume poor weight gain is from low caloric intake. Sometimes, your child's physician may need to check blood work or other studies to help figure out why he is not gaining weight appropriately.

Some common behavioral causes include drinking too much prior to eating, picky eating, or parents failing to offer enough calories. Sometimes tweens and teens develop a pathologic fear or anxiety about gaining weight and deliberately decrease their food consumption. These kids have eating disorders and need immediate medical attention.

A common scenario we often see is the underweight toddler whose parents describe as a “picky eater.” Meal times are stressful for the entire family. Mom has a stomach ache going into dinner knowing the battle that will ensue. Her child refuses everything on the table. Mom then offers bribes or other meal alternatives. Dad then gets into the fray by making a game out of eating, and when the child does not eat, in frustration he yells at the child. Grandma then appears with a big cookie because “well, he needs to eat SOMETHING.” All the adults end up arguing with each other about the best way to get their toddler to eat. If you recognize your family in this example, please see our post on how to help picky eaters for ways to break out of this cycle.

Just as obese children need to see their doctors to check for complications relating to their increased weight, underweight children require weight checks to make sure that they gain enough weight to prevent poor height growth and malnutrition.

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

About gender identity: when your boy says he is a girl or your girl says she is a boy

2012-01-23T04:31:06Z

The news is filled with stories about boys wearing pink nail polish, a baby whose gender will be kept a secret by his/her parents, and Chaz Bono’s new book and identity as a man. What’s the deal with gender, and why have the media waves exploded in the past few years? Is gender variance becoming more common, or just more recognized? And what should you do if your son wants to wear pink or your daughter cuts her hair short?

First, some definitions.

-Gender is one’s internal sense of self as male, female, or neither, while sex is assigned at birth based on external appearance. As one astute child told me, “sex is what’s between your legs, while gender is what’s between your ears.”

-Gender expression is how one chooses to portray his or her sex or gender—for example a male child (sex assigned at birth) who feels he is a girl (gender) might still wear boys’ clothing and hairstyles to fit in with peers (gender expression). Or, a female child (sex) feels she is a girl (gender) but prefers to wear boys’ clothing (gender expression) and chooses a gender-neutral name. Her gender expression is masculine.

-Gender variant, gender diverse, and gender nonconforming refer to a child who expresses gender identity or expression that is different than what one expects based on sex. These terms refer to a wide range of children—from the little boy who likes to play with Polly Pocket dolls to the male child who insists he is a girl and wears dresses to school. Some gender variant children will be transgender, which refers to a child who persistently feels the sex assigned at birth is incorrect.

When gender variant children reach puberty, they may become aware of their sexual orientation, or who they are sexually attracted to. They may find that they are attracted to the “opposite gender” and have a straight (heterosexual) orientation, or they may be attracted to the same or any gender, and identify as gay, lesbian, or bisexual. Of course, these labels become especially confusing when discussing gender variant teenagers. For example, is a female-bodied teen who identifies as a man (transgender) and attracted to women heterosexual or homosexual? For this reason, many young people choose to identify as queer, an umbrella term with a positive connotation that conveys many ways of loving people with different bodies and gender expressions.

How common is gender variance?

International epidemiologic studies estimate the prevalence of transgender adults to be anywhere from 1 in 1,000 to 1 in 30,000. That’s a huge range. When you include children who are gender variant but not transgender, the numbers are much higher. For example, Gender Spectrum, an organization that I work with in California, conducts trainings at schools that have identified a gender variant child who is facing bullying or discrimination. To date, they have been invited to nearly every elementary and middle school in their geographic area. Most schools in this area have approximately 100-500 students, so my best estimate of gender variance in my geographic area is 1 in 500.

How do you know if a child is gender variant?

The child tells you. Many of the gender variant children I know recall telling their parents at an early age that they felt different. For example, some transgender boys (i.e. born in a female body, identify as male) I know corrected the adults who tried to call them girls as children, insisting they were boys. One parent recalls her transgender son telling adults “I am a boy now, but when I grow up I will be a mommy.”

Most kids exhibit some sort of gender exploration in their early childhood, and this is a normal part of development. However, a child who is shows gender variance generally makes claims that are early and persistent, and then develops distress when corrected by adults. The “test” becomes when a child is given the freedom to express his/her internal sense of gender. In gender variant children, this distress will be alleviated.

What do you do if this describes your child?

The emerging consensus among experts is to let your child guide you, and to aid your child in his or her gender exploration by working with local resources to create a supporting and accepting environment. In the past, some experts recommended a sort of reparative therapy, for instance removing all “girlish” toys from a boy-bodied child’s home and insisting that he wear only “masculine” clothing. While this may have worked for a short time, the child’s distress often emerged later on, often in puberty, with depression and suicide. In fact, a survey of transgender adults showed that one-third of them had attempted suicide in their life, some as young as age seven or eight. These are good reasons to pay attention to your young child. Research shows that children raised in supportive families have more positive outcomes.

Parents raising gender variant children worry about their safety and acceptance in their schools, neighborhoods, and extended families—and for good reason. Gender variant children are bullied and face discrimination, abuse, and violence at rates much higher than their peers. Often, parents do not agree with each other—as one parent may allow more gender exploration than the other. The child’s gender presentation may not be accepted in churches or within the family’s religious belief. It is imperative that families obtain professional help, especially when there is disagreement between parents on how to support the child. In addition, there are many parents groups and conferences where families can meet each other for mutual support.

If you are concerned about a child in your own life, there are wonderful organizations that can help you.

Resources:

Resources: Gender Spectrum www.genderspectrum.org

Family Acceptance Project http://familyproject.sfsu.edu/

Trans Youth Family Allies http://www.imatyfa.org/

My favorite blogs, articles, and videos about raising Gender Variant Children

Sarah Hoffman’s Parent Blog http://www.sarahhoffmanwriter.com/

A Boy’s Life from the Atlantic http://www.theatlantic.com/magazine/archive/2008/11/a-boy-apos-s-life/7059/

Two Families Grapple with Son’s Gender Identity from NPR http://www.npr.org/2008/05/07/90247842/two-families-grapple-with-sons-gender-preferences

Transgender Kids recent CNN segment http://www.cnn.com/2011/09/27/health/transgender-kids/index.html

Ilana Sherer, MD

Returning guest blogger Dr. Ilana Sherer is the Director of General Pediatrics of the Child and Adolescent Gender Center at UCSF. She is a recipient of the Chancellors Award for LGBT leadership at UCSF and also of the American Academy of Pediatrics Dyson Child Advocacy Award.

The Hidden Homeless: Children and Families

2012-01-16T12:42:22Z

As a call to service in honor of Martin Luther King Day, we bring you an eye opening child advocacy post from guest blogger Dr. Heidi Román, who works with underserved children and their families in California .

Early in my pediatric residency training I entered the exam room to see a one-year old patient. Her mom blurted out excitedly, “We finally have a place to live.” It turned out that they had been living in motels or with relatives for most of the child’s life. I paused for a moment as I realized that it had never really registered. She had been seen in our clinic for multiple visits, but no one had noticed the changing addresses. No one had asked the questions in a way that allowed her to tell us. They were homeless. This was my wake up call. Since then, I have met many families affected by homelessness. Many hard working families are pushed into poverty and homelessness by loss of a paycheck, foreclosure, or divorce. They are reluctant to talk about it. Children and families are the “hidden” homeless.

While the mainstream media consistently covers the recession, quoting jobs numbers and the like, there is a disturbing new set of data out that doesn't seem to be getting much press. Last month the The National Center on Family Homelessness released their report on child homelessness entitled "America's Youngest Outcasts 2010", and the news is not good. During the time period of the recession (2007-2010) there was a 38% spike in the number of homeless children. Currently, there are 1.6 million homeless children in the United States. Children now make up almost 40% of the homeless population and families with children are the most rapidly growing segment of the homeless population.

That's a lot of kids and families. And, as children are often not included in homeless statistics, the number is probably higher. Why don't we hear about it more? Well, homeless families tend to be the invisible segment of the homeless population. They fly under the radar. They move from place to place. They "double up" with friends or relatives for a few months, and then stay in a shelter or motel for a while. They sleep in their car. Parents may not even report that they are homeless to teachers or health care providers for fear of losing their children. There are various reasons that families become homeless. Certainly worsening poverty, due to job loss or changes in welfare programs, is a major cause of housing loss for families. But, domestic violence or parental separation is also very often to blame.

Once families become homeless, it is very difficult to escape. Even if the parents are lucky enough to find a job, it will likely pay only minimum wage. Adequate housing is still out of reach for these families. This is true regardless of the state, city, or town the family lives in; and the gap between income and housing costs is even greater in areas with a high cost of living. With long waits for Section 8 housing and shelter beds, families are left with few options.

Experiencing homelessness profoundly affects a child's physical, psychological, and educational health. Homeless children have higher incidence of trauma-related injuries, poorly controlled asthma, developmental delays, growth problems, and anemia, among other health problems. Homeless children are far less likely to have a medical home or adequate health insurance. They are far more likely to utilize the ER for care at a later stage of illness. Homeless adolescents have much higher risk of being victims of violence or sexual abuse and have higher rates of substance use, HIV, and teen pregnancy.

Homeless children, regardless of cognitive ability, do far worse in school. They are more likely to change schools during the year or miss more school days, greatly affecting their ability to do well academically and flourish socially. Even simple things, like being asked by a teacher to draw their room or describe their house, become awkward and painful.

What's being done about this? Sadly, not much. Per the State Report Card on Child Homelessness, only seven states have extensive plans relating to services for homeless families. In the current economic and political climate, the number of homeless children and families continues to increase and the services provided to them are shrinking.

What can we do?

If you or someone you know is at risk of homelessness:
- Talk to someone you trust- a physician, teacher, church staff, or social worker. Learn about emergency assistance programs in your area.
- If you will be homeless in a few days or weeks, The National Coalition for the Homeless has a list of things to do. It includes making sure you have a current and available ID, packing a bag of essentials for each family member, and applying for public and transitional housing. Search the Coalition’s directory of homeless advocacy organizations and shelters.

If you are a person who cares about these kids and families:
- Learn about the “hidden homeless” and start talking to friends and colleagues. Work to change misperceptions about homelessness. Find out how your state is doing in terms of providing services to homeless families.
- Consider volunteering with or donating to an organization that fights to end homelessness. National organizations include The National Coalition for the Homeless, The National Law Center on Homelessness and Poverty, and The National Center on Family Homelessness. Find a local organization to work with here or via internet search.
- The National Coalition for the Homeless has a great list of other creative ways to get involved.
- Finally, contact your congressperson and tell them you support H.R. 32 The Homeless Children and Youth Act of 2011. This bi-partisan bill changes the definition of “homeless person” to include certain adolescents and youth that are currently excluded for technical reasons. Their inclusion would allow them to access much needed services. If I can’t convince you, perhaps these kids can. They testified about their experience being homeless at the H.R. 32 hearing on child and youth homelessness, held by the U.S. House of Representatives’ Financial Services Subcommittee on Insurance, Housing, and Community Opportunity last December.

Heidi Román, MD

Heidi Román MD, FAAP is a mother and pediatrician who practices in San Jose, California. She has special interest and experience working with under-served families from diverse racial and socio-economic backgrounds. Dr. Román is a passionate child health advocate who works towards improved health for all kids, both in and out of the clinic. She writes about everything from parenting to policy at mytwohats.wordpress.com.

©2012 Two Peds in a Pod®

An overlooked source of mouth sores

2012-01-10T04:50:51Z

When I was a kid I used to be afraid the suction tube used at the dentist's office would suck up my tongue. I have never seen that happen, but I have noticed that when children undergo long dental procedures, the suction is often hooked at the corner of the mouth for an extended period of time. Between the saliva that accumulates under the hook and "digests" the lip and the wet irritation from a piece of plastic pressing against the edge of the mouth, the kids may emerge with a sore at the corner of their mouths. The catch: the sore usually does not appear for a couple of days, sending parents into my office concerned about cold sores or infection after they have forgotten about the dental visit.

Fortunately, the mucosal (moist) areas of the mouth heal rapidly because of a rich blood supply which brings nutrients to the area quickly. However, before it heals, the area on and around the lip where the suction sat looks ugly, white and heaped up the by the third or fourth day after the dental visit. Keep the area clean with soap and water and put on a barrier protection such as petroleum jelly based product (eg Vaseline, aquaphor) so that any drool will not further irritate the area. Apply barrier protection the next time your child visits the dentist.

Still better than having your tongue sucked up.

Naline Lai, MD with Julie Kardos, MD
©2012 Two Peds in a Pod®

Parents of one-year-olds: Rule your Roost!

2012-01-04T05:22:05Z

When your baby turns one, you'll realize he has a much stronger will. My oldest threw his first tantrum the day he turned one. At first, we puzzled: why was he suddenly lying face down on the kitchen floor? The indignant crying that followed clued us to his anger. “Oh, it’s a tantrum,” my husband and I laughed, relieved.

Parenting one-year-olds requires the recognition that your child innately desires to become independent of you. Eat, drink, sleep, pee, poop: eventually your child will learn to control these basics of life by himself. We want our children to feed themselves, go to sleep when they feel tired, and pee and poop on the potty. Of course, there’s more to life such as playing, forming relationships, succeeding in school, etc, but we all need the basics. The challenge comes in recognizing when to allow your child more independence and when to reinforce your authority.

Here’s the mantra: Parents provide unconditional love while they simultaneously make rules, enforce rules, and decide when rules need to be changed. Parents are the safety officers and provide food, clothing, and a safe place to sleep. Parents are teachers. Children are the sponges and the experimenters. Here are concrete examples of how to provide loving guidance:

Eating: The rules for parents are to provide healthy food choices, calm mealtimes, and to enforce sitting during meals. The child must sit to eat. Walking while eating poses a choking hazard. Children decide how much, if any, food they will eat. They choose if they eat only the chicken or only the peas and strawberries. They decide how much of their water or milk they drink. By age one, they should be feeding themselves part or ideally all of their meal. By 18 months they should be able to use a spoon or fork for part of their meal.

If, however, parents continue to completely spoon feed their children, cajole their children into eating “just one more bite,” insist that their child can’t have strawberries until they eat their chicken, or bribe their children by dangling a cookie as a reward for eating dinner, then the child gets the message that independence is undesirable. They will learn to ignore their internal sensations of hunger and fullness.

For perspective, remember that newborns eat frequently and enthusiastically because they gain an ounce per day on average, or one pound every 2-3 weeks. A typical one-year-old gains about 5 pounds during his entire second year, or one pound every 2-3 months. Normal, healthy toddlers do not always eat every meal of every day, nor do they finish all meals. Just provide the healthy food, sit back, and enjoy meal time with your toddler and the rest of the family.

A one-year-old child will throw food off of his high chair tray to see how you react. Do you laugh? Do you shout? Do you do a funny dance to try to get him to eat his food? Then he will continue to refuse to eat and throw the food instead. If you say blandly,” I see you are full. Here, let’s get you down so you can play,” then he will do one of two things:

1) He will go play. He was not hungry in the first place.

2) He will think twice about throwing food in the future because whenever he throws food, you put him down to play. He will learn to eat the food when he feels hungry instead of throwing it.

Sleep: The rule is that parents decide on reasonable bedtimes and naptimes. The toddler decides when he actually falls asleep. Singing to oneself or playing in the crib is fine. Even cries of protest are fine. Check to make sure he hasn’t pooped or knocked his binky out of the crib. After you change the poopy diaper/hand back the binky, LEAVE THE ROOM! Many parents tell me that “he just seems like he wants to play at 2:00am or he seems hungry.” Well, this assessment may be correct, but remember who is boss. Unless your family tradition is to play a game and have a snack every morning at 2:00am, then just say “No, time for sleep now,” and ignore his protests.

Pee/poop: The rule is that parents keep bowel movements soft by offering a healthy diet. The toddler who feels pain when he poops will do his best not to have a bowel movement. Going into potty training a year or two from now with a constipated child can lead to many battles.

Even if your child does not show interest in potty training for another year or two, talk up the advantages of putting pee and poop in the potty as early as age one. Remember, repetition is how kids learn.

Your one-year-old will test your resolve. He is now able to think to himself, “Is this STILL the rule?” or “What will happen if I do this?” That’s why he goes repeatedly to forbidden territory such as the TV or a standing lamp or plug outlet, stops when you say “No no!”, smiles, and proceeds to reach for the forbidden object.

When you feel exasperated by the number of times you need to redirect your toddler, remember that if toddlers learned everything the first time around, they wouldn’t need parenting. Permit your growing child to develop her emerging independence whenever safely possible. Encourage her to feed herself even if that is messier and slower. Allow her to fall asleep in her crib and resist rocking her to sleep. Everyone deserves to learn how to fall asleep independently. You don’t want to train a future insomniac adult.

And if you are baffled by your child’s running away from you one minute and clinging to you the next, just think how confused your child must feel: she’s driven towards independence on the one hand and on the other hand she knows she’s wholly dependent upon you for basic needs. Above all else, remember the goal of parenthood is to help your child grow into a confident, independent adult… who remembers to call his parents every day to say good night… ok, at least once a week to check in…. ok, keep in touch with those who got him there!

Julie Kardos, MD with Naline Lai, MD
©2012 Two Peds in a Pod®

Top changes in pediatrics every parent should know: 2011

2011-12-29T22:40:25Z

There is a saying we heard in medical school, “Half of what you learn now will change in ten years… you just don’t know which half.” In pediatrics, where we specialize in change, the saying certainly holds true. We ring in the New Year by picking the top 2011 changes in pediatrics all parents should be aware of:

Car seats- keep children rear facing in car seats until two years old (or until they physically cannot fit rear-facing any more) and keep your child in a booster seat until a seat belt fits properly-- across his chest and not his neck, and low on the waist across the hip bones, not across his belly. Sitting in the back seat is the safest spot for those 12 years and under. For more information check out our post Buckle up: the latest in car seat safety.

Meningitis Vaccine- A booster dose for older teens is now recommended for the vaccine against the germ Neisserria meningitidis in addition to the dose routinely given to tweens.

Flu vaccine- Having an egg allergy is no longer an absolute contraindication to getting the flu vaccine. Turns out there is so little egg in the vaccine, most kids with egg allergies can safely receive the injectable form, though they still should not receive the spray-up-the-nose form. Ask your child’s pediatrician or allergist if your egg-allergic child is a candidate.

Bye-bye food pyramid- The difficult to understand food pyramid finally bit the dust and is replaced by My Plate .

SIDS prevention and safe sleep- keep soft bedding away from baby’s face- no crib bumpers! And continue to place your baby on his back to sleep. AAP Expands Guidelines for Infant Sleep Safety and SIDS Risk Reduction and Sleep Safety: How to decrease your baby's risk of Sudden Infant Death Syndrome (SIDS)

An old recommendation gets reinforced: in 2011, Dr Wakefield’s paper suggesting a link between the Measles, Mumps and Rubella (MMR) vaccine and autism is reaffirmed as fraudulent. MMR vaccine schedule does not change.

Genital Wart and cancer from HPV prevention in males- HPV vaccine is now not only approved for boys, but recommended for boys, as well as girls, by the ACIP (vaccine branch of the CDC). With over 35 million people having received this vaccine, evidence supporting its safety has become well established.

All liquid acetaminophen products (Tylenol) are now the same strength. Watch out if you have the old formulation in your medicine cabinet, double check the dosing.

Changes in when and how to start solids foods: For about the last fifteen years, pediatricians advised delaying the start of solid foods and the start of commonly allergenic foods such as eggs or wheat to prevent food allergies. Unfortunately, food allergies have risen during this time. Current advice is back to the old advice. According to the National Institute of Allergy and Infectious Diseases sponsored guidelines (November 2011 Pediatrics), solid foods should be introduced by 4-6 months of age and any potentially allergenic foods may be introduced at this time as well.

We look forward to more advances in pediatrics for 2012. Please keep reading and tell parents about us.

Best wishes for a healthy New Year.

Your Two Peds,

Naline Lai, MD and Julie Kardos, MD

Managing Moolah

2011-12-22T19:35:58Z

As a new year rolls around and our pockets start to feel empty after the holidays, we look back at an older post for ways to penny-pinch without short-changing your kids: Save money: How to penny pinch without hurting your children. And whether your children receive gift cards, gelt, or cash gifts this season, we direct you to the popular post Teaching kids money smarts for ideas on how to help them manage their new stash.

Best wishes from your Two Peds,

Drs. Kardos and Lai
©2011 Two Peds in a Pod®

Spotted on the horizon: Roseola

2011-12-15T11:44:02Z

Your toddler wakes from his afternoon nap a tad grumpy and with flushed cheeks. You grab your thermometer and see that his temperature is… 104F! But, because you have read our prior posts about fever Part 1 and Part 2, you do not panic. He has no cough, no runny nose, no vomiting, no diarrhea, no rash. He is fully immunized. In fact, considering how well he was acting before his nap, you are very surprised to find fever. You give him Tylenol and and hour later he becomes a happy toddler. This pattern continues for three days. He has fever, but no new symptoms, and he continues to run about energetically. On the fourth day, the fever breaks. A rash pops up, and your pediatrician diagnoses your child with roseola.

A viral illness seen in kids typically between six months and two years of age, roseola usually runs a course similar to your toddler’s illness and requires no specific treatment. Many kids remain relatively cheerful despite the fever, and those who become fretful regain their good moods after a fever reducer medication such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) is administered. The associated light-pink rash may cover a child from head to toe as seen in our photo. The rash does not itch or hurt. Once the rash appears, the child is no longer contagious. If you press on the rash and lift up, the redness will momentarily turn white (blanches). It lasts for hours to a few days, and then fades. Up to 50% of affected kids never even get the rash.

My twins had roseola at age 18 months. I remember one had fever for three days, the other had fever for two days, and both acted quite well despite their high temperatures. I kept waiting for more symptoms, dreading what I thought would turn out to be twin colds or worse, twin stomach viruses (double diarrhea really stinks), but no other symptoms emerged. When one broke out in a rash, I remember thinking “Oh finally, I know what you both have... roseola.” My other twin never did get the rash. Thus, I suppose my family shows that 50% of affected kids really don’t get the rash.

What else causes fever for a few days and no other symptoms in a young child? In girls and uncircumcised boys, we mainly worry fever alone can be the sole sign of a urinary tract infection.

In general, if your child seems especially ill, refuses to drink, becomes difficult to console, has any new rash WITH FEVER, or has fever alone for MORE than a few days, then you should call your child’s doctor. For more information on when to call your child's physician, please see our "How sick is sick" post.

Now that you've learned about the symptoms, if you recognize Roseola, you'll be "spot on".

Julie Kardos, MD with Naline Lai, MD

Chatting with Janet Zappala: Food for Thought Episode-help for overweight kids and picky eaters

2011-12-07T03:47:20Z

In case you missed the live internet radio show- hit the arrow to tune in here:

Food For Thought with Janet Zappala

2011-12-06T02:07:13Z

Join Two Peds in a Pod as we chat with Janet Zappala, certified nutritional consultant/Emmy award winning television host, on her new internet radio show Food For Thought on Tuesday, Dec. 6th, at 2pm Pacific Time, 5 p.m. EST. We'll have useful parenting tips and holiday nutrition suggestions for getting your kids to eat better. Log in to listen live www.voiceamerica.com

Newborn eyes: blocked tear ducts, crossed-eyes, vision, and eye color

2011-12-03T04:42:38Z

This post was inspired by a newborn whose mom asked me about his eyes. “Here’s looking at you, kid”:

What is this goop in my baby’s eye?

Blocked tear duct: About 25 percent of infants by the second or third week of life develop some slightly yellow or clear discharge. The discharge looks worse when the infants first awaken. At this age, they start to produce some tears (although they do not “cry tears" until closer to three months old). But because newborn tear ducts, the drainage system for tears, are not completely open, tears either spill over, causing a watery discharge, or accumulate in the eyes during sleep and become slightly thicker “goop” that wipes away easily.

Babies with blocked tear ducts have normal appearing sclera (the whites of the eyes) and normal vision. Blocked tear ducts are not painful. Fortunately, they spontaneously open up in most babies without intervention. This process, which is usually complete by three month of age, can take up to one year of age. An infection in the eye causes a baby’s eye to become painful, red on the inside, and sensitive to light. The discharge becomes pus-like and increases in amount. If you are not sure if your baby’s eye discharge is from an infection or a blocked duct, consult your pediatrician.

Why do my baby’s eyes cross?

Young infants’ eyes may cross as they gaze at an object. This crossing is a result of an immature nervous system. By three to four months of age, a baby’s eyes should always move in concert when she gazes or follows an object with her eyes. If your baby’s eyes cross after this age, alert your child’s pediatrician, who will likely refer your baby for an exam by an ophthalmologist who is comfortable examining babies. It is important to make sure the eyes are both seeing equally and adequately, as well as to make sure the eye muscles work properly. See our previous post on crossed-eyes.

What is normal vision for a newborn?

Babies are born nearsighted. They see clearly the distance to a face when being held. Some newborns will stick out their tongues in response to seeing their parents do the same. So, be sure to look at your infant when you are feeding or rocking her. Far vision develops gradually over months to years. A child's vision is not 20/20 until about five-years old.

When will my baby’s eyes change color?

The color of a baby’s eyes generally becomes established during the first year. Some stay the same color from birth. My own children were all born with either blue or grey eyes but now all are brown, much to the delight of their blue-eyed grandmother. My oldest was nine months before his eyes turned brown. Some of my patients did not develop their permanent eye color until two years.

The part of the eye with color is called the iris. The hole in the center of the iris is called the pupil. Pupils should always look black. In a photograph they can look red from a flash. If you ever see white, yellow, or grey reflected in the pupils, alert your baby’s doctor.

Julie Kardos, MD with Naline Lai, MD

When your kid comes out: How to support your gay, lesbian, bisexual, or transgender child

2011-11-27T16:58:53Z

Today our guest blogger, pediatrician Ilana Sherer, MD, Director of Primary Care for the Child and Adolescent Gender Center at University of California San Francisco, addresses how to respond supportively to your child if he or she “comes out.”

When Jaime recently came out as gay, his mother, a Catholic Mexican immigrant, initially felt fear: “When he told us that he was gay, we were afraid for him. We were afraid of what his life would be and we were afraid that he would not accomplish our dreams for him.”

Contrast this response to Laura's experience. Laura came out to her parents as lesbian when she was depressed and suicidal. Quickly recognizing the crisis, her parents responded by assuring Laura that they loved her no matter what, and got her into counseling with a local and Lesbian/Gay/Bisexual/Transgender (LGBT) conscious mental health professional. Her parents eventually joined the Board of Directors of their local Parents and Friends of Lesbians and Gays support group (PFLAG) and now Laura and her mom speak to other groups about their experiences.

How can parents support their child? Many parents react in loving ways from the moment their child comes out. However, if you’re reading this article, you may have already responded in a way that you regret. That’s okay, and it’s okay to feel sad, hopeless, depressed, blamed, embarrassed, ashamed, or guilty—most parents feel all of these things at one point or another in the process of acceptance. In fact, even parents who feel they are open and accepting to LGBT issues or parents who are LGBT parents may react negatively. However, it’s never too late to show your child that you support and love him or her unconditionally.

Ways to Support your Child:

1. Talk with your child about his LGBT identity, express affection, and support him even if you feel uncomfortable. Support his or her gender expression, clothing choices, and physical expression.

2. Connect your child with community resources geared toward adolescents. If you live near an urban area, there may be an LGBT community center nearby with youth programming. If not, there may be a school or community group available. Check the internet and newspaper listings. If you know any LGBT adults who are part of your community, consider asking them for resources.

3. Connect your family with resources, such as PFLAG (see below). Siblings may also need support.

4. Check in with your child about bullying in school. If he is being bullied, demand that the school address the perpetrators and create a safe educational environment for your child. Advocating for your child is a powerful sign of acceptance.

5. Require that all family members respect your LGBT child.

6. Welcome your child’s friends and partners into your home.

7. It is important for your child (and family) to identify healthy adult LGBT role models. If none are available in your community, point out LGBT people in the media who are leading successful lives. Thankfully, there are no shortage of visible "out" LGBT people in television, music, and movies, but if you need help identifying them, Wikipedia has an exhaustive list.

8. If your church or religion contains messages demeaning the worth of LGBT individuals or suggests that homosexuality can be reversed, consider finding a new worship community.

9. Monitor internet usage. Your child has likely already been on the internet. Hopefully, she found some great resources or has made friends with LGBT teenagers in other parts of the country. However, there is also a lot of misinformation. There are also pornography and social networking sites which can take advantage of your child. As always, keep track of the sites she visits and who she networks with online.

10. Let your child know that you believe he will have a happy future as an LGBT adult.

Unsupportive Behaviors to Avoid:

1. Hitting, slapping, or physically hurting your child.

2. Verbally harassing or name-calling.

3. Excluding your child from family activities.

4. Blocking access to LGBT friends, events, and resources.

5. Blaming your child when she is discriminated against because of her LGBT identity.

6. Tolerating bullying and harassment.

7. Pressuring your child to be more or less masculine or feminine in clothing choices and external appearance.

8. Telling your child that God will punish him because he is gay.

9. Telling your child (or acting as if) you are ashamed of him or that he will shame the family.

10. Making your child keep her LGBT identity a secret or blocking her from telling close family members and friends, or conversely, “outing her" (telling others about her identity) against her will or without permission.

Resources:

Parents and Friends of Lesbians and Gays (PFLAG) www.pflag.org

Gender Spectrum Education and Training www.genderspectrum.org

Gay, Lesbian, and Straight Education Network www.glsen.org

Trevor Project (crisis intervention and suicide hotline for LGBT youth) www.thetrevorproject.org. 1-866-4-U-TREVOR

Center Link (for a listing of LGBT Community Centers) www.lgbtcenters.org

The National Gay and Lesbian Task Force www.thetaskforce.org/issues/youth

The National Youth Advocacy Coalition www.nyacyouth.org

Listing of rural youth resources at www.nyacyouth.org/docs/ruralyouth/resources/index.php

Advocates for Youth www.advocatesforyouth.org

Gay and Lesbian Medical Association Provider’s Directory (for finding an LGBT-competent medical provider) www.glma.org

Youth Resource: a website by and for LGBTQ youth www.youthresource.com

Illana Sherer, MD

Dr. Ilana Sherer is the Director of General Pediatrics of the Child and Adolescent Gender Center at UCSF. She is a recipient of the Chancellors Award for LGBT leadership at UCSF and also of the American Academy of Pediatrics Dyson Child Advocacy Award.

©2011 Two Peds in a Pod®

We give thanks for parental sanity savers

2011-11-20T12:20:29Z

We give thanks for the opportunity to parent our children always. With the many challenges of raising children, this Thanksgiving we give thanks for things that save our sanity. We heave a huge sigh of relief for:

carpools
the neighbor who will meet your child at the bus stop when you are running late
double strollers
pizza
ability to Skype with your teen the first time he is way from home

those folding sports chairs you lug along to all of your children’s sports games
pacifiers

training wheels

Elmo

ketchup

Band aids—a sure cure-all

a same day laundry machine repair person

Happy Thanksgiving from your two Peds,

Naline Lai, MD and Julie Kardos, MD

What you need to know about Whooping Cough

2011-11-16T04:24:38Z

Pertussis is “whooping cough,” also known as the “100 day cough.” In children and adults, the disease starts out looking like a garden-variety cold, complete with runny nose, runny eyes, and mild cough. Sometimes fever is present, sometimes not. However, after a few days, coughing spasms emerge - severe, persistent coughing spasms that go on and on and on. In between coughing fits, children may appear okay.

There is no treatment except to "ride it out" and the cough can last up to three months. Doctors prescribe antibiotics to a child with pertussis because antibiotics can decrease how much a person with whooping cough will spread it to others. Close contacts of kids with pertussis may also receive antibiotics to reduce their chance of getting pertussis.

Whooping cough gets its name from the “whoop” noise kids make after a coughing fit. The fits leave them so breathless that it’s difficult to take a breath in again after the coughing spell. To hear the “whoop” with coughing fit, visit www.whoopingcough.net.

Teens and adults with whooping cough don’t tend to make the whoop sound because their airways are bigger, but the coughing spasms can leave them feeling like they might throw up or pass out. Some in fact do end a coughing fit with vomiting or fainting.

Babies don’t make the whoop either. Instead, babies with pertussis simply cannot catch their breath and stop breathing. That is why babies are the ones who tend to die from this illness. Dr. Lai and I both have watched over hospitalized infants blue from pertussis.

Thankfully, we have a vaccine that is effective at preventing pertussis. The “P” in pertussis is the “P” in the DtaP vaccine that children receive as babies, usually at two, four, and six months of age. The DtaP vaccine is then next given after the first birthday, another between ages four and six years old, and another at age eleven years. Teens who have not received the pertussis vaccine since they were in preschool, and adults who care for infants also should also get the vaccine. For more specific up-to-date recommendations: www.vaccineinformation.org/pertuss/.

As we enter the season for catching snowflakes and coughs, we hope none of your children catch whooping cough.

revised Nov 16, 2011 to reflect the indications for antibiotic prophylaxis

Not cute as a button: Babes and button batteries

2011-11-10T20:02:15Z

In a couple of weeks my 16 month old nephew will visit my non-baby proofed house. Chances are, he will find things in my house to chew on besides turkey. The first items I am hiding are the devices which contain the tiny round batteries called button batteries. Below, Kristen Casavale of The Battery Controlled reminds us about the hidden hazards of button batteries.

Electronic devices are a part of daily life. And they’re getting smaller, slimmer and sleeker. But inside the battery compartment of mini remote controls, small calculators, watches, key fobs, flameless candles, singing greeting cards and other electronics, is a very powerful coin-sized button battery. When swallowed, these batteries can get stuck in the throat and food pipe, causing severe burns in as few as two hours.

“Our trauma surgeon told us that they see 10 ingestions a month. Unfortunately, I didn't really think twice about Emmett playing with the remote control,” said Karla Rausch, mom of son Emmett, age two.

Small children often have easy access to these devices; parents often don’t know about the risk and little ones can’t always communicate with adults. Grown ups may be unaware of an ingestion until the battery starts to erode through a child's food pipe. The Battery Controlled is a partnership to raise awareness about the severity of the issue and share information with parents, caregivers and the medical community. Launched by Energizer and Safe Kids USA, this effort is committed to helping parents prevent children from swallowing coin-sized button batteries.

three main points for parents:

1. Keep out of reach. Devices with coin lithium “button” batteries have no place in unsupervised hands or toy boxes.

2. Get help fast. Life-threatening damage can happen in as few as 2 hours.

3. Tell others.

We thank, and my nephew thanks Kristen for her safety alert.- Dr. Lai

Those stinky kitchen sponges: how germy are they?

2011-11-02T10:37:03Z

Dr. Lai and her husband had a running debate about when to replace kitchen sponges. Today we thank guest blogger Dr. Karina Martino, Food Safety Engineer, for exposing the germs in our kitchens. We certainly learned a lot, and Dr. Lai's husband lost a bet.
Naline Lai, MD and Julie Kardos, MD

WHO’S THE WORST OFFENDER IN THE KITCHEN???

The winner is…….the kitchen sponge (and dishcloth)! The next worst offender is your kitchen sink. This is where vegetarians have a definite advantage since they don’t bring raw meat into their homes. There’s less chance of E. coli and Salmonella spreading, but vegetarians still have to be on the lookout for viruses and parasites.

What are the kitchen’s hot germ zones?

In descending order by highest bacterial count, these are:

1. Sponges and dishcloths

2. Sink drain area

3. Faucet handles

4. Cutting boards

5. Refrigerator handles

Here are simple steps that you can follow to create a healthier kitchen environment:

Dip sponges after every use in dilute sanitizer water (1 teaspoon bleach per quart of water); boil them for 3 minutes on a weekly basis.

• Change dish cloths daily, especially after wiping up raw meat juices.

• Wash sinks with hot soapy water prior to food preparation and before washing dishes.

• Wipe down refrigerator handles daily with dilute sanitizer water.

• Choose non-porous cutting boards that are easy to clean.

• Avoid rinsing raw meats. It contaminates the sink. If you cook meat at the correct temperature for enough time, bacteria on raw meat will be killed.

When we are handling food products everything in the kitchen must be clean, especially ourselves. It is vital to wash our hands with soap and hot water for at least 20 seconds before handling any food product. Each time you re-enter the kitchen from outdoors or any other place in the house where you might have contaminated your hands, you should wash your hands again.

Clean clothing, including aprons, is also an important part of personal hygiene. Dirty clothes and dish towels are a good place for bacteria to hide and grow. Sneezing and coughing spreads germs from our lungs, throats, and noses. When handling food, we must control the spread of germs from these natural occurrences by covering our mouths with disposable tissues and then rewashing our hands.

While the Centers for Disease Control (CDC) provides information about illness from food in homes, it does not yet offer statistics about how many people become ill from their kitchen sponges. However, here are some facts for you to keep in mind:

• The kitchen environment can be more heavily contaminated with fecal bacteria (those bacterial species associated with feces) than the bathroom, suggesting that the risk of spreading infection in the home may be highest in the kitchen-the area in the home where food is prepared.

• Microbiological surveys of domestic kitchens have found significant contamination from a variety of bacterial contaminants, including E. coli, Campylobacter, and Salmonella.

• Pathogenic organisms (germs that cause disease) have been shown to be introduced in the home by people, food, water, pets and insects.

• The domestic kitchen is not used only for food preparation, but may serve as a laundry, a workroom, and a living area for family pets. Each of these functions can serve to introduce bacterial contamination into the kitchen environment.

Moreover, research focusing specifically on the kitchen environment has found:

• 67% of kitchen sponges may be contaminated with fecal bacteria

• Contaminated cloth towels serve to transfer bacteria to dishes during drying

• 82% of sink faucet handles are contaminated during food preparation

• 60% of people do not wash the cutting board after cutting raw meat or poultry and before cutting fresh vegetables for salads

• 9% do not wash the work surface at all after cutting raw chicken

So, please don’t duplicate these mistakes! The next time that you get ready to do your dishes with your six-month-old sponge… think again!... either toss it or get your Clorox immediately!

Karina G. Martino, PhD

Dr. Martino received her Masters degree and her PhD in Food Safety Engineering from Michigan State University. A former professor at University of Georgia, she now has her own consulting business (www.kgminnovations.com) and is the mom of two children.

©2011 Two Peds in a Pod®

Who would have thought? Walking in a prewinter wonderland

2011-10-30T01:05:21Z

If you live on the East Coast of the United States, you were bombarded today by a surprise pre-Halloween snowstorm. Now that we have our power back, we thought we'd share with you a few posts we were reminded of today:

As Dr. Lai struggled with chimney flues, she was reminded about hidden sources of carbon monoxide.

Scrambling around for a halloween costume reminded Dr. Kardos of ways to keep the candy intake down to a reasonable amount.

Squeezing children's toes into snow boots from last year reminded us of how to dress your child appropriately for cold weather.

Looking for matching mittens reminded us of home remedies to prevent dried chapped hands.

Surely the cold, harsh weather is the fault of the retail industry- the big box stores lined their shelves with winter-holiday knick-knacks halfway through October. Mother Nature, like other mothers, was not pleased.

Naline Lai, MD and Julie Kardos, MD

Two Pediatricians return from Boston: dispelling myths about pot, steroids and prescription drugs

2011-10-25T01:26:13Z

We’re back from the national American Academy of Pediatrics conference in Boston and we’re galvanized to make a positive impact on youth. Just in time for Red Ribbon Week, the national campaign for halting substance abuse Oct 23-31 (www.redribboncoalition.com), we bring you facts for you to use as you talk about three drugs kids generally consider “harmless”: marijuana, anabolic steroids, and prescription medications.

Marijuana: In 2010, one out of five high school seniors and eight percent of eight graders reported using marjuana. Unlike popular belief, marijuana is addictive. Use starting in adolescence is associated with an almost 20 percent risk of dependence. It’s strong stuff. As little as five uses of pot can lead to addiction and withdrawal symptoms are similar to withdrawal symptoms from heroin. The good news is that a teen can withdraw safely at home. If your kid tells you he is not addicted and can quit at any time, challenge him to stop smoking for two weeks. If he can’t, then he is in deeper than he realizes.

Pot clouds up the brain and makes it more difficult to remember recent events. Although kids say they can drive after smoking weed, their reaction time is impaired, just as it is with alcohol use. In the past researchers thought brains did not develop much in adolescence. However, brain development does continue to the early twenties, and pot can affect that development by altering mood and executive function (planning) centers in the brain. In short, marijuana causes brain damage.

Steroids: It’s just as likely to be the kid who wants to look “buff,” and not just the athlete who wants to play better, who uses anabolic steroids. Addiction does occur… and in a lot of users. One-third of all users end up addicted. Not only do steroids affect muscles, but also they affect the brain. Adolescents are already known for emotional volatility and steroids heighten aggressiveness. Additionally, sex organs pay a price for steroid. In males, testicles can atrophy and breast development can occur. For females, non-reversible facial hair growth and deepening of voice are side effects.

Prescription medications: Throw away those unused prescription pain killers and lock up controlled substances still in use. Prescription medications seem unintimidating to kids because they are prescribed legally and they see their parents taking them. Over the last few years, reported use of Vicodin in the past year by 12^th graders ranged from about eight to ten percent. Deaths occur from overdose or from accidents from impaired driving.

Data show teens listen to advice they hear from their parents and their pediatricians, even if they sometimes take time to digest and act on that advice. We pledge to do our part when we talk to your kids about the harmful effects of drug use. We urge you to continue communicating with your children, even if they are away at college. One helpful website to assist you in talking to your kids about drugs is The National Institute on Drug Abuse: http://www.nida.nih.gov/nidahome.html.

Culled from talks given at the American Academy of Pediatrics National Convention and Exibition, 2011, by Patricia Kokotailo, MD, MPH and Greg Landry, MD, FAAP University of Wisconsin School of Medicine and Public Health, Madison, WI, John Kulig MD, MPH,FAAP, Tufts University School of Medicine, Boston. If you live in the Central Bucks area of Pennsylvania contact CBCares for more information on local Red Ribbon Week events.

Naline Lai, MD and Julie Kardos, MD

Should I vaccinate my child?

2011-10-19T16:16:23Z

Yes, yes, yes.

There are many deadly diseases we can't prevent, but we do have the power to prevent a few. We now have the ability to prevent your children from getting some types of bacterial meningitis, pneumonia, and overwhelming blood infections. With vaccines we can prevent cases of mental retardation, paralysis, blindness, deafness, and brain infections. Immunizations are a safe way of boosting children's natural immune systems. Yet some of our parents continue to doubt the benefits of vaccines and to fear harm from them.

Let’s look at another kind of prevention. You would never drive your car without putting a seatbelt on your child. Even if you don't know anyone who was in a fatal car accident, you still buckle you and your child up. You may know a kid who emerged from a car accident with only a scrape, yet you still buckle you and your child up.

You may never know a child who is paralyzed by polio or who died of whooping cough, but it does happen and can be prevented. Just like with car accidents, it's better to prevent the injury than to play catch-up later. Dr. Kardos's grandfather routinely rode in the front seat of his car without his seatbelt because he "had a feeling" the seatbelt might trap him in the car during an accident. Never mind that epidemiologists and emergency room doctors have shown people are much more likely to die in a car accident if they are not wearing a seat belts, he just “had a feeling.”

When it comes to your children, parental instinct is a powerful force. We routinely invite our patients' parents to call us about their children if their instincts tell them something might be wrong, and we always welcome and at times rely on parents’ impressions of their children's illnesses to help us make a diagnosis and formulate a treatment plan.

However, in the face of overwhelming evidence of safety and benefits of vaccines, we pediatricians despair when we see parents playing Russian roulette with their babies by not vaccinating or by delaying vaccinations. We hope fervently that these unprotected children do not contract a preventable debilitating or fatal disease that we all could have prevented through immunizations.

There is no conspiracy here. We both vaccinate our own children. We would never recommend any intervention where the potential for harm outweighs the potential for good. We have valid scientific data that every year vaccines save thousands of lives. One of them could be your child's life.

Should you vaccinate your child?

YES!

Julie Kardos, MD and Naline Lai, MD
©2011 Two Peds in a Pod®

Visit these posts for more infomation about vaccines: How Vaccines Work, Evaluating Vaccine Sites on the Internet, and Closure: there is no link between the MMR vaccine and autism

Also, please visit the recent Institute of Medicine's analysis of vaccine side effects.