The surprising first signs of dehydration

dehydrationIt’s 100 degrees Fahrenheit  outside. We’re hiking around the Southern Utah desert and one of my kids vomits once. Nope, it’s not the stomach bug; that was last vacation. This time one of my kids vomited because of dehydration. Strangely, humans don’t always complain of thirst once they start becoming parched, and my kid was no exception.

Right now many kids are at camp running about in high temperatures and soon enough, kids will be called back to school for sport practices. Before they go off, let them know that the first signs of dehydration are usually a vague headache and nausea. Warn them not to depend solely on their sense of thirst to signal them to hydrate. If they “just don’t feel right,” take a break. Other signs of heat exhaustion and stroke are outlined here

For kids who only play for an hour or so, water is a good choice for hydration.  For the more competitive players who churn up a sweat or participate in vigorous activity, electrolyte replenishers such as Gatorade® and Powerade®  become important, because after 20-30 minutes of sweating, a body can lose salt and sugar as well as water. In fact, my sister, an Emergency Medicine doctor,  tells the story of a young woman played ultimate frisbee all day, and lost a large amount of salt through  sweating.  Because she also drank large amounts of water, she “diluted” the salt that was still in her blood and had a seizure.

If your child plays an early morning sport, start the hydration process the night before so that they don’t wake up already behind on fluids. If your child goes more than six to eight hours without urinating, she needs to drink more.

Avoid caffeine which is found in  some sodas, iced tea and many of the energy drinks.  Caffeine dehydrates. The American Academy of Pediatrics recommends that children and teens never drink “energy drinks” because of the adverse effects of the stimulants they all contain. Some of the newer highly touted rehydration fluids of the adult world such as coconut water or chocolate milk are fine.

Keep in mind it’s not only sports that can dehydrate kids. Years ago I knew of a tuba player who went to the emergency room after marching band practice on a hot August day.

Next vacation we take along paper towels and cleaning fluid in addition to extra water bottles.

Naline Lai, MD and Julie Kardos, MD

©2015 Two Peds in a Pod®




Breast feeding and returning to work

breast pumpPicture this: you are going back to work after a too-short maternity leave. Briefcase? Check. Lunch? Check. Breast pump? Check. Photo of your baby to put on your pump for inspiration? Check.


Many moms ask how to continue breastfeeding when they return to work. Because babies should receive breast milk or formula for at least their first year, here is how you can incorporate breastfeeding into your work routine:


Offer bottles by four weeks of age. Bottles can contain breast milk or formula, but you need to give your baby practice taking milk from a bottle by four weeks old. If you wait much longer, your baby will likely refuse the bottle. Have someone other than yourself give at least one bottle per day or every other day. In this way, your baby learns to accept nutrition from someone else.


Store breast milk using the simple and conservative “rule of twos.”  Leave breast milk in a bottle at room temperature for no more than two hours, store breast milk in the refrigerator for no more than two days, and store in the freezer for no more than two months. If your baby has already sucked out of a breast milk bottle, that milk is only good for up to two hours. Remember to write the date on your milk storage bags and use the oldest ones first.

 Now select from the following breast feeding menu, understanding that you might start with an earlier option and then change to a later one. The best option is the one that works best for you and your baby.


Option 1: Continue to breast feed at work. This option works for moms who work from home, moms who have child care in their work setting, and moms close enough to dash home to breast feed during the day or who have caregivers willing to drive babies over to work for feedings.

Advantage: no pumping, no buying formula, no bottle washing. Disadvantage: may require some creative scheduling.


Option 2: Breast feed when home and pump and store breast milk at work. The baby gets breast milk in bottles during the work day. This method allows moms to provide exclusively breast milk to their babies. Start pumping after the first morning feeding (or any other feeding that you feel you produce a bit more than your baby needs for that particular feeding) beginning when your baby is around four weeks old. Also pump if your baby happens to sleep through a feeding. Store this milk in two or three ounce amounts in your freezer. You can obtain breast milk freezer bags from lactation consultants and baby stores, or you can store milk in zip lock bags.  As you continue to pump after the same feeding each day, your body will produce more milk at that feeding.

Pumping should not take longer than 15 minutes if you’re pumping both breasts at the same time and can take as short as 7-10 minutes. Remember to wash your hands before pumping.

 What kind of breast pump should you buy/rent? If you are in it for the long haul, we recommend the higher-end electric double pumps with adjustable suction. Ask the hospital nurses, your midwife, or your obstetrician for names of people who rent or sell pumps in your area.

Once you have some breast milk stored and you are a few days out from returning to work, try pumping during the feedings you will miss while at work. Have someone else feed your baby breast milk bottles for these feedings. Finally, when you return to work, continue to pump at the same schedule and leave the stored breast milk for your child’s caregivers. Consider leaving some formula in case caregivers run out of breast milk. Remind them never to microwave the milk (this kills the antibodies in breast milk as well as creates a potential burn hazard) but rather to thaw the milk by placing in a hot water bath.

This method becomes easier as babies get older. Once babies start solid foods, they breast feed fewer times per day. Somewhere between six to nine months, your baby eats three solid food meals per day and breastfeeds four or five times per 24 hours. Thus, the number of times you need to pump decreases dramatically.

Advantage to this option: breast milk with its germ-fighting antibodies given through the first year and no expense of formula. Disadvantage: having to pump at work.


Option 3: Breast feed before and after work and give your baby formula while you are at work.  If you do not pump while at work, your body will not produce milk at these times. If you work full time, then on weekends you might find it easiest on your body to continue your “work time” feeding schedule. If you choose this method, wean your baby from daytime breast feeding over that last week or so before returning to work. Suddenly going a long time without draining your breasts can lead to engorgement, subsequent plugged ducts, and mastitis.

Advantage: baby continues to receive breast milk. No need to pump at work. Disadvantage: you still have to wash bottles and have the added cost of formula.


Option 4:  Breast feed until you return to work, then formula feed. Wean over the last week you are home with your baby to avoid engorgement and leaking while at work. Your baby still benefits from even a few weeks of breast milk.

 Advantage: No need to incorporate pumping into your work schedule.  Baby still gets adequate nutrition. Disadvantage: babies who are in childcare and exposed to many germs miss out on receiving extra antibodies in breast milk. However, weaning your baby off breast milk will not cause illness. Do what works for your family. Another disadvantage:  more expensive to buy formula and time-consuming to wash bottles.


Finally, remember that the calorie count and nutritional content of breast milk and formula are the same. So do NOT feel guilty if pumping does not pan out and you and end up giving some formula. Your baby is almost always going to be more efficient than a breast pump and some breasts just don’t produce milk well during pumping sessions. In contrast, some of my patients never got the hang of breast feeding and their moms pumped breast milk and bottle fed them for the entire first year. Dr. Lai and I have each had patients who refused to take a bottle at childcare but just waited patiently for their moms to arrive. These babies got the nutrition they needed by nursing throughout the night. The babies didn’t mind what time of day they ate. Just like many aspects of parenting, sometimes with breast feeding, you just have to “go with the flow.”

Julie Kardos, MD with Naline Lai, MD
2015 Two Peds in a Pod®, reposted from 2010


Teething warnings and tall tales

Amber bead necklace

Amber bead necklace

About five years ago, we started noticing Amber Bead Necklaces adorning the necks of infants. We also noticed a plastic giraffe named Sophie. These relative newcomers are the latest in a long line of treatments that claim to soothe the discomfort of teething. Some work. Some don’t. And some are dangerous.

If you look at the consumer product safety commission recalls over the years, recalled teething devices and other baby products usually have a two things in common: they have small pieces that can come off and become a choking hazard, or they can cause a baby’s neck to become caught and cause strangulation.

We worry about Amber Beads necklaces. They fit all the potential safety hazard criteria. Although they are not to be chewed on (they purportedly work by excreting a mysterious substance into the skin of an infant), you never know when a bead will pop off and pose a choking hazard or the necklace will get caught and cause strangulation. Besides, we find it odd that parents would be willing to let an unknown substance seep into their baby’s skin.


Sophie the giraffe

Also, the FDA has repeatedly warned against the use of topical anesthetics. Benzocaine gels can lead to methhemoglobinemia, a rare but serious and potentially fatal condition.  Adults will sometimes use viscous lidocaine prescribed for themselves on a baby’s gums, but any numbness extending to the back of the throat can make it difficult for babies to swallow.

Ultimately, the best cure for teething discomfort is the emergence of a tooth. Until then, chewing on a safe toy or cool wash cloth and an occasional dose of acetaminophen or ibuprofen (if over six months old) can be helpful.

Be patient with teething. “Curing” teething does not cure all maladies. In fact, parents should be aware of these symptoms which are NOT caused by teething:

  • Teething does not cause fever. Fever usually indicates infection somewhere: maybe a simple viral infection such as a cold, or maybe a more severe infection such as pneumonia, but parents should NOT assume that their baby’s fever  is caused by teething. These babies could be contagious. Parents should not expose them to others with the false sense of security that they are not spreading germs
  • Teething does not typically occur in four-month-olds. Usually the first teeth erupts at around six months of age. Some don’t get a tooth until their first birthday. Most drooling and mouthing behavior prior to six months, such as babies putting hands in their mouths,  is developmental. Although you may not see a tooth erupt for a few months, babies at this age still enjoy gnawing on a toy.
  • Teething does not cause diarrhea severe enough to cause dehydration. If a child has severe diarrhea, then he most likely has a severe stomach virus or another medical issue.
  • Teething does not cause a cough severe enough to increase work of breathing. Babies make more saliva around four months of age and this increased production does result in an occasional cough. But babies never develop problems with breathing or a severe cough as a result of teething. Instead, suspect a cough virus or other cause of cough such as asthma.
  • Teething does not cause pain severe enough to trigger a change in mental state. Some children get more cranky as their gums swell and redden with erupting teeth. But, if parents cannot console their crying/screaming child, the child likely has another, perhaps more serious, cause of pain and needs an evaluation by her pediatrician.

From a logic standpoint, if teething causes symptoms as babies get their primary teeth, shouldn’t incoming permanent teeth cause the same symptoms? Yet we’ve never heard a parent blame teething for a runny nose, rash, cough, fever, or general bad mood in an eight, nine, or ten-year-old child who is growing permanent teeth.

Maybe these parents are too busy bemoaning the cost of early orthodontal work.

Julie Kardos, MD and Naline Lai, MD
©2015 Two Peds in a Pod®


Happy Father’s Day 2015

father's day poem

Enjoy Father’s Day, and enjoy the following poem written by our pediatrician colleague at CHOP Care Network Newtown, Dr. Bob Sasson. It depicts a common parenting quandary.– Drs. Kardos & Lai

The New Bicycle

Bursting with Joy

She mounts her new bicycle

Pink and blue streamers

Extend from the white rubber grips

At the end of the shining handlebars


With unbridled excitement

She presses down hard on the pedals

The wheels begin to turn


She giggles with glee

Smiling at the neighbors

As she moves quickly past the nearby houses

Her youthful energy exuberant

Spilling over with an abundance

Of Vitality and Joy


Turning back to see her parents approving eyes

She smiles…loses her focus…

The bicycle tumbling to the ground

A scrape of her knee…a trickle of blood

A moment of Hesitation

Looking back again

Awaiting her parent’s cues


How will they respond?


How would you?


By Robert Sasson, MD

Visions of Thought

A collection of inspirational imagery and poetry, 2008



When your child’s friend moves away

movingsignThis sign now sits on my friend’s lawn. I still remember four years ago when I pulled my big blue minivan up in front of their house after the moving van left. A mommy sat on the stoop with her children. “How old are they? I hollered out. The ages of the children matched my children’s and I was delighted. Indeed they became good friends. And now, there’s the “For Sale” sign.

It’s  the end of the school year, and “For Sale” signs dot lawns all over the United States. Chances are, one of them belongs to your child’s friend. Just as the child who moves will have to adjust to a new environment, your child will have to adjust to a world without a friend who was part of his daily routine.

Much has been written about how to transition the child who moves into a new environment, but how can you help your child when his close friend moves away?

Your child may experience a sense of loss and feel that he was “left behind.” Some children perseverate over the new hole in their world. Others take the change in stride.

In the late 1960’s, psychiatrist Elisabeth Kubler-Ross described “the five stages of grief.” The stages were initially applied to people suffering from terminal illness, but later they were applied to any type of deep loss such as your child’s friend moving. The first stage is denial: “I don’t believe he moved.” Anger follows in the second stage: “Why me? That’s not fair!” Your child may then transition into the third stage and bargain: “If I’m good maybe he will hate it there and come back.” The fourth stage is sadness: “ I really miss my friend,” or, “Why make friends when they end up moving away?” The final stage is acceptance: “Everything is going to be okay. We will remain friends even if he doesn’t live here.”

Some pass through all stages quickly and some skip stages altogether. The process is personal and chastising your child to “just get over it” will not expedite the process. However, there are ways to smooth the journey:

· Reassure your child that feeling sad or angry is common. Parents need to know that sad children may not show obvious signs of sadness such as crying. Instead, rocky sleep patterns, alterations in eating, disinterest in activities or a drop in the quality of school work can be signs that a child feels sad. If feelings of depression in your child last more than a month or if your child shows a desire to hurt himself, consult your child’s health care provider.

· When you discuss the move with your child, keep in mind your child’s developmental stage. For instance, preschool children are concrete and tend to be okay with things being “out of sight, out of mind.” Talking endlessly about the move only conveys to the child that something is wrong. Children around third or fourth grade can take the move hard. They are old enough to feel loss, yet not old enough to understand that friendships can transcend distance. For teens, who are heavily influenced by their peers, a friend’s moving away can cause a great deal of disruption. Acknowledge the negative emotions and reassure your child that each day will get better. Reassure him that despite the distance, he is still friends with the child who moved.

· Prior to the move, don’t be surprised if arguments break out between the friends. Anger can be a self defense mechanism employed subconsciously to substitute for sadness.

· Set a reunion time. Plan a vacation with the family who moved or plan a trip to their new home.

· After the move, send a care package and write/ help write a letter with your child.

· Answer a question with a question when you are not sure what a child wants to know. For example if he asks,” Will we always be friends?” Counter with “What do you think will happen?”

· Share stories about how you coped with a best friend moving when you were a child.

Social media and texting can be ways for older kids to stay in touch with a friend who moves away. Be sure to monitor your child, however, because too much time texting, skyping, and posting takes away from time your child needs to spend acclimating to a new routine.

As for my children, when I told one of my kids that I will sign her up for soccer, she squealed with delight, “Oh, that’s the league Kelly belongs to.”

My heart sank. I said as gently as I could, “She’s moving- she won’t be here for soccer season.”

And so we begin the process…

Naline Lai, MD with Julie Kardos, MD
© 2010, rev 2015 Two Peds in a Pod®


Soothe the itch of poison ivy

poisonivyRecently we’ve had a parade of itchy children troop through our office.  The culprit: poison ivy.

Myth buster: Fortunately, poison ivy is NOT contagious. You can catch poison ivy ONLY from the plant, not from another person.

Also, contrary to popular belief, you can not spread poison ivy on yourself through scratching.  However, where  the poison (oil) has touched  your skin, your skin can show a delayed reaction- sometimes up to two weeks later.  Different  areas of skin can react at different times, thus giving the illusion of a spreading rash.

Some home remedies for the itch :

  • Hopping into the shower and rinsing off within fifteen minutes of exposure can curtail the reaction.  Warning, a bath immediately after exposure may cause the oils to simply swirl around the bathtub and touch new places on your child.
  • Hydrocortisone 1%.  This is a mild topical steroid which decreases inflammation.  We suggest the ointment- more staying power and unlike the cream will not sting on open areas, use up to four times a day
  • Calamine lotion – a.k.a. the pink stuff. This is an active ingredient in many of the combination creams.  Apply as many times as you like.
  • Diphenhydramine (brand name Benadryl)- take orally up to every six hours. If this makes your child too sleepy, once a day Cetirizine (brand name Zyrtec) also has very good anti itch properties.
  • Oatmeal baths – Crush oatmeal, place in old hosiery, tie it off and float in the bathtub- this will prevent oat meal from clogging up your bath tub. Alternatively buy the commercial ones (e.g. Aveeno)
  • Do not use alcohol or bleach– these items will irritate the rash more than help

The biggest worry with poison ivy rashes is not the itch, but the chance of infection.  With each scratch, your child is possibly introducing  infection into an open wound.  Unfortunately, it is sometimes difficult to tell the difference between an allergic reaction to poison ivy and an infection.  Both are red, both can be warm, both can be swollen.  However, infections cause pain – if there is pain associated with a poison ivy rash, think infection.  Allergic reactions cause itchiness– if there is itchiness associated with a rash, think allergic reaction.  Because it usually takes time for an infection to “settle in,” an infection will not occur immediately after an exposure.  Infection usually occurs on the 2nd or 3rd days.  If you have any concerns take your child to her doctor.

Generally, any poison ivy rash which is in the area of the eye or genitals (difficult to apply topical remedies), appears infected, or is just plain making your child miserable needs medical attention.

When all else fails, comfort yourself with this statistic: up to 85% of people are allergic to poison ivy.  If misery loves company, your child certainly has company.

Naline Lai, MD and Julie Kardos, MD

©2015 Two Peds in a Pod®, updated from 2012



Would you recognize if your child was overweight?

recognizing obesity

In these posters put out by the Pennsylvania medical society, the children on the right are considered obese.


Nearly all parents of overweight preschoolers and most parents of obese kids are unaware their children are classified as such , say researchers at New York University and two other medical centers. Click here for  Happy Healthy Kids‘ interview with Dr. Kardos on the subject.

Julie Kardos, MD with Naline Lai, MD
©2015 Two Peds in a Pod®


Sunburn and Sunscreens: your burning questions answered

sunburnJust in time for Field Day and pool openings, today we provide sunburn protection information.


Pictured is a kid with a second degree burn. No, this burn wasn’t caused by hot water or by touching the stove, but by the sun. A sunburn is still a burn, even if it was caused by sunlight.

Treat sunburn the same as you would any burn:

  • Apply a cool compress or soak in cool water.
  • Do NOT break any blister that forms- the skin under the blister is clean and germ free. Once the blister breaks on its own, prevent infection by carefully trimming away the dead skin (this is not painful because dead skin has no working nerves) and clean with mild soap and water 2 times per day.
  • You can apply antibiotic ointment to the raw skin twice daily for a week or two.
  • Signs of infection include increased pain, pus, and increased redness around the burn site.
  • A September 2010 Annals of Emergency Medicine review article found no best method for dressing a burn. In general, try to minimize pain and prevent skin from sticking to dressings by applying generous amounts of antibiotic ointment. Look for non adherent dressings in the store (e.g. Telfa). The dressings look like big versions of the plastic covered pad in the middle of a Band aid®.
  • At first, the new skin may be lighter or darker than the surrounding skin. You will not know what the scar ultimately will look like for 6-12 months.
  • If the skin peels and becomes itchy after a few days, you can apply moisturizer and/or over-the-counter hydrocortisone cream to soothe the itch.
  • Treat the initial pain with oral pain reliever such as acetaminophen or ibuprofen.

Preventing sunburn is much easier, more effective, and less painful than treating sunburn.

What is SPF? Which one should be applied to children?

  • SPF stands for Sun Protection Factor. SPF gives you an idea of how long it may take you to burn. SPF of 15 means you will take 15 times longer to burn… if you would burn after one minute in the sun, that’s only 15 minutes of protection!
  • The American Academy of Pediatrics recommends applying a minimum of SPF 15 to children, while the American Academy of Dermatology recommends a minimum of SPF 30. Dr. Lai and I both apply sunscreen with SPF 30 to our own kids.
  • Apply all sunscreen liberally and often– at least every two hours. More important than the SPF is how often you reapply the sunscreen. All sunscreen will slide off of a sweaty, wet kid. Even if the label says “waterproof,” reapply after swimming.
  • Watch out for sunlight reflecting off water as well as sunburning on cool days. One pediatrician mom I know was aghast at seeing signs posted at her kid’s school reminding parents to apply sun screen “because it will be in the 80’s” … kids burn on 60 degree days too. Lower temperatures do not necessarily mean less UV light.

Why does the bottle of sunscreen say to ask the doctor about applying sunscreen to babies under 6 months of age?

  • Sunscreens were not safety-tested in babies younger than 6 months of age, so the old advice was not to use sunscreen under this age. The latest American Academy of Pediatrics recommendation is that it is more prudent to avoid sunburn in this young age group than to worry about possible problems from sunscreen. While shade and clothing are the best defenses against sun damage, you can also use sunscreen to exposed body areas.
  • Clothing helps to block out sunlight. In general, tighter weaves protect better than loose weaves. However,  a study from 2014 suggests regular clothing is as protective as expensive “sun-protective clothing.”
  • Hats help prevent burns as well.
  • Remember that babies burn more easily than older kids because their skin is thinner.

Which brand of sunscreen is best for babies and kids?

  • For babies and kids, no one brand of sunscreen is better than another. Dr. Lai and I tell our patients to apply a “test patch” the size of a quarter to an arm or leg of your baby and wait a few hours. If no rash appears, then use the sunscreen on whatever body parts you can’t keep covered by clothing.

Remember when we used to call sunscreen lotion “suntan lotion,” and tolerating red, blistering shoulders was considered a small price to pay for a tan? Live and learn.

Julie Kardos, MD with Naline Lai, MD
rev ©2015 Two Peds in a Pod®



Blame it on Mom

blame it on momIn honor of Mother’s Day, teach your children the time-honored way to get themselves out of a bad situation: Blame everything on mom.

If your child realizes that she’d rather not attend a particular party or other social event, have her say:“I can’t go- my mom won’t let me.”

If your teen is at a friend’s house or party, is uncomfortable and  wants to leave, but does not want the other kids to know his discomfort (such as in the presence of alcohol or drugs) have him text or call you and say a predetermined code, such as: “Oh, my mom wanted me to check in with her  at (fill in the current time, whatever it is)”. Then, have him say: “I can’t believe it! She says she has to come get me now!” Remember, Moms, do not ask questions if you hear or read: “I’m checking in like you said I had to.” Just go rescue your child!

Does your child need a reason not to try smoking? Tell him to say: “Are you kidding? My mom can sniff out when I forget to brush my teeth. She would kill me if I came home smelling like smoke. Or at the very least she would ground me for life!”

Do your kids already blame a bad hair day on Mom? A forgotten lunch on Mom? Oversleeping an alarm clock on Mom? That’s all okay as long as they know to blame Mom when it really counts.

Happy Mother’s Day

Naline Lai, MD and Julie Kardos, MD
©2015 Two Peds in a Pod®