Using melatonin in children

sleepingOur guest blogger, Dr. Kristann Heinz, a doctor who practices with a holistic and integrative approach, shares her knowledge about melatonin use in children. — Drs. Kardos and Lai

When we got back from Hawaii my three year old daughter, Ruby, was a hot mess! The eight-hour time difference made it hard for her to adjust her internal clock. At first, I just attributed it to routine jet lag but after a week of the same sleep-wake cycle, I knew something was going on. She was wandering around the house in her pink spotted pajamas WIDE AWAKE until 1am, 2am, and 3am. And then in the morning, she was dead asleep and I could barely get her up. So at this point, I took her to our doctor to make sure everything was all right. The doctor told us my daughter’s jet lag was leading to a sleep disturbance and suggested I try melatonin. I gave melatonin to Ruby that night. She was asleep by 11pm and slept soundly until morning. Over the next few days, she adjusted beautifully and we were back to a normal sleep routine in 3 days. After that, we stopped the melatonin.

What is Melatonin?
Melatonin is a hormone that occurs naturally in our bodies. A hormone is a signal containing a message from one part of the body to another. Melatonin is naturally secreted by the pineal gland, a gland located in the brain that is very sensitive to light. As night falls, the pineal gland secretes melatonin to tell the brain that it is time to sleep. This process is sometimes described as the “opening of the sleep gate.”

Why would my doctor prescribe melatonin to my child?
People often use melatonin to help adjust their sleep-wake cycles. For adults melatonin is used to treat a variety of medical disorders including cancer, headaches, and autoimmune disorders as well as insomnia. In children however, the primary reason melatonin is prescribed is for sleep disturbance. Some children with certain medical conditions are thought to have lower levels of naturally produced melatonin, which contributes to sleep-wake disturbances. For these children supplementing with melatonin can be beneficial and enhance sleep. Melatonin has been studied and shown to be helpful to children with developmental delays, ADHD, cerebral palsy, autism, and jet lag.

What dose should I use?
The dose of melatonin should be discussed with your doctor. Doses can range from 0.03mg – 6mg, generally given at bedtime. To establish the appropriate therapeutic dose, your doctor will take into account your child’s weight and the health condition you are trying to treat.

Are there different kinds of melatonin?
Melatonin is synthetically produced but there are also products that contain biological glandular material, a source of natural melatonin. Synthetically produced melatonin is recommended by most doctors because it provides a more consistent dose and is less likely to be contaminated.

Melatonin comes in three different forms: immediate release, sustained released and sublingual. The most convenient form of melatonin for children is the sublingual form because their bodies begin to absorb it as soon as it is placed in the mouth. The sublingual form is easier than swallowing a pill, which can be difficult or uncomfortable for some children. There are many different liquid brands available as well, which have the same benefit. Another good way to administer melatonin to a child is to dissolve an immediate release melatonin tablet in juice or mix it with applesauce before offering it to your child. Taking melatonin with food does not change the effectiveness of the supplement.

How long does it take to work?
Melatonin should work the first night it is given to a child and it does not require multiple doses to be effective. It can take up to 30 minutes after taking the medication to experience its full effect. Often your child will begin to feel drowsy and tired soon after taking the supplement.

Let’s use jet lag as an example of how to use melatonin. You may give the melatonin to your child just before bedtime in the new time zone. The supplement will facilitate sleep within 30 minutes of taking it. But, remember, our internal clocks usually adjust one hour a day when we travel to different time zones, and melatonin can only help to a point. The greater the time difference the more difficult it is for our bodies to resume a normal sleep pattern in the new time zone. If, for instance, there is a twelve-hour time difference, it will still take time for our biologic rhythms to change, even with the help of melatonin. However, the transition is often faster and smoother with the aid of melatonin. Melatonin is not a sleeping pill. It is used to enhance the onset of sleep naturally.

Are There Side Effects or Contraindications?
Melatonin is very safe. The most common side effect for children is excessive sleepiness, which can be moderated by decreasing the dose. In high doses, which are used mostly in treating adults (10mg-60mg melatonin), side effects include headaches, nausea, dizziness and fatigue. For children, taking melatonin is not associated with any short or long-term side effects in relation to growth, development or puberty. Drug interactions can take place between melatonin and sedatives, antidepressants and hormones, so if your child is taking medications of this kind, be sure to discuss whether it is safe to give your child Melatonin with your child’s doctor before doing so.

Kristann Heinz, MD, a graduate of University of Pennsylvania School of Medicine, is board-certified in Family Medicine and Integrative-Holistic Medicine, as well as certified in Medical Acupuncture. She is also a Registered Dietician and Licensed Nutritionist. A mom living in Bucks County, PA, she practices medicine at Stockton Family Practice in Stockton, NJ.

©2014 Two Peds in a Pod®



Cold weather is here: time to start an organic produce garden with your kids

gardening with kidsWe welcome pediatrician Dr. Marion Mass to talk about starting a garden from a piece of suburban lawn. — Drs. Kardos and Lai

A few years back, my family was getting ready for my parents to come for dinner and I was peeling the skins off the roasted beets we had grown for my mother.  One of her favorites…but not mine.  My five-year-old Brian had picked the beets and was eager to try them. As Brian brought a sliver of beet up to his mouth I braced myself for a “ yucky face”. Instead, I was shocked to see him gobble the beets up.  He loved them.  To this day, beets are one of his favorite veggies.

Hands down, the best activity I have ever done with my family is planting and nurturing an organic garden for 11 years.  Along the path to growing delectable vegetables, we have discovered together gardening’s health, intellectual and social benefits.

Actively tied to the process of supplying their own food, gardening kids will naturally want to eat more and more produce. Kids develop a sense of pride (truly, a basketful of beans, lettuce and cucumbers is so attractive) and eventually they develop a positive association with the outdoors and vegetables.  In addition to eating more quantity, what your kids eat will be healthier than store bought veggies.  Produce closer to harvest contains more nutrients and you don’t get closer than your own yard to table.   If you garden organically, you will also avoid potentially harmful chemicals.  Lastly, there is a sense of relaxation upon stepping into a garden.  It is a balm for anxiety, for depression, for anger; in short, one of the best adjuvants to mental health therapy that I know.

If you want to harvest a crop next year, and you live in a cold weather area of the northern hemisphere, NOW is the best time to start.  The most cumbersome task of starting a garden is to dig up the sod (existing lawn), but a few tricks in the fall can prevent this disc-slipping chore.

  • Chose a spot in your yard that gets at least 6 and preferably 8 hours of sunlight a day.
  • If possible, stay away from edges, tree lines and spots where large garden parasites (such as deer, rabbit and groundhogs) lurk.
  • If you live next to a pesticide happy neighbor, you will want to locate your garden away from a spray zone and will want to think about runoff.  A helpful site to determine runoff capabilities of specific pesticides is:
  • Remember you may need to water your organic garden bed once in awhile, so keep it close to a water source (or at least someplace to which you don’t mind lugging a hose).
  • Start small:  a 3 x 10 foot plot can grow a good bit if you plan well.  Lay out a 12 layer thick plot of newspaper over the grass where you want your garden to grow and dump 4 inches of composted manure, manure and hummus mix or mushroom soil over top of the newspaper.  You can purchase in bulk from a garden center (I would do 2 cubic yards for a 3 x 10 spot) or in bags (about 15 40 lb bags).

That’s it.  Now go away and leave the garden alone until spring. During the fall and winter, the grass will die and the newspaper will rot.  Both will become a source of composted nutrients for your garden veggies. While you hibernate this winter, start your wheels turning and think about what crops you will grow. Buy a few packs of discounted seeds now; they will still germinate next year.

When the ground is ready in the spring, rent a tiller or get a sturdy pitchfork (trust me, the tiller is SO much easier!!) and turn over the soil mixing the composted manure, rotted newspaper and dead sod into the rocky soil we have around here.  The result will be a much richer garden soil that your vegetables will love.

What are you waiting for??  Get cracking now and start your produce garden.  Hopefully, by next spring your kids will be eating and enjoying organic beets that they grew !!!!


Marion Mass MD, FAAP

©2014 Two Peds in a Pod®

In practice for 17 years, Marion Mass MD, FAAP graduated from Penn State and Duke University Medical School. She completed  her pediatric residency at Northwestern University’s Children’s Memorial Hospital in Chicago. Currently Dr. Mass works at Jellinek Pediatrics in Doylestown, PA and serves on the Wellness Council of the Central Bucks School District, PA.  Produce from her kids’ garden garnishes the plates of many local families as well as the plates of the restaurant Puck. All garden profits benefit Relay for Life.  When she is not in her home garden, you can find her also tending to her son’s middle school garden. 

Why is my potty trained child’s underwear occassionally damp?

damp underwearA mom of a six-year-old patient asked recently, “Why is my daughter’s underwear damp?”

—She’s been potty trained for 3 years.

—She is dry overnight.

—She urinates about 6 times in the daytime.

—She doesn’t complain of pain during urination.

Yet,  her underwear is occasionally slightly wet.

We don’t know if anyone has ever tracked the statistics, but this girl’s cause of wet underwear is common in little girls.  Called vaginal voiding,  vaginal voiding occurs when a girl urinates on the toilet with her legs tightly pushed together. She pulls her pants down minimally, to about mid-thighs so urine gets trapped in the vagina as it comes out the urethra. When she stands up and pulls up her pants, the drop of urine that was trapped in the vagina will drip out into her underwear.

The treatment of vaginal voiding is simple. Make sure your daughter pulls her pants all the way down to her ankles when sitting on the toilet and encourage her to spread her knees apart. A way to ensure proper positioning on the toilet while she urinates is to have her sit on the toilet seat BACKWARDS, facing the back of the toilet. This position forces the knees apart  and prevents any urine from becoming trapped. In turn, her underwear will remain dry.

A reason both girls and boys occasionally have wet underwear is giggle incontinence or cough incontinence, which is exactly what it sounds like—a bit of urine gets leaked during laughing or coughing.

To help kids who leak during coughing or laughing, first make sure that they are not holding in their urine for too long. Have your child do a potty check, as in “go sit on the potty,” every 2-3 hours throughout the day. Try setting an alarm on her iPod or on your cell phone. Often, merely providing enough opportunities during the day to empty the bladder cures the problem of leaking during laughing or coughing.

After trying these simple measures, if your child’s underwear is still wet or your child tells you that she still leaks during coughing or laughing, discuss this problem with your child’s doctor. In addition, please know that while laughing daily is wonderful, daily coughing is not normal and your child may need further evaluation for the source of the cough.

Damp or wet underwear may not be the most glamorous pediatric topic, but it is important for the kids who suffer from it. Hopefully this post offered a quick fix for some of your kids. You and your laundry machine will be happier.

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



Enterovirus D-68 put into perspective

enterovirus D-68 No doubt, there has been an uptick in respiratory illness in our area, but the news media is causing panic specifically over one of them: enterovirus D-68.
The name “enterovirus” does not imply “deadly.” Many of you are well familiar with hand-foot-mouth disease, aka “Coxsackie virus.” Guess what? This extremely common, benign but annoying virus is also an enterovirus!

Let’s put into perspective how this “new” respiratory virus compares with an “old” well-known respiratory virus, influenza (The Flu). Remember that both flu and enterovirus D-68 are tracked by REPORTED cases. Most of the time doctors do not test children with mild disease so most reported cases are hospitalized patients.

Enterovirus D-68, the numbers: From mid-August through the first week in October (peak enterovirus season)- 664 people are known to have been infected in the USA, most of whom are children. You can track these numbers on this Centers for Disease Control website.
Influenza, the numbers: Each year in the US, approximately 200,000 people (children and adults) are hospitalized from complications of the flu. This year’s flu season in the northern hemisphere is just starting. Generally peak flu season is in the winter months. Large numbers of people contract the flu but they are not sick enough to be hospitalized- they suffer a week of fever, cough, sore throat and body aches at home but recover uneventfully. Up to 20% of the population are infected with flu each season.

Death from enterovirus D-68: 1 child. Four other children died who tested positive for this virus but it is unknown if the virus caused their deaths.
Death from influenza during the 2013-2014 flu season: 108 children

Symptoms of enterovirus D-68: range from mild cold symptoms to high fever and severe respiratory symptoms
Symptoms of flu: usually abrupt at the onset: fever, body aches, cough, and runny nose. Please see our prior post for more information.

Prevent enterovirus D-68: same as for all “cold” viruses- wash hands, sneeze/cough into elbow, not hands.
Prevent flu: Same as for enterovirus D-68, AND we have an Influenza vaccine for all children aged 6 months and above, with a few exceptions-see our article for more information. Last year the flu vaccine was about 60% effective: it’s not perfect, but it is certainly better than not vaccinating.

Overall, remember that enterovirus D-68 is one of many cold viruses that circulate the country. We are all familiar with back-to-school viruses. My teen-aged son told me, amid his sniffles and nose-blowing last week, that “more than half my school has a cold now.”
Certainly some of those colds could be enterovirus-D-68. But please don’t panic. All respiratory illnesses, including colds, have the potential to travel into your child’s lungs. It is more important to practice good illness prevention techniques and to recognize the signs of difficulty breathing. As we have said before, if we parents could worry all illnesses away, no one would ever be sick.

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


The birth of Happy Healthy Kids

happyhealthykidsbannerWe’re thrilled to join the advisory board of Happy Healthy Kids as it kicks off its inaugural season. The new website, pioneered by Editor Kelley King Heyworth, is dedicated to all of us parents who say, “I just want my child to be healthy. And happy.” A frequent contributor to Parents Magazine, CNN and Sports Illustrated, King Heyworth brings  journalistic expertise to her website to create a kids’ health site chock full of nonjudgemental, reassuring posts.

We’re currently on her home page with a pediatrician’s wish list— check out 5 things we’d love for you to know.

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


When a peer dies: How to help your grieving teen

lonely backpackThree of my son’s high school classmates died in a tragic car accident just before school started this year. As parents, many of us may have lost someone close to us, and we know from our experience that over time, the acute pain of loss decreases as we ultimately derive strength and joy from our memories of our loved one instead of experiencing only sadness and pain over their loss. Our hearts ache watching our kids experience death first hand, often for the first time. But teens need time to experience this transition for themselves. Telling them “it will get better” will not help them.

If you are parents of a grieving teen who has lost a friend or classmate, following are some things that you can do to help:

Offer to be available, to listen, or to find someone outside your family for your teen to talk to if he wants. Do not insist that your teen talks about his feelings.
Refrain from lecturing- it does not help your teen at this time to hear things like “THAT’S why we won’t let you drive with young drivers.” She’s already figuring this out for herself.
Allow her to talk or gather with friends during the daytime.
Go back to basics: make sure your teen eats, drinks and sleeps. Enforce bedtime. Turn off phones and computers by a bedtime that allows your teen to get at least 8-9 hours of sleep. Do not allow your teen to text late into the night or to continue talking to friends late into the night, even if this means insisting that YOU take his phone for the evening. Be cautious of sleepovers, which only cause sleep deprivation, leading to exhaustion and more difficulty handling strong emotions.
Offer to go for a walk with your teen. Exercise is helpful and encourages dialogue.
Allow your teen to grieve by attend viewings and funerals. However, do not mandate that she goes. Giving her an idea of what to expect (e.g., there may be an open casket, here are some things you can say to the family) may help ease any discomfort. Offer to go with your teen, but again, don’t insist on going.
Help your teen to do something constructive to help other survivors. Send a condolence card to the deceased friend’s parents that includes an anecdote of how their teen helped your teen, or of how his deceased friend encouraged, made him laugh, or inspired him. Suggest that your teen cook a meal for the grieving family, mow their lawn, run some errand, or to babysit a younger sibling of the deceased.
Utilize community resources. School guidance counselors provide a wealth of information and support.

Your teen may experience intermittent, intense sadness even months or years after a tragedy, but as time goes by more time should pass between feelings of sadness. Kids who lose close friends learn, over time, to live with their grief. Continue to acknowledge your teen’s feelings of loss and continue to be available for your teen. Initial depression usually fades into sadness in a month’s time.

It is normal for the death of a classmate to trigger, for the first time, your teen’s contemplation of his own mortality. It is normal for him to express fears of his own death.

Normal grief behaviors include:
• Crying
• Talking about their loss
• Wanting to talk to other friends
• Spending more time with friends
• Some might want to be alone with their grief.
• Some kids might want to busy themselves with sports, reading, etc, in order to distract themselves from their grief.
• Temporary altered appetite and difficulty sleeping.
• Temporary difficulty with concentrating on schoolwork.

Abnormal grief behaviors:
• Inability to eat or sleep
• Gaining or losing more than a couple of pounds
• Inability to stop crying
• Refusing to attend school
• Failing classes
• Using alcohol or other drugs to cope with sadness
• Withdrawal from things your teen used to take pleasure in such as sports, hobbies, music, friends, or family.
• Preoccupation with death
• Suicidal thoughts, wishes, or plans

If you see any of these abnormal signs, or you are concerned about how your teen is coping, consult with your pediatrician or a psychologist. For more signs of clinical depression in children, please see our post on child and teenage depression.  Also know that the National Suicide Prevention Lifeline is 800-273-8255.

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


Baby Basics: How to get your baby to sleep through the night

sleep training cartoonContinuing our series on the essentials of life…

If you have a newborn, stop reading and go back to feeding. It’s too early for your baby to sleep through the night. All babies lose a little weight in the first couple days of life, but then they are expected to gain. In fact, you may find that you need to awaken your baby to eat every couple of hours to eat in order to stabilize her weight loss. (see our prior post on breast feeding your newborn and our formula feeding post). While you feed your newborn, listen here to understand newborn sleep patterns:

Click here for our podcast – Sleep During the First Six Months

So, when to expect your baby to sleep longer at night? Usually after three months, your baby naturally takes more milk at each feeding and thus lasts longer between feedings. And once your baby is at least six months old, your baby may be able to sleep through the night. Set reasonable expectations. For some babies, sleeping through the night means six hours, for others ten.

At six months, object permanence fully emerges. Your baby will understand that you are somewhere even when you are not within sight. This is why he laughs hysterically when you play peek-a-boo with him. If he is dependent on you rocking him or feeding him to fall asleep, then he will look for you every time he awakens for help falling back to sleep. Also, don’t be fooled into thinking that because your baby nurses or drinks from a bottle at every night time wakening, he must be hungry. Usually he’s just looking for a way to fall back to sleep.

Training starts with making sure your baby knows how to fall asleep on his own. Make sure he can fall asleep on his own at the beginning of the night before you train for the middle of the night and above all, make sure you and your partner are on board with the same training strategy.  Keep bedtime roughly the same time every night, and start the bedtime routine before your baby is crying from exhaustion so he can enjoy this time with you. A typical bedtime routine for an older infant is bath (if it is a bath night), formula/breastfeed, wipe gums/brush teeth, read book, lullaby, kiss, and then bed. The exact order and events do not matter much, just finish the routine BEFORE your baby falls asleep. Lay him down on his back awake so that he has an opportunity to fall asleep on his own.

Don’t be frustrated if you try to sleep train for a few days and give up. There is no such thing as “missing” a golden window of opportunity to sleep train. If it’s not working out this week, try again next week.

Ultimately, use these principles behind a soothing, consistent bedtime and bedtime routine all the way through high school!

Sweet dreams

Click here for our podcast- Sleep from 6mo to toddler

Naline Lai, MD and Julie Kardos, MD

©2014 Two Peds in a Pod®


Enterovirus D68, RSV, The flu! How do I know my kid’s having trouble breathing?

teachers Mid-west respiratory virus, RSV, The Flu! Lots of  respiratory-distress-causing- germs. Although Enterovirus D68 is in the news these days, a slew of infections can hit the lungs hard. So even if you think your child has a simple cold, it’s important  to recognize when your child is having difficulty breathing. Share this information with all of your child’s caretakers, including teachers. As this cartoon illustrates, many people wear medical hats. Too often we get a child in our office with labored breathing which started during school hours but was not recognized until parent pick up time. 
Signs of difficulty breathing:

  • Your child is breathing faster than normal.
  • Your child’s nostrils flare with each breath in an effort to extract more oxygen from the air.
  • Your child’s chest or her belly move dramatically while breathing—lift up her shirt to appreciate this.
  • Your child’s ribs stick out with every breath she takes because she is using extra muscles to help her breathe—again, lift up her shirt to appreciate this. We call these movements “retractions.”
  • You hear a grunting sound (a slight pause followed by a forced grunt/whimper) or a wheeze sound at the end of each exhalation.
  • A baby may refuse to breast feed or bottle feed because the effort required to breathe inhibits her ability to eat.
  • An older child might experience difficulty talking.
  • Your child may appear anxious as she becomes “air hungry” or alternatively she might seem very tired, exhausted from the effort to breathe.
  • Your child is pale or blue at the lips.

In this video, the child uses extra chest muscles in order to breath. He tries so hard to pull air into his lungs that his ribs stick out with each inhalation.  


For those with sensitive asthma lungs,  review our earlier asthma posts.  Understanding Asthma Part I explains asthma and lists common symptoms of asthma and  Understanding Asthma Part II tells how to treat asthma, summarizes commonly used asthma medicine, and offers environmental changes to help control asthma symptoms.

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

updated from our previous 2012 post


The Scoop on Poop- another essential of life

IMG_8913As we said to Robin Young on NPR’s Here and Now, “a lot of life’s issues all boil down to the essentials of life…eat, sleep, drink, pee, poop and love.” Continuing our ideas and updates on all of those baby essentials, here’s the scoop on poop :

Okay, admit it.

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

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

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

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

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

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

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

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

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

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

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

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

They are afraid of the toilet or potty seat.

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

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

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

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

Julie Kardos, MD and Naline Lai, MD

©2014 Two Peds in a Pod®

modified from original 2009 post


Flu vaccines: what you need to know for the 2014-2015 flu season

school supply listWe gave our kids their back-to-school haircuts, donated their pants that fit like floods, and bought them new folders and notebooks. As shown on our back-to-school supply list photo, back-to-school also means the start of hand sanitizer and tissue season. Yes, it’s time for your child’s yearly flu vaccine. Even if you gave your child a flu vaccine last year, she’ll need another one this season. Not only does the flu or influenza virus (not to be confused with “the stomach bug/stomach flu”) usually come back every season in a slightly different form, but your child’s immunity has waned over the past year. With every flu season, the Centers for Disease Control comes out with new recommendations. Here is a snap shot:

Who needs the flu vaccine?
All children aged 6 months or older, with a few exceptions discussed below, should receive a flu vaccine every year.

How many doses of flu vaccine does my child need this year?

If your child is nine years or older, your child only needs one dose this season.

If your child is younger than nine, your child only needs one dose this season UNLESS:

  • This year will be the first time your child receives the flu vaccine. Then, she will need a second (booster) dose at least 4 weeks later.
  • Your child skipped last year’s flu vaccine. Then, she may need a booster dose this year. Check with your child’s doctor.

Which type of flu vaccine is better, a shot or the mist (squirt in the nose)?

This year, the Centers for Disease Control suggests,  if available, to give children aged 2-8 years the squirt in the nose. However, if the mist is unavailable, do not delay the vaccine. Give your child a flu shot instead. For older kids, the data is not as clear cut as to which vaccine works better to prevent the flu. Give your child either form of the vaccine.

Who cannot receive the mist?
Kids younger than 2 years; kids with certain medical conditions such as ongoing asthma (wheezing in the past year, or 2 through 4 years of age with asthma) and diabetes; kids undergoing  aspirin therapy; kids who have had influenza antiviral therapy in the last 48 hours; kids with immune deficiencies; and kids around immunosupressed people who require a protective environment (e.g. around people hospitalized in a bone marrow transplant unit), should not receive the mist. These kids should receive the injectable form of flu vaccine. Your child’s doctor can provide the complete list of contraindications.

Who should NOT receive any flu vaccine?
Babies younger than 6 months old and children with severe egg allergy (anaphylaxis) should not receive the flu vaccine.

Our office is slotted to receive our annual supply of flu vaccine in the next few weeks. Our own families have learned to expect the annual flu vaccine with the start of each school year. Now we just need to convince them that they needed the haircuts.

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