When should your child go home from daycare because of illness? The surprising answers

IMG_3038 - Version 2It was wonderful speaking at the DVAEYC (Southeastern Pennsylvania’s association for early childhood education professionals) conference at the Philadelphia Convention Center today. We enjoyed the discussion generated by our presentation and appreciated the opportunity to teach the teachers. For those who attended and for those who wish they attended, here’s the gist of what we discussed. Guidelines are based on Managing Infectious Diseases in Child Care and Schools, 3nd edition, Editors: Susan S. Aronson, MD, FAAP and Timothy R. Shope, MD, MPH, FAAP, published by the American Academy of Pediatrics. You can purchase a copy from the American Academy of Pediatrics bookstore at www.aap.org.

When should a child go home from daycare? Remember these overriding goals:

  • To expedite the child’s recovery
  • To prevent undue burden on teachers
  • To protect other children and teachers from disease


  • Fever is a sign of illness and we refer you to our posts on fever, part 1 and part 2, to better understand fever itself.
  • If a child with a fever has no other symptom of illness, acts well, and does not require extra attention from teachers, then that child is medically safe to stay in school. Sending them home is unlikely to protect others because that child was likely contagious the day before the fever started and thus has already exposed his class to his fever-provoking illness.
  • If the fever causes the child to become dehydrated or makes the child too sleepy or miserable to participate in class, then that child should go home.
  • The reason many schools have a “no school until fever-free for 24 hours” policy is that most children usually feel better from illness and are unlikely to have another fever spike once their fever has been gone for 24 hours.
  • Any baby younger than 2 months with a fever of 100.4 or higher needs immediate medical attention, even if he is not acting sick.

Vomiting more than one time is a reason to go home from school.

  • Some kids vomit when excited, anxious, or have reflux (heartburn) and these kids do not need to go home if they throw up once in school.
  • Vomiting more than once may indicate stomach virus or other illness and will take up too much time of the teacher’s time to manage in a classroom .
  • Vomiting more than once after a head injury could be a sign of bleeding in the head and that child should leave school for a medical evaluation.
  • Read more about how to treat a vomiting child here.

Diarrhea, meaning an increase in stool frequency, or very loose consistency of stools, is a reason to go home if the diarrhea

  • cannot be contained in a diaper,
  • causes potty accidents in the toilet trained child
  • contains blood
  • is contained in the diaper, but results in more than two stools above baseline for that child—too many diaper changes compromises the teacher’s ability to attend to other children.

Children are rash prone. 

Children who show the rash of Fifth disease are not contagious at the time of the rash and by all means should remain in school. This is an illness, however, that can be dangerous to an unborn baby. Therefore, any  pregnant teachers who have been exposed to the child with Fifth disease should alert their obstetricians to their exposure. Please see our post on this subject.

Poison ivy rash is not contagious to other people. The reason to exclude a child from school is if the itch from poison ivy makes her too miserable to participate in class activities. Also some children can scratch their way to a skin infection which IS contagious. So the child with poison ivy who develops a painful infected skin area that cannot be completely covered should go home from school. Read more about poison ivy here.

Hives are not contagious. Hives often result from allergic reactions or from viruses and typically the itch as well as the hives respond well to diphenhydramine (brand name Benadryl). However, this medication often causes sedation so if the child is too sleepy, she may need to go home. Likewise, if the itch from the rash makes her miserable and demanding, she should stay home until she is able to enjoy school.

Hand-foot-mouth disease causes a blister-like rash on hands, feet, and in the mouth and sometimes in the diaper area. This disease is spread through saliva which is fairly plentiful in early childhood education centers. The child who is becoming dehydrated from refusing to drink because of painful mouth lesions should go home so the parent can help improve hydration. In addition the child who refuses to participate in activities because of feeling sick should stay home. Otherwise, careful hand washing measures limit spread of this illness and the child does not need to be excluded on the basis of this rash alone. You can read more about this virus here.

Molluscum contagiosum is a benign “only skin deep” illness similar to warts—direct vigorous contact or sharing of towels or bath water can spread the virus among kids but the rash itself is harmless and not a reason to stay home from school. Read our prior post for More on this little rash with the big name.  

MRSA is a skin infection that looks red and pus filled and is typically painful for the child. Treatment involves draining the infection and/or taking oral antibiotics. If the lesion is small and can be covered completely, the child may stay in school.

Measles: recent outbreaks in California occur because not enough children are vaccinated. In Chicago, a daycare outbreak occurred in children who were too young to be vaccinated. The rash of measles starts at the head and works its way down the body. With this rash, children also have high fever, cough, runny nose, runny eyes, and cough. One in 20 children with measles will get pneumonia. If someone in your child’s daycare class has measles, send them home and call the local department of public health for further direction. Parents should ask if all childcare workers have been vaccinated against measles to prevent further risk to their own children.

Head lice, while icky and makes our heads itch just to think about them, carry no actual disease.

  • The child with lice should go home at regular dismissal time, receive treatment that night, and be allowed back in school the next day.
  • By the time you see lice on a child’s head, they have been there for likely at least a month. So sending them home early from school only punishes the child, causes the parent to miss work needlessly, and does nothing to prevent spread.
  • Lice survive off of heads for 1-2 days at most so a weekend without people in school kills any lice that may have crawled off of any heads during the week.
  • Lice do not jump or fly and thus need close head-to-head contact to spread, so follow those standard recommendations about how far apart children need to stay for naps in daycare and do not allow kids to share hats or combs.

Pink eye:

  • There are different causes of pink eye
  • If caused by allergies, the discharge is either absent or just watery and eyes feel itchy. These kids should stay in school.
  •  Think of a runny eye the same way you would a runny nose,  runny noses can stay in school, so can runny eyes.
  • Any child with pink eye who suffers eye pain, inability to open an eye, or has so much discharge that she is uncomfortable, needs to go home.
  • A child does not need to be on antibiotic eye drops in order to attend school.
  • Good hand washing technique is key to preventing spread of pink eye.

Julie Kardos, MD and Naline Lai, MD
©2015 Two Peds in a Pod®, updated from our 2011 post


Why is my teen so tired?

"Oh mom, ten more minutes"

“Oh mom, ten more minutes”

Do you recognize yourself in this scenario? It’s early morning and you hear your teen’s cell phone buzz but you do not hear your teen getting up for school. You go into his room several times to rouse him until he finally drags himself into the bathroom. Several times more you implore him to move quickly. You argue as you do every day that he needs breakfast. You pack his lunch, remind him to put it into his backpack and end up driving him to school because he missed the bus 15 minutes ago.

Here’s the thing: teens are developmentally capable of getting themselves up in the morning, washing, dressing, getting breakfast, packing a lunch, and arriving at the bus stop on time by themselves. If you are integral in your teen’s morning routine because he can’t wake up in time to get ready for school, then consider becoming much more involved in his bedtime routine.

The quick answer to, “Why is my teen so tired?” is that your teen likely is not getting enough sleep. How much sleep do teens need? According to the National Sleep Foundation, the average teen requires 8-10 hours of sleep per day in order to enjoy optimum health and to feel well-rested. But teens now get less sleep than they did twenty years ago.

Reasons for teen sleep deprivation are myriad. Children naturally become more nocturnal as they age. Their biologic circadian rhythms change to favor staying up late and sleeping late. Yet, just as their bodies crave a later start to the day, they enter high school, which usually starts earlier than their previous schools. Studies find in school districts that have experimented with later start times, teens do not stay up later, but do get more sleep per night. Overall, the teens function better in school, have fewer car accidents, and suffer less depression than their counterparts in other schools.

To gauge if your teen gets enough sleep, ask yourself, does he pop up in the morning, happy and awake seconds after the alarm sounds? If so, your teen reached her optimal amount of sleep. Keep in mind, this differs for everyone. Dr. Lai knew a teen who went to bed at 8 p.m. and slept until 2 a.m. At that point the teen woke up, did her homework and went happily to school.

Helping your teen sleep:

Cut down on screen time. Computer, phone, TV, tablets, and game consoles are known to delay sleep onset when used in the hour prior to going to bed. In fact, according to a study of teens in Norway, screen use for more than 4 hours per day, even when used early in the day, leads to an average of 2 hours less sleep a night.

Of course teens have lots of homework, but try watching her do homework with her cell phone buzzing for her attention every minute- it’s like having your toddler poke you for attention when you try to balance your checkbook. Suggest that your teen turn off her phone or leave it in another room for periods of time while she does homework. Getting homework done more efficiently will leave more time for sleeping.

After school activities are important, but some teens need to scale back in order to have time for homework and a bedtime that allows for at least 8 hours of sleep. Teens are often too illogical to say “no” to any of the obligations that come their way. You will have to be the bad guy.

What if your teen has an acceptable bedtime but can’t fall asleep? Caffeine may be the culprit. Even a cup of coffee in the morning can affect falling asleep at night- caffeine stays in the body for 24 hours. Often teens may not realize that the soda or ice tea they drank at dinner contains caffeine.
On that same note, cold medications can keep kids up at night and even prescription medications such as ones prescribed for Attention Deficit Hyperactivity Disorder interfere with falling asleep.

Make sure your teen’s sleep is restful and restorative. A clogged nose from allergies, or if he is itchy from bug bites, may be disturbing his sleep.
To shift a late bedtime up, have your teen move his bedtime up 15 minutes a night, but keep his wake-up time the same. Don’t let him nap in the day and gradually you will be able to shift him back. On weekends don’t allow him to sleep in. Sleeping in too long will result in late bedtimes and an overtired kid Monday morning. If you’ve tired everything, but if your kid has difficulty resetting her clock to an earlier bedtime, ask your doctor about using melatonin.
Now if your teen is getting the proper amount of sleep and good quality sleep and yet still feels tired, this is fatigue. Fatigue is how a woman feels when she is pregnant. A pregnant woman may have had plenty of sleep, but she still feels tired. Medical problems other than pregnancy can cause fatigue- “Mono” or Mononucleosis, anemia, and sleep apnea are just a few. Other causes of fatigue include mental illness and drug addiction. Weight loss and depression are other signs that should trigger you to bring your tired teen to his physician for further evaluation.

Although it’s hard to watch your kid learn the misery of sleep deprivation, do your best not to say “I told you so.” Keep in mind you are looking at the same child who, as a three-year-old protested leaving a party, insisting “I am not tired,” as he fell asleep midsentence during the car ride home. He just grew into the teen who says, “I am not tired,” as he falls asleep with ear buds in and with the lights still on. As Dr. Lai is fond of saying, “Choosing sleep is what distinguishes grown-ups from kids. You know you are a grown-up when instead of fighting sleep, you chose to sleep.”

Your teen may look grown up, but he still needs you to enforce good habits, including establishing a bedtime that allows him to function optimally during the day. Remember to check in with your teen before bed, just like you talked to him at bedtime when he was young. Your involvement at bedtime can result in less stressful mornings for both of you.

For more, if you live in the Bucks County PA area, go to the  Community Conversations Workshop March 25 , 2015 at 7pm at Council Rock South High School, Holland, PA. We will be part of a group of experts talking about Communication Do’s and Don’t, Optimizing Teen Sleep and Dealing with Stressed Out Students. Presented by the Council Rock Education Foundation and the Council Rock Coalition for Healthy Youth. Made possible by The Children’s Hospital of Philadelphia. 

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


Deception in Packaging: Navigating the Nutrition Information Highway

how to read nutrition labels

Today, we welcome Health Coach Mary McDonald’s insight on how to read food labels for nutritional content…

Have you ever stood in the cereal aisle staring at the rows and rows of choices and feeling like a deer in headlights? You know that you want to select a cereal that is healthy for your family, but you are not sure which one to choose. So, you start reading the nutrition claims on the front of the box. “Multi-grain. Low fat. Good source of vitamins and minerals. No high fructose corn syrup.” You select a cereal that you think is a good option, only to find out later that the first two ingredients are sugar and grains that are void of nutrition. Navigating the nutrition information highway can be extremely complex, even for an educated person.

One of the reasons for the confusion is the mass influx of marketing from major food manufacturers. According to the Federal Trade Commission, the 44 major food and beverage marketers spent $2.1 billion marketing food to youth in 2006. A second report in 2012 compared data from 2006 to 2009 and found that total spending on food marketing to youth dropped 19.5% to $1.79 billion. But, spending on new media, such as online and viral marketing, increased 50%. The report found that the overall picture of how marketers reach children did not change significantly.

With the major food manufacturers sending constant messaging about the health benefits of their products, a consumer can get very confused about what is healthy to eat. Couple this with the fact that most formal nutrition education ends when a person graduates from high school. Therefore, the major food manufacturer, whose purpose is to sell food, has become the nutrition education for our society. This creates a perfect storm and makes it really difficult to know what is healthy to purchase and consume. So, how we fix this problem? Here are a few quick tips that can help you navigate the nutrition hype:

  1. Don’t look at the front of the packaging to determine if a product is nutritionally sound. Remember, the claims on the packaging are designed to sell more products. In our fast-paced society, it’s easy to fall into this trap, but ignore the marketing because there is more reliable information in the ingredient list. Which brings me to my next point.
  2. Read the ingredient list. You may be surprised if you open your pantry and start to read the labels on the food sitting on your shelves. Many products contain ingredients that are difficult to pronounce, let alone know what they are. What is more concerning is the fact that some ingredients are deceptive in the way that they are represented. For example, enriched wheat flour sounds like a nutritious ingredient, but in reality it is a refined grain that is very similar to white flour. Enriched wheat flour is milled to strip the bran and germ and then some vitamins and minerals are added back in. When reading your labels, don’t be fooled into thinking that you are eating something packed with nutrition when you see enriched wheat flour. If you are looking for a nutritious grain, then look for labels that say whole-wheat flour, and make sure that it is one of the first ingredients on the label.
  3. Five is the magic number. Michael Pollan, the author of Omnivore’s Dilemma, suggests that you should not eat anything with more than five ingredients, or with ingredients you don’t recognize or can’t pronounce. In my opinion, this is singularly one of the best pieces of advice. When you use this rule of thumb, it will naturally lead you towards healthier foods with less additives and preservatives. For example, compare labels on snack bars. According to Eat This Not That, the “coating” on Special K Double Chocolate Protein Meal Bar is made with trans fats, soy, and sugar with a little cocoa processed with alkali, artificial flavor, polysorbate 60 and other artificial ingredients. And that’s just the outside! Then there are the “Chocolatey Chips,” which is market slang for “not real chocolate.” Instead they are just more sugar, soy, trans fats, and artificial flavors mixed with a little cocoa that’s been “alkalized,” a type of processing that destroys up to 75 percent of the healthy nutrients in the chocolate. Compare that snack bar to Clif Kit’s Organic Peanut Butter bar that has only four (yes, 4) ingredients: Organic Dates, Organic Peanuts, Organic Almonds, Sea Salt. I recognize all of those ingredients!
  4. Positive nutrition messaging. One of the best ways to achieve success in any goal is to surround yourself with positive messaging. I have connected with a variety of websites that provide great nutrition education. Eatright.org, a division of the Academy of Nutrition and Dietetics, and Nutritionaction.com, a division of Center for Science in the Public Interest, are two credible sources. Search for a site that fits your needs and sign up for free newsletters. The information will come to you and you can choose when and what to read. It’s that simple.
  5. Cook more at home. Yes, cooking at home can be one of the most effective ways to navigate the nutrition information highway. I realize that this is not always easy considering work, school, and sports schedules. But, it is important to make time for the things that matter most. What can be more important than the health of you and your family?Just like a major roadway, navigating the nutrition highway is complex. Fortunately, we live in a time when there are a variety of ways to receive information.

Mary McDonald, MA

©2015 Two Peds in a Pod®

Mary McDonald has a Masters of Education from Arcadia University and completed her health coach certification from Institute of Integrative Nutrition. She is a high school teacher, a mom of four daughters, and an advocate for healthy food choices. For more information on her health coaching services, please contact her at nutrition101withmary@gmail.com or visit her website at nutrition101withmary.com.

If you live in Bucks County, PA, the Doylestown Food Co-op will be hosting a screening of the documentary, Fed Up, hosted by Katie Couric. This is an eye-opening account of how we view the food that we consume. The screening takes place Thursday 3/26/15 at 7 pm at the County Theatre in Doylestown, PA.


Coming out: How do I respond if my teen comes out as Lesbian, Gay, Bisexual or Transgender?

rainbow flagToday 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. 

Drs. Kardos and Lai

When Jaime recently came out as gay, his mother 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,” she said. 

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. Based on work done by the the Family Acceptance Project, here are some behaviors to engage in and to avoid with your children.

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.


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 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

Ilana 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.


©2015 Two Peds in a Pod®

Updated from the original 2011 post


Umbilical hernias

Time for a Two Peds photo quiz.

What is up with this baby’s belly-button?

umbilical hernia

It’s called an umbilical hernia, which is an out-pouching at the belly button, caused by loose belly muscles.

In the womb, babies’ belly muscles migrate across the abdomen and meet in the middle. Sometimes they don’t meet up before birth, causing a small bit of the gut to out-pouch. Usually more noticeable during crying, umbilical hernias do not hurt, nor do they get “stuck” out like a groin hernia (located at the scrotum or labia) and thus they are not a medical emergency. In fact, they do not even need treatment.

Fortunately, umbilical hernias tend to close up on their own by age five years, often much sooner. Don’t do what my grandmother suggested, which was to place a quarter on top of my son’s umbilical hernia and then tie it into place with a belt-like contraption. This does NOT hasten the hernia’s resolution.

Sometimes if an umbilical hernia is particularly large, it fails to regress after a few years, and at that point, for cosmetic reasons, a surgeon can repair it.

We see many babies with umbilical hernias in our office, and we are happy to reassure parents about them. If you were wondering, my son who had the umbilical hernia as a baby, now has a belly button that looks exactly the same as his twin who did not an umbilical hernia. Both are “in-ies.”

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



Get your kids off the couch: ideas for indoor exercise

couch potato family

Let’s face it, it’s hard to move when it’s cold , and it’s freezing at my home.  I believe today’s high is 20 degrees Fahrenheit.  Now while this may not deter younger children from bundling up and going sledding, teen couch potatoes are busy whining that it’s “too cold.”  So there they sit.

What’s the secret to keeping them active in the winter months?  Have them schedule an activity, and be an example yourself.

Ideas for teens (and you) to do when it’s cold outside:

  • Have a 15-minute dance party
  • Have a Wii contest
  • Try swimming (indoors please!)
  • Dust off the treadmill or stationary bike in the basement and GET ON IT
  • Play ping-pong
  • Do a few chores
  • Jump rope
  • Jog during T.V. commercials
  • Pull out some “little kid games” such as hopscotch, hula-hoop or Twister
  • Let each child in your house choose an activity for everyone to try


Teens, like everyone else, need exercise to stay healthy.  Staff from the Mayo Clinic recommend kids ages 6-17 years should have one hour of moderate exercise each day.  Exercise can help improve mood (through the release of endorphins), improve sleep and therefore attention (critical with finals coming up), and improve cardiovascular endurance. Those spring sports really ARE just around the corner.


Here are some numbers to get the kids moving:  All activities are based on 20 minutes and a teen who weighs 110 pounds.  The number of calories burned depends on weight.  If your teen weighs more, he will burn a few more calories, if he weighs less, he’ll burn a few less.  Below the table are links to some free and quick calorie calculators on the web so your teen can check it out for him self.  For those attached to their phones, there are web apps too.




Shooting Basketballs


Pickup Basketball game/practice


Biking on stationary bike






Ice Skating


Jogging in place




Jumping Rope


Ping Pong


Rock Climbing


Running at 5 mph




Treadmill at 4 mph






What’s the worst that can happen?  You’ll have a more fit, better rested, and happier teen!  Or at least you’ll have a cleaner home!


Try these activity calculators:






Deborah Stack, PT, DPT, PCS

With nearly 20 years of experience as a physical therapist, guest blogger Dr. Stack heads The Pediatric Therapy Center of Bucks County in Pennsylvania www.buckscountypeds.com. She holds both masters and doctoral degrees in physical therapy from Thomas Jefferson University.

© 2011, 2013, updated 2015 Two Peds in a Pod®


Measles outbreak: Would you recognize measles in your child?

A typical measles rash, courtesy of the public health library, Centers for Disease Control and Prevention

A typical measles rash, courtesy of the public health library, Centers for Disease Control and Prevention

Who knew when we first published this post in June 2014 that another measles outbreak would occur in the US. In light of the numerous measles cases that emerged out of the California Disneyland exposure, we re-publish signs of measles in children. Parents who have children who are not completely immunized against measles should be especially vigilant.

Measles typically starts out looking like almost every other respiratory virus— kids develop cough, runny nose, runny bloodshot eyes, fever, fatigue, and muscle aches.

Around the fourth day of illness, the fever spikes to 104 F or more and a red rash starts at the hairline and face and works its way down the body and out to arms and legs, as shown here at the Immunization Coalition site. Many kids also develop Koplik spots on the inside of the mouth: small, slightly raised, bluish-white spots on a red base 1-2 days before rash. Call your child’s doctor if you suspect that your child has measles. Parents should be most suspicious if their children have not received MMR vaccine or if their immunized child was exposed to a definite case of measles or visited an area with known measles.

In the US, one in 10 kids with measles will develop an ear infection and one in 20 will develop pneumonia. Roughly one in 1000 kids develop permanent brain damage, and up to two in 1000 who get measles die from measles complications. Kids under age 5 years are the most vulnerable to complications. These statistics are found here. For global stats on measles, please see this World Health Organization page.

There is no cure for measles and there no way to predict if your child will have a mild or severe case. Fortunately, one dose of the MMR (Measles, Mumps, Rubella) vaccine is 92-95% effective at preventing measles, and two doses are 97-99% effective at preventing measles. That’s the best we can do, and this protection rate works great when everyone is vaccinated. The American Academy of Pediatrics recommends giving the first dose of MMR vaccine at 12-15 months and the second dose at school entry, between 4-6 years of age.

If parents refuse the MMR vaccination for their children, then more people are left susceptible to measles. This leads to more people who can spread  the disease when it hits a community. Measles is one of the most contagious diseases known: 9 out of 10 unvaccinated people exposed to measles will become sick, and infected people are contagious even before symptoms appear. One of the reasons behind the increase in measles cases is the increase in unvaccinated children. One patient of Dr. Kardos’s was a four-year-old boy who was behind on his vaccines and hospitalized for measles pneumonia. Before he was diagnosed he exposed an entire Emergency Department to measles.

In our global world, another reason for the spike in measles cases is the increase in travel between countries. In fact,  young children traveling internationally should now get the MMR vaccine outside of the routine schedule. If you plan on traveling,  check here to see if you need to give your child the MMR vaccine on an early schedule.

With increased vigilance and vaccination, hopefully measles will once again become a disease few doctors have ever encountered. After all, vaccines did eradicate small pox. The last case of smallpox in the United States was in 1949, and the last case in the world was in 1977. In the meantime, you’ll know how to “spot” a case of measles too.

Julie Kardos, MD and Naline Lai, MD
©2014 Two Peds in a Pod®, updated February 2015


Dry, chapped hands: home remedies

dried chapped hands

Raw hands- recognize your kid?

I wash my hands about sixty times a day, maybe more. This frequent washing, in combination with cold Pennsylvania air, leads to chapped hands. Here are the hands of a patient. Do your children’s hands look like these?

To prevent dry hands:

• Don’t stop washing your hands, but do use a moisturizer afterwards.

• Whenever possible, use water and soap rather than hand sanitizers. Hand sanitizers are at minimum 60% alcohol- very drying. Be sure to fully dry hands after washing.

• Wear gloves or mittens as much as possible outside even if the temperature is above freezing. Remember chemistry class- cold air holds less moisture than warm air and therefore is unkind to skin. Gloves will prevent some moisture loss.

• Before exposure to any possible irritants such as the chlorine in a swimming pool, protect the hands by layering heavy lotion (Eucerin cream) or petroleum based product (i.e. Vaseline or Aquaphor) over the skin.

To rescue dry hands:

• Prior to bedtime, smother hands in 1% hydrocortisone ointment. Avoid the cream formulation. Creams tend to sting if there are any open cracks. Take old socks, cut out thumb holes and have your child sleep at night with the sock on his hands. Repeat nightly for up to a week. Alternatively, for mildly chapped hands, use a petroleum oil based product such as Vaseline or Aquaphor in place of the hydrocortisone.

• If your child has underlying eczema, prevent your child from scratching his hands. An antihistamine such as diphenhydramine (Benadryl) or cetirizine (Zyrtec) will take the edge off the itch. Keep his nails trimmed to avoid further damage from scratching.

• For extremely raw hands, your child’s doctor may prescribe a stronger cream and if there are signs of a bacterial skin infection, your child’s doctor may prescribe an antibiotic.

Happy moisturizing. Remember how much fun it was to smear glue on your hands and then peel off the dried glue? It’s not so fun when your skin really is peeling.

Naline Lai, MD and Julie Kardos, MD
© 2009, 2015 Two Peds in a Pod®



Should I vaccinate my child?

measles outbreak

“Let’s skip this ride.”

Should I vaccinate my child? Yes, yes, yes!

The recent measles outbreak originating in Disneyland among mostly-unvaccinated children and adults highlights how important it is to continue to immunize children against preventable infectious diseases, even if we think they are rare.

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.”

We know no one likes a needle jab, but for most vaccines, no one has invented any better way of administration.

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?


Julie Kardos, MD and Naline Lai, MD

©2015 Two Peds in a Pod®

Updated from our earlier 2011 post

Visit these posts for more infomation about vaccines:
How Vaccines Work, Evaluating Vaccine Sites on the Internet, Do Vaccines cause autism? 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.