Teen Vaccines

This 16 year-old boy was slipping away.  He had come to the Emergency Department sleepy and feverish.  Mom noticed that he was covered with red freckles, and new freckles were coming out while we spoke.  As the nurses and I worked, he became more lethargic, an ominous sign in a kid with obvious overwhelming infection: meningococcus.  The second-to-last procedure I did was the spinal tap.

This is a procedure where a needle is put into the back to obtain fluid from the spinal cord.  This fluid comes from the brain and is used to diagnose meningitis.  Instead of a trickle of clear fluid we see in well kids, yellow pus-laden spinal fluid shot out of the needle onto my gowned chest. This definitely was meningitis. The last procedure I did was to sedate him and put him on life-support, and then I did my best to comfort his parents as he went to the ICU.

The year was 1995.  The episode above happens less often now, thanks to the meningococcus vaccine introduced in 2005.  This is one of the vaccines kids get at age 11-12.  Yet a large amount of teens aren’t getting this and some other life-saving vaccines.  One-in-ten adolescents don’t get a tetanus booster, almost 1 in 4 don’t get the meningococcus vaccine, and less than half of teens get the cancer-preventing HPV vaccine!

Why are so many teens not getting these crucial shots?  The main reason is many no longer go to their regular doctor- parents fall out of the habit of taking them there. This because older kids don’t get the flurry of vaccines that the younger ones need, and don’t get sick as often.  On the occasion that an older child does get sick, walk-in clinics are more convenient- no waiting for an appointment!  With no regular doctor visits, there is no one to remind the parents that their kid needs this one more vital set of shots. Most “quick-care” does not care about illness prevention, scoliosis, acne, and keeping up vaccines.

What are teen vaccines, and why are they so important?  The most dramatic infection they prevent is the meningococcus/meningitis bacteria that our teen above had (cliff-hanger resolution: he survived and walked out of the hospital six days later). Meningoccus is highly contagious, particularly in crowded living conditions that teens often go live in: college dorms and military barracks.  Remember the UL-Lafayette meningitis scare from a few years back?  And once a teen gets meningococcus, he or she can get deathly ill very quickly.  Fortunately this is becoming less common as successive years of kids get vaccinated.

The least given vaccine for teens is the cancer-preventing HPV vaccine.  This is partly because HPV (Human Papilloma Virus) causes a less dramatic infection than meningococcus- teens get some warts in sensitive spots.  Also HPV is a three-vaccine series rather than just one shot for meningococcus- you’ve got to go back two more times to complete the series. However, HPV causes deadly cervical cancer and anal cancer (actress Farrah Fawcett died from anal cancer).  The vaccine prevents this.  But cancer is also less dramatic than meningoccus in this way: what teen and parent are looking ahead to the “later in life” of cancer?  Worrying about cancer down the road is just not on many teens’ and parents’ radar.  Surviving Driver’s Ed and teen parties are drama enough.

Finally, teens need to get two other vaccines: influenza vaccine and the good ol’ tetanus booster “Tdap.”  Influenza season approaches, and influenza is a nasty virus causing a whole week of cough, fever, body aches, headaches, nausea, and sometimes worse. Get the “flu” shot every year to avoid this highly contagious misery. And tetanus is a deadly illness that can infect any dirty wound- not just rusty nail pokes. What kid doesn’t get dirty wounds?

So don’t lose touch with your child’s “regular” doctor as your kid becomes a teen.  Your regular doctor knows your child best and treats the whole kid, unlike a “quick-care” clinic that only cares about your child’s latest illness.  Your kid’s doctor knows what your child truly needs for things like scoliosis, sports and school physicals, and acne.  And when to get the Teen Vaccines.

The Flying Menace

This week’s guest columnist is Dr. John Giuffreda, a Family Practice resident at the University Hospital and Clinics here in Lafayette.  His column reminds me of when I was playing catch with my son.  When he went looking for a missed ball in some ivy, he stepped on a wasp nest.  Like a scene from the cartoons, he ran to the house trailing a cloud of wasps, yelling “Bees, bees, bees!!”  After we swatted them away and killed the ones that got inside, we counted 13 stings on his butt. We did everything Dr. Giuffreda talks about below, and my son did fine.

Bugs bites and stings are usually no worse than a homework assignment- annoying but basically harmless.  Some crying after a sting (wasps, bees, fire ants), but that’s it. Occasionally an insect bite can cause serious problems.  You should know when a simple ice pack can bring relief and when to visit your doctor, or the Emergency Department.

Bee and Wasp Stings:  For most kids bee stings are a minor nuisance.  The area may swell, turn red, and be somewhat painful, but that’s it. But bee and wasp stings can be real problems for people who are allergic.  A person can get a localized reaction (swelling, heat, or itching around the site) or a systemic allergic reaction, meaning that the venom affects the whole body.

In the case of a systemic reaction the person may break out in hives.  Other more serious symptoms include wheezing, shortness of breath, rapid heartbeat, and swelling of the face, lips, tongue, or throat. More subtle symptoms include weakness, nausea and vomiting, or a feeling of dread.  If a kid has any of these symptoms, call 911 immediately.  If an Epipen is available use it right away.  It’s rare, but severe allergic reactions to bee and wasp stings can be fatal if the person doesn’t get medical help.

Mosquito Bites: As you know, Louisiana is Mosquito Country, and mosquitoes hang out anywhere with still water.  Generally they are nothing to worry about.  They bite, you itch, end of story. But sometimes mosquitoes can give people diseases.  You have probably heard of West Nile Virus, which humans can get from mosquitoes.  The good news is that most kids, and any healthy person under age 50, who get West Nile virus get over it without symptoms and never know it.  Less than 1% of the people infected with West Nile become seriously ill.

What To Do: For most bug bites and stings, antihistamines like benadryl lessen itching and swelling.  Acetaminophen (Tylenol) and Ibuprofen can ease pain. Use 1% hydrocortisone cream (over-the-counter) for itching too.  If it’s a honeybee sting and you see the stinger, immediately scrape it out with your fingernail.  This lessens your kid’s dose of venom.

Wash the bite with soap and water and keep it clean. If it really bothers and you want more immediate relief than benadryl or Tylenol, ice can help.  Ice it for 10 minutes, every few hours or so.  If your child scratches and breaks the skin, you need to prevent infection.  Put on antibiotic ointment like Neosporin and again, keep the site clean and covered with a bandaid.

Preventing Bites and Stings: Kids don’t have to sit around and be a sample on the insect buffet.  Take some preventative steps:

Avoid mosquitoes by staying away from still pools and ponds where they breed, especially in hot weather.  Pour out standing water from bird baths, buckets, old tires, etc.  Stay inside when mosquitoes are most active (dusk, night, and dawn).

Use insect repellent when outdoors camping, hiking, or in the yard. DEET repellents on skin keep away mosquitoes and ticks.  Permethrin repellents are good to put on clothes. In wooded areas, tuck shirts into your pants and long pant legs into socks.  Make your kids wear shoes and socks outside, even if it’s just for a minute. Bees, wasps, and ants can sting unprotected feet.

Finally, don’t swat at buzzing insects.  It just swirls the mosquitoes around and can make the real stingers- wasps and bees- feel threatened so they will be more likely to sting.  Just keep away… from the Flying Menace.

Teens Behind The Wheel! Look out!

My three teens may not believe it, but I also once was a teen.  And one night I was bombing down a snowy road in our old iron Jeep Cherokee, the radio blasting my rock station, not a care in the world.  Then I topped a hill and headed down.  Now, four-wheel-drive is fine for getting you started on slippery ice and snow, but it’s no help slowing you down.  And down I went, at speed.

The hill had a turn and when I put on the brakes, I started sliding out of control towards some trees. So I pumped the brakes as best I could, made the turn, and headed for the intersection at the bottom.  Unable to stop, I hung on and hoped for the best.  Just before I crossed that road, a Honda Civic zipped by. Luckily that was it for traffic.  I skidded across and came bumping to a stop on a snow-covered lawn.  After a few minutes I was able to quit shaking and drive away.

My wintery adventure illustrates some safety issues with teen drivers.  Teens are inexperienced drivers.  They haven’t had enough time on the road to learn things like braking in time or driving slow enough for road conditions.  Teenagers also like speed. Speeding is fun, even though it’s not safe.  Teens don’t think about consequences. They’re temporary sociopaths- who cares about the future, I’m all about here and now. Though I had driven and jogged over that hill thousands of times, I didn’t foresee going over in a heavy car on snow.

Teens are also easily distracted behind the wheel. Like teen me, they listen to the radio too loud.  They drive with friends and have intensely important conversations, or a lot of laughs.  They talk on phones.  They text.  These things take a teen’s eyes and mind off what is out front.  Another car slams on the brakes, a red light is ignored, a turn is too tight, disaster ensues.

The above safety issues with teen drivers are why their car insurance is so expensive. Teenagers crash- they incur car repair bills and medical expenses.  So what can we do to keep our teens safer while they gain experience behind the wheel?  Fortunately Louisiana has Graduated Driver Licensing. This system allows teens to gain experience while keeping them, and those driving around them, safer.

The first rule in GDL is when a teen gets a permit at age 15, they must drive at least 50 hours before they get their license.  This means they should spend about one full hour per week driving with an adult, hopefully more.  15 of those hours should be gaining experience driving at night.  When a teen gets licensed at 16, there are more rules for that first year of solo driving.  By Louisiana law, no driving after 11 pm.  Teens can’t have passengers after 6 pm, except an adult over 21.  They can’t use cell phones.  And no texting. Ever. Even after 17.

Here are some ideas to keep your teen driver even safer. First, try to delay when they start driving.  The older teens get the more their brains mature, and they become safer drivers. Take advantage of teen procrastination.  Don’t drive them to the Office of Motor Vehicles on their 15th birthday- let them decide when to go in their own good time. Wait for them to badger you incessantly before you (eventually) get around to bringing them. Before you go, make them look up what they will need to bring to get their permit, and get those things themselves- this alone will buy you another few weeks of brain maturity.

Also, wait another year or two after 17 before you let them drive with friends or with a phone, or with the radio on.  More time driving with good concentration will help form better driving habits.  Finally, limit the time they drive in the rain, on the highway, at night, or at rush hour.  They do need to get experienced driving in adversity, but take it slow.

I’ve got three teens on the road myself and followed these rules and my wife and I still worry at night.  Look out!  Teens on the road!

Doc, My Kid’s Heart Is Beating Out His Chest!

This week’s guest columnist is Dr. Danielle Duhon, a family practice resident at the University Hospital and Clinics here in Lafayette.

First the child complains of chest pain.  She might even say it in scarier terms: “My heart hurts.”  Then mom puts a hand on daughter’s chest- mom can feel her heart beating!   Maybe Uncle Joe just died of heart disease.  Now it’s panic time!

Chest pain and palpitations are scary things.  Adults think about heart problems and assume the worst.  After all, we have been told over and over: if you have chest pain, get seen, it could be a heart attack.  In kids however, chest pain is rarely the heart- it’s usually strains in the chest wall- ribs, cartilege, and muscle. Sometimes it’s heart burn or occasionally lung issues.

But what about palpitations- that feeling of heart pounding?  Your child complains, you feel their chest, and you’re certain the heart is going to jump right out!  Before you lose your cool, try to think.  Lots of things can cause your child’s heart to race: recent activity, caffeine, or many medicines.  If your child has been running around or doing other high-energy exercise, have them rest for a moment.  See if it slows down.

Consider other causes of a pounding heart.  Caffeine can ramp up your child’s heart rate. Soda, coffee, and especially energy drinks all contain caffeine and other stimulants. The extra ingredients that give energy drinks their “boost,” like guanara, can be more stimulating than caffeine and make the heart race like crazy.  Now there are “energy” candies, gum, gels, and water mix-ins.  With all that stimulant coursing through your veins, it’s no wonder your heart is going BA-DUM, BA-DUM!

There are several medications that can push the heart. Even if your kid is adult-sized, children metabolize medications differently than adults. Always read the bottle or talk to your doctor to make sure the medication and dose are safe.  Examples of medications that can stimulate the heart include antihistamines (benadryl, chlorpheniramine, hydroxyzine, zyrtec, claritin, allegra), decongestants (pseudophedrine, phenylephrine), and cough suppressants (dextromethorphan).

Besides caffeine and over-the-counter medications, your child could be prescribed a medication that can cause palpitations.  These include stimulants to treat ADHD or inhalers for asthma.  If a kid combines those medications with other stimulating medications or caffeinated drinks, he is getting double duty and can certainly have a pounding heart.

Unfortunately some teenagers smoke cigarettes (real or electronic) or use chewing tobacco.  These contain nicotine, which is a stimulant.  Used alone or in combination with medications, caffeinated or “energy” drinks, and/or prescriptions, nicotine will certainly get some teenagers’ hearts going overtime.

Finally, anxiety is a common cause of palpitations.  Some kids are worriers.  Kids have lots to worry about.  There is pressure to do well in school.  There can be family strife like parental fighting and divorce, bullying siblings, or loss of a loved one through moving or death.  There are social worries: am I too fat/ugly/stupid/boring/etc? Some kids also worry about the big questions: Will the world end?  What is the meaning of life?  Does the little red-haired girl like me?

Some kids live with worry so much they internalize it and don’t realize that worries are the cause of their pounding heart.  Sometimes we ask the child what is worrying them and they can’t say because they are so used to the worry that they don’t realize it IS a worry. Or they are afraid to talk about it in front of a parent.  This is where counseling can be helpful so the child can explore and diffuse the anxiety.

Now don’t hesitate to call your doctor if your child is having a pounding heart with dizziness, fainting spells, or breathlessness.  There are medical conditions that need be checked.  If you can’t talk to your doctor and are concerned, you can go to the Emergency Department. But perhaps you can think back and figure it out before you get to that point. Kids have strong hearts, so strong that even though it’s probably not a heart problem, it feels like its going to beat right out of his chest!



What The Heck Is Measles Anyway?

It was 5 o’clock, July 2, 1991.  I know the date and time because it was the end of my first 36 hour shift as Chief Resident.  And it was a true 36 hour shift, not a wink of sleep, with sick kids piling into the hospital like we were having a sale.  But finally it was time to sign out to my fellow residents and go home for a quiet supper and some sleep.  Then the Emergency Department called- has anyone up there seen Measles before?

I had.  Two years before, in medical school, I had gone to the Philippines for a month for a course in third-world medicine.  In the Philippines vaccinations are a luxury few can afford and I saw lots of diseases we seldom see in the States-measles included.  I went downstairs to the ED, saw the child, and when he opened his mouth, I saw the blue-white spots on the roof of his mouth that clinch it: he had measles.  I didn’t feel sorry for myself that my well-earned break was put off by one more patient; I was elated.  I made a diagnosis no one else could!

Measles is in the news a lot lately.  We are having an epidemic- lots of kids are getting the disease this year.  Many parents are refusing to get their kids vaccinated because of fears of injury from the vaccine.  Those unvaccinated kids are vulnerable and when they come in contact with someone infected, often someone who has been in another country, they get infected too.

What is the measles?  Measles is a virus that has been with mankind for centuries.  It is a virus that starts off like many cold and flu viruses.  The child starts with a cough, runny nose, and fever.  He might have some red eyes, sore throat, and maybe some vomiting.   Then in about 2 to 3 days a spotty rash develops, and those white spots in the mouth.  The rash starts on the face, then spreads to the torso and then the arms and legs. The whole thing lasts about 10 days before it goes away.

So what is so bad about the measles?  Why all the news, why a vaccine in the first place? Well, the bad news is that the measles can be deadly.  Before the late 20th century, measles was a terror for families.  Lots of kids with measles developed bad complications- pneumonia or encephalitis (brain infection).  Many children died.

It was common and terrible scene in many households.  The parents and doctors could do little for a badly infected child.  There were no IV fluids, no respiratory support, no antibiotics for pneumonia.  All anyone could do was hold the child’s hand and watch helplessly as he slipped away, comatose and struggling to breathe.

As the century progressed, improved nutrition, hygiene, and medical care helped more kids survive. Then in 1963 a vaccine was invented and the world rejoiced- finally children were safe from measles!  But in the span of my lifetime, we in medicine became victims of our own success.  With the near-eradication of measles, the next generations did not learn to fear it.  People began to question- what’s in those shots that you’re putting into my kid?

Then in 1998 there was a study that suggested the measles vaccine caused autism. Since then mountains of evidence have refuted that, and the study itself was found to have fraudulent data.  However, the seeds of doubt were planted.  Some parents won’t get their kids vaccinated and that makes for a chink in the armor of our population’s immunity. Pockets of unvaccinated kids are vulnerable to the measles.  And measles is highly contagious- viral particles can hang in the air up to an hour after the infected, coughing patient has left the room.

Now we doctors are having to re-learn what measles looks like.  We are having to explain over and over the safety of vaccines, and the threat of disease that history has forgotten. So help us, and help your own kids- keep them vaccinated.  Enjoy one of the benefits of modern science and technology- safety from one of the world’s worst illnesses, once thought gone for good, now threatening to come back.


Is That Measles???

This week’s guest columnist is Dr. Jesse Livingston, a family practice resident at the University Health Center here in Lafayette.

Rashes are a common reason parents bring their children to the doctor. Sometimes the parents get so alarmed by a rash that they come to the Emergency Department.  Maybe the child has been mildly ill for a few days- some cough, some fever, but has been doing okay.  Then one morning the kid wakes up covered head to toe with red spots!  Not only does the rash look horrible, but Grandma chimes in with the worst cases: “Looks like measles!”  ”Could be meningitis!”  Get him seen!  Now!

To Grandma’s credit, in her earlier years rashes were sometimes the herald of life-threatening infections.  However, these days those bad illnesses- meningitis, measles, rubella, pneumococcus- are prevented by your child’s vaccinations.  The vast majority of infectious rashes today are benign.

Viral rashes (what doctors call “exanthems”) are extremely common and usually go away within a few days.  Generally theses rashes appear red and blotchy and are present from head to toe.  Unlike allergic rashes, they are not swollen or “raised.”  Many viruses can cause a similar-appearing rash as the skin has only a limited amount of responses. This can make it difficult to tell what virus is responsible.

Viruses can affect many different parts of the body besides the skin.  For example, the common cold viruses make a person cough and sneeze, but may also cause a rash.  The list of viruses that cause rashes is long.  Some of the more common are Roseola (virus HHV-6) and Fifth Disease (Parvovirus).  These viruses often start with a fever and then in a few days the rash comes.  A more unusual rash is Hand, Foot, and Mouth Disease, caused by the Coxsackie virus.  This virus causes a strange, spotty rash to appear on the palms of the hands, soles of the feet, and inside the mouth.  It can cause fevers and diarrhea as well.  Unlike most viral rashes, the sores and spots of Coxsackie are painful.

Like our child from above that scared mom and Grandma with his head-to-toe spots, viral rashes can look pretty freaky.  They can look like red lace on the skin, or like leopard spots all over- even the top of the head!  Though they look pretty bad, they usually don’t feel bad. They mostly don’t itch or hurt and there is no specific treatment required.  There is nothing to put on the rash that will make it feel better or go away sooner. The child often does not feel well, but that is because of the virus, not the rash.

Like above, viral rashes come with other symptoms: fever, fatigue, headache, no appetite, aches, and irritability.  Supportive care at home is the best treatment.  Make sure the child stays hydrated.  Not eating is fine.  If the child is drinking enough to make pee once or twice per day, you’re doing okay.  Acetaminophen (Tylenol) or Ibuprofen can lower the fever and reduce the aches and pains.  Antihistamines may help with occasional itching. These rashes usually only last for a few days.

The main reason to see a doctor with a rash is if the child acts truly sick.  These warning signs are: poor drinking leading to urination less than once per day, worsening fatigue such that the kid becomes progressively harder to wake up, or shortness of breath.  If you are worried that your child is getting sicker, call your doctor.  They can steer you to the office or the Emergency Department.

It is important to note that viruses that cause rashes can be contagious.  Close contact with others should be avoided until the rash is gone, and take special care to avoid exposure to pregnant women or people with immune problems.

Childhood rashes are usually benign, go away by themselves, and often go with other symptoms.  Vaccinations prevent many of the harmful diseases that cause rashes, so keep your child’s immunizations up to date.  If you have any concerns about the rash or the warning signs above, call your doctor.  She can help decide if your child needs to be seen, and tell you Its Not The Measles.

Ear Pain in Merry Olde England

My daughter is in London, England, taking a summer college course.  She woke up last Sunday with “the whole left side” of her head hurting, particularly her ear.  She took two ibuprofens and then she and a friend went out in the unfamiliar city looking for medical care.  All the walk-in clinics were closed on Sunday so she ended up at an Emergency Department, what the british call “Accident and Emergency.”

An irish nurse took them in, radiating frustration.  Her attitude was “ear pain-this isn’t an emergency!”  However, the young indian doctor was quite kind, diagnosed an ear infection, and prescribed Amoxicillin.  Given that England has a National Health Service paid for by the government, her visit was free.  She had only to pay 8 pounds (about 16 dollars) for her prescription at the “chemist.”

This story highlights several points about ear pain in particular and health care in general. First, for ear pain, try some pain medicine.  So many times a mom brings a child to Emergency and I ask, “Did you give anything for pain?” and they say no.  My daughter felt much better after taking the ibuprofen. If the pain had started at night, she would have felt good enough to sleep and find a doctor in the morning.  If you give a decent dose of ibuprofen or tylenol to your child for her pain, give it a half hour to work, you often won’t need to schlep out in the middle of the night.  No one wants to wait in an Emergency waiting room at 2 am when they could have stayed in bed.

The second point is England’s more relaxed attitude about medical care.  Note that no walk-in clinics were open on Sunday, in the country’s biggest city!  Brits aren’t clamoring for care 24/7 like americans, and british doctors aren’t working seven days per week.  In an Emergency, their “A and E”s are there to help.  And again, with some pain medicine in your child, you too can wait until Monday to see your doctor about that ear.

When my daughter woke up with ear pain that morning, she took two ibuprofen tabs before setting out to find care.  She is an adult, but kids who weigh 90 pounds can take that much.  I had a mom yesterday question me on this- I recommended two ibuprofens for her 12 year-old boy’s ankle pain and she was shocked- TWO tabs??  I did not point out that the child (his football team’s lineman) weighed a hundred pounds more than me.

When I see a child in the Emergency Department with ear pain, I ask “Did you give some pain medicine, like ibuprofen or tylenol?”  If mom did, often she didn’t give enough.  Many parents are afraid to overdose their child.  Now this is a healthy fear: no one wants to accidentally hurt their child.  However, you do want to take care of their pain too.

Kids come in different sizes and have different needs for a dose of medicine that is just enough, but not too much.  We in pediatrics use algebra all day long to calculate drug doses (our math teachers were right- we will have a real-life use for math after all!).  I don’t expect parents to do that math though- it can be tricky.  However, the drug companies put doses-by-weight intructions on the package.  You can use that to know how much to give, but in the companies’ zeal to be safe they sometimes end up under-dosing a bit.  If you really want to know exactly how much to give, call your doctor.  The doctor or nurse can calculate the right amount for you.

So if your child wakes up with ear pain, give some pain medicine, and give enough.  Give the medicine a half hour to work and elevate the child’s head on some pillows or on the couch to take pressure off the ear.  Doing this often helps your child go back to sleep so you can wait to see your doctor in the morning.  Save the Emergency Department (or in England, the “Accident and Emergency”) for the emergencies.




Oh no! I think I broke my kid’s arm!

This week’s guest columnist is Dr. Michelle Taylor, a family practice resident at University Health Center here in Lafayette.

2 year-old Lily was playing around the pool.  You go to move her from the edge and grab her hand.  She slips in a puddle and her arm gets tugged.  She bursts into tears and now keeps her arm at her side and doesn’t move it.  Now you’re crying too: “What did I do to my baby?  Did I break her arm?”

Thankfully, you didn’t.  Lily has what’s called a “Nursemaid’s elbow.”  Nursemaid’s elbow is a common injury of early childhood, in infants, toddlers, and preschoolers.

What exactly happens?  You have two bones in your forearm, the radius and the ulna. They lie side by side and their upper ends are part of your elbow joint. Those ends are bound together by a ligament, like a rubber band holding two sticks together.  In some kids that ligament is weak and the radius end slips out when tugged.

Actions that cause a Nursemaid’s elbow include 1) jerking a child by the wrist.  Even something as minor as pulling a child’s arm through a sleeve can cause the radial head to slip. 2) Pulling a child up by the hands.  Lifting a child under the armpits is safest. 3) Swinging a child around by the arms.  While lots of kids love this, save it for when they are older than 4 years.  4) Falling over.  Sometimes if a baby is sitting up and flops over on her side, her arm can be pinned under her so that the radial head clicks out.

How do you know if your child has a Nursemaid’s elbow?  First of course, the arm is tugged like above.  When it happens, the parents usually feel a pop in the child’s arm, often in the wrist.  Since they are holding the wrist, they think that’s where the injury is. However, the pop happens in the elbow and the parent feels the pop transmitted down the child’s radius to the wrist.

The child cries at the time of dislocation, but often settles down and acts fine as long as the elbow doesn’t move.  He will walk around with his arm hanging by his side.  Only when he forgets and tries to use that elbow will he whimper.  There is no swelling.

How do you know if the elbow is broken, not just a Nursemaid’s elbow like above? Let’s change Lily’s story from above.  Instead of having her arm tugged, say she was running around the pool, slipped, and fell on her elbow.  She cries and cries and doesn’t settle down and the elbow swells.  Then it may be cracked.

Sometimes with toddlers, we don’t know how they got hurt.  Say Lily was playing in her room with 3 year-old cousin Elliot.  You hear a cry and Lily comes running out holding her arm.  Did Elliot pull on the arm and cause a nursemaid’s elbow, or did she fall off the bed and break it?  Elliot and Lily can’t say- they don’t have the words yet .

Those cases we have to x-ray.  Broken elbows are often swollen because the crack in the bone bleeds within the joint, but not always!  If we don’t have a clear story that the child’s elbow was only pulled on and not fallen on, a cracked bone is possible.  Broken elbows need to be casted so that they will hold still for the month or two it takes for the bone to heal.

However, if it is a nursemaid’s elbow with a clear story of the arm simply being pulled on, no casting or xrays are necessary- the doctor fixes it right away. We have the child sit on mom’s lap, perform a gentle twisting and flexing maneuver, and feel the radius pop back in place.  The child cries, but usually settles down and within 5 minutes is using the arm normally.

You are not a bad parent if your child has a nursemaid’s elbow.  You can’t know if your child has loose ligaments in the elbows until it happens.  Kids who get it may get it again- those ligaments don’t tighten up until age 4 or 5.  Remember to avoid tugging your child’s arm or swinging them around.  And if that elbow pops out again, bring them in and we’ll pop it right back.







Call Poison Control! 1-800-222-1222

One of my favorite movies is a 1991 comedy called Defending Your Life, starring Albert Brooks and Meryl Streep.  The premise is when someone dies, before going to heaven he must defend his life in a trial with lawyers and judge. The evidence presented is scenes from the deceased’s life.  At one point for fun the prosecutor shows scenes of Albert Brooks just being stupid.  He shows the character in the bathroom picking up shampoo instead of mouthwash, taking a swig, and then spewing shampoo all over.

A similar goof happened to two kids last month.  They picked up hydrocortisone cream instead of toothpaste while brushing.  They started brushing with the cream and I am sure re-enacted Albert Brooks.  I found this pretty funny, because I KNOW brushing with hydrocortisone is harmless.  The two moms didn’t know this.  One mom called Poison Control, who told her that this was perfectly safe and she could stay home.  The other mom didn’t call and came to the Emergency Department, waited an hour to get seen, to have me say her kid was fine.

So here are things that I have seen kids, usually those pesky exploring toddlers, eat that are perfectly harmless.  Shampoo and hydrocortisone cream, of course.  Sugar ants (had invaded a restaurant’s soda machine and mom found them floating in her daughter’s drink).  Poinsetta leaves (turns out that these are only mildly irritating on contact, maybe leading to some brief vomiting and diarrhea at worst).  Ibuprofen (brand names Motrin or Advil).

Here are some things kids drink that are USUALLY harmless in small doses. One of the most common toddler ingestions is household bleach.  A few teaspoons is harmless, which is usually all they can stand before gagging and spitting.  Tylenol, Aspirin, and ADHD medications are also okay in small amounts. Call Poison Control to be sure.  They can help you decide if your child needs to be seen. If your child should be checked out, Poison Control calls the Emergency Department to alert us you are coming.

Occasionally a child poisoning is not as goofy as those kids from above who brushed their teeth with hydrocortisone.  Once police were called to a house where the parents were fist fighting.  When the officers entered they found a 3 year-old boy lying unconscious among empty pill and liquor bottles.  When the child got to us he was breathing but unarousable.

We tested the boy for everything we could- brain bleeding, alcohol poisoning, narcotics, etc.  All the tests came up negative, but there are many medicines we do not have tests for (real life is not like CSI:Miami). There was a grandmother in the house also, who took eight medicines. Worried that the child took one of those, we reviewed the list with Poison Control.  Four of the drugs could have made this kid like he was.  We admitted him for observation and fortunately he woke up the next morning and was fine.

What kinds of grandma medicines could have done this?  Many adults take blood pressure medicines, heart medicines, and diabetes pills.  All these can hurt kids.  Other dangerous medicines include antidepressants, anti-anxiety drugs, and narcotic pain medications. Believe it or not, one of the most dangerous medications a toddler can take is adult iron pills.  Keep all these medicines where small children absolutely cannot get them!  Elderly people often organize their many pills in plastic daily dispensers; if the grandkids are around and granddad leaves it out, that’s big trouble waiting to happen.  Toddlers who see granddad pop his pills will imitate him and do the same.

Finally, do not leave fuels like gasoline and kerosene around in cups.  To a toddler, a cup is an invitation to drink.  They don’t understand the difference if that cup was filled with old lawnmower gas or juice.  Be just as careful with drain cleaners like Drano or Liquid Fire- these can be deadly too.

Again, when in doubt call Poison Control.  They can tell you if you need to come in, or stay home and not wait in Emergency for me to tell you: brushing with hydrocortisone is pretty funny, and safe.

Baby Fall Go Boom

This week’s guest columnist is Dr. Leslie Birdsong, a family practice resident at the University Health Center here in Lafayette.

You are downstairs doing a million things.  Your kids are upstairs playing, making sounds like herding elephants.  Suddenly you hear a louder crash.  You strain to listen, and have that stab of anxiety: what sound is next?  Laughter and more elephants, or gut-wrenching silence?  You yell up the stairs, “Is everybody ok?” More silence.  Now you are truly frightened and bound up the stairs .

Every parent fears their child having a head injury.  Head injuries make up many hospital visits for kids.  Here are some numbers: In kids less than 14 years, yearly there are over 500,000 Emergency Department visits for head injuries.  37,000 of those kids get admitted to the hospital for observation, or surgery.  So when do you need to bring your child to the hospital?  Here are some rules.

We divide head injuries into two groups: those younger than two years old, and those two and older.  This is because younger children react differently to head injuries. They are more difficult to assess because they can’t tell us what’s wrong. Also, infants may not show many outward signs of injury.

In kids less than two, here are the rules.  1.  Is the child walking, talking, and acting well for their age when we see them in the ED?  2.  Is the child acting like themselves for mom and dad?  You are with your child a whole lot more than the 10 minutes we get. Tell us if your kid is acting “funny.”  3. Are there big lumps on the scalp? Swelling and bruises on the forehead are okay, but swelling on other parts of the skull needs checking.  4.  Did the child lose consciousness?  Any child that gets knocked out should be seen.  5.  Was the injury mechanism severe?  If a child falls over from standing and hits her head- no big deal.  But a fall on the head from greater than three feet could be trouble.  A fender-bender car crash doesn’t require an evaluation, but if the car rolled over the kids need to be checked.  Impacts from baseball bats and golf clubs- bring ‘em in!

For little kids, the common and scary scenario is usually like above- the parent hears boom and then silence.  For older kids it is the call from the school or worse, from the police- your child has had an accident.  Still, most older kids have mild head injuries they easily shake off.  The rules to assess children older than two are a little different than the ones for the babies and toddlers from above.

1.  Is the child awake, alert, and acting normally?  2.  Was the kid knocked out?  3.  Is the child vomiting?  Note that vomiting is NOT on the list for kids under two years- they can vomit just from crying really hard or gagging on mucus.  But if kids over two are vomiting because of a head injury- that worries us.  4.  Does the child have a bad headache?  The littler kids can’t tell us about this but the older kids can, and that counts.  5.  Was the mechanism of injury severe?  This means falls onto the head from greater than 5 feet, a car roll-over, or an impact from a thrown baseball or swung bat.

When a kid meets any of these criteria, they may need a CT scan of the brain.  CT scan helps find bad things like bleeding in the brain or skull fractures.  So why don’t we just scan every kid and be sure?  No, it’s not about the money.  CT scan uses lots of radiation, up to 500 times the radiation of a regular x-ray.  Our physician motto “Do No Harm” comes into play.  The benefit of seeing into the skull needs to outweigh the risk of future cancers.

What is the bottom line here?  If your child falls down and goes boom and has any of the signs we listed, get him seen.  If you are unsure if any of the rules above are positive, call your doctor.  But if you have good answers for all the rules, then all baby needs after falling and going boom is a hug and a kiss on the noggin.