Island of Misfit Toys

This week’s guest columnist is Dr. Matthew Morgan, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

I have fond memories of Sunday dinner at my grandfather’s.  We followed the same routine: mom brought the potato salad, grandmother made fried chicken, grandfather made the coffee.  And we’d play games: dad liked horseshoes, my brother… lawn darts.  Remember lawn darts?  They were comically-enlarged versions of traditional darts with a weighted end, to be tossed in the air at a target on the grass.  You may not remember them because of the Consumer Product Safety Commission, a government agency that banned them after several children were injured, some critically.

Many toys have been removed from the market over the years.  Some people think “they’re taking childhoods away from us!” Perhaps, but lawn darts had a proven record of hazards, and some toys prior to the Safety Commission’s founding were just flat-out ridiculous.  Look up the Gilbert Atomic Energy Lab, a toy marketed in 1950 by Alfred Gilbert (inventor of the more popular, and safe, Erector Set).  This set contained actual uranium ore which, besides producing cool effects, brought low levels of radiation into the household, and could cause radiation burns if handled improperly.  One play suggestion: secret the ore somewhere in the house, and play hide-and-seek with the included geiger counter.

Another obvious benefit of this agency was the removal from the market of Aqua Dots, an arts-and-crafts toy with beads manufactured in China.  After several toddlers were hospitalized with comas after ingesting the beads, they found that their chemical coating contained GHB. Popularly known as the “date rape” drug, GHB is particularly toxic to children.

A more routine responsibility of the agency is assigning age ranges for toys.  There’s a common misconception that the age suggestions are based on intellect or maturity level.  Thus parents buy the toy or game for their child who’s younger than the age range, thinking that their kid is advanced enough to enjoy it.  However, the age range is actually for safety’s sake, particulary for kids under age 3.  It’s decided by rigorous testing to assess the choking risk of small parts.

I recall when my brothers and I got our go-kart.  Back then, a go-kart was a glorified piece of sheet metal with wheels bolted on each corner, one of which attached to a small motor.  I vaguely remember a steering mechanism, but we ran into trees and dirt piles so much I can’t be certain.  It’s easy to remember the safety features though, because there were none.  Of course our parents didn’t make us wear helmets either.  I carry a reminder of that go-kart on my right elbow, a shiny white scar from when I jumped off while riding on the back, one thing mom did specifically warn us not to do.

Things have changed since then.  Go-karts and other motorized toys have become more complex.  While there’s been some focus on safety, they’ve also gotten more powerful, with new and different dangers.  With advancement in battery technology, there’s even electric dirt bikes for kids, though their size and speed don’t necessarily correlate with age-appropriateness.

Like we discussed above, the Consumer Product Safety Commission sets age levels for toys and games.  Though they base these assessments on proven algorithms, the science is still evolving concerning motorized riding toys.  For example, many of these are intended for use on dirt roads and isolated driveways.  They are unsafe on paved streets, particularly top-heavy and overpowered ATVs.  Another consideration is use of these toys by children with Attention Deficit Hyperactivity Disorder.  These kids have  decreased attentiveness and a penchant for risk-taking, so it’s important to keep in mind your child’s potential for accidents.  And bad injuries happen with these toys to any child, ADHD or not.

Parents can limit the use of these devices, ensure safety measures, and purchase them with their child’s capabilities in mind.  Helmets, elbow, knee, and wrist pads, and boots are helpful.  Designate safe areas for play, keeping kids off roads where they’re hard for cars to see and avoid.  Set use hours with the best visibility, for kids to see hazards and the hazards (cars) to see them.  Be there when your kids are riding or using potentially dangerous items.  We see castastrophes all the time in the Pediatric ER; don’t let your child be one of them.

 

Phone Zombie Children

Portable and “wearable” computers, according to designers, are supposed to enhance the human experience.  Like science fiction cyborgs with a fitting over one eye, the user goes through the world with “augmented reality,” being fed data about what he’s seeing.  So far though, the most ubiquitous portable computer, the smart phone, seems to de-augment reality.  The user walks through the world texting, until he caroms off a lamppost that reality put in his way.

The latest generation of kids are growing up with much of their reality supplanted by screen time.  Phone apps and tablets designed for toddlers are perhaps teaching them, mostly entertaining them, certainly keeping them quiet.  The proponents of this technology brag that it enhances their learning, teaching them words and math, making learning fun. The detractors worry that these devices are raising a generation of zombies: drooling slaves to their screens, unable to have a conversation, much less hold down a job.

The scientific jury is out on this subject.  We won’t know for another 10 years how this generation will turn out.  There were similar worries for my generation, the first raised with television, and we haven’t seemed to make more zombies than before.  However, small screens are different than a TV set.  Instead of just watching it in a room and then walking away to do other things, now you bring the screen with you everywhere you go.  And you interact with it- ask it questions, communicate through it, play games with it.

One thing we do know- these devices can be addictive, which affects at least some people, which we’ll go into more below.  For your child’s mental development, well-being, and happiness, stick with the American Academy of Pediatrics guidelines for screen use, applicable to TVs, PCs, phones and tablets.  Don’t allow your child under 3 years-old to use these much at all.  This is a time of critical brain development, when the abilities to learn, to practice interactions, and to love and be loved, are hard-wired.  It’s best for the human parent to do this, since the computer as child-rearer is nowhere near a “mature technology.”

Everyone knows of a computer addict.  It’s often a teenager or young adult, raised on video games, who can’t quit.  Holed up in their rooms, they play and play, not showering or doing homework, mawing junk food without thought. They don’t get jobs or boyfriends or girlfriends.  Their parents wring their hands, torn between enabling their kids’ addiction and the horrible behavior that ensues if they cut them off.

Like drug addicts, these kids become monsters when their devices are removed. They scream that the parents hate them, and that they hate the parents back.  They break things, steal and lie, then leave the house to get their fix on a friend’s computer, or a stolen phone.  Even toddlers can display this behavior when their tablets or phones are taken away, throwing violent tantrums until the parents acquiesce.

Like we discussed above, the science is still out about how harmful screens- computers, games, and phones- are to children.  One question: will they turn only some people into zombies; like alcohol, where a few people get addicted, but most people drink in moderation?  Or are they more like heroin, so addictive that any exposure is risky?

There’s no doubt that these devices are helpful to busy parents, keeping the toddler quiet when necessary, like when waiting in an office or the DMV.  Otherwise the parent must keep the toddler quiet themselves, when simultaneously trying to have adult conversations.  But when are screens too much?  What’s the line between raising an intelligent, happy, and loving kid; and letting the screens turn the kid into a computer zombie?

While waiting for more science, The American Academy of Pediatrics has put out guidelines for children’s “media diet,” based on what we do know.  Babies under 18 months-old should have no screen time.  Kids between 18 and 24 months can have a little, but it needs to be “high quality” (think PBS), and parents should sit with the child to monitor and talk about what they’re seeing.  Kids between 3 and 5 years should max out at only one hour per day, again high quality, with the parent present.  Over 6 years, the screen time should be limited to not supplant more important activities like family meals, reading, playing with friends, and sleeping in a screen-free bedroom. 

Opposite of Obesity

This week’s guest columnists are Dr. Jacob Sellers and Dr. Anna Malesky, Family Practice Residents at the University Hospital and Clinics here in Lafayette.

Imagine this.  Your teen has been experiencing months of headaches, dizziness and fatigue.  You’ve been to countless doctors, had blood tests and EKGs, and finally she has a diagnosis.  “We don’t know exactly how it happens,” this last doctor explains, “but untreated, there’s a 1 in 10 chance it could be fatal.”  Your heart sinks.  Bad news continues: “It will take many months, even years, for your daughter to fully recover. She should be admitted to the hospital now to start treatment.”  The diagnosis: Anorexia, a psychological illness that’s more common than you’d think.

Anorexia is an “eating disorder,” wherein the teenager sees themselves as overweight, and goes to extremes to lose weight.  Even when skinny, anorexic teenagers still think they need to shed more pounds.  Their intense fear of weight gain leads to severe dieting, purging through vomiting or laxative use, and calorie burning through vigorous exercise.  Anorexia has the highest death rate of any psychiatric disorder, about 10%.

Bulimia is the other common eating disorder, consisting of uncontrollable overeating, followed by distress and guilt.  This leads the teen to purge by vomiting, laxative use, and extreme exercise.  Eating disorders affect girls ten times more than boys, and these girls tend to be intelligent and capable, enabling them to achieve life-threatening feats of weight loss.

These kids rarely seek help- they want to lose that weight.  Parents can miss the early warning signs too, being so busy with their jobs and other kids.  Teens often have vague complaints that mimic other common illnesses- headaches, fatigue, dizziness, abdominal pain.  They also have behavior changes that are passed off as normal teen “phases”- moodiness, wanting to be alone, body image concerns, frequent trips to the bathroom.  More obvious changes are noticeable weight loss, wanting to eat alone, and only eating at certain times.  Affected kids will refuse to eat favorite foods, not eat at restaurants, and not eat at holiday gatherings where the rest of the family is stuffing themselves.  If you notice these signs, get your child to their doctor for a weight check and evaluation.

Teen girls are more susceptible to eating disorders, because mass media has always shown the ideal girl to be skinny.  TV, movies, and even Barbie dolls depict girls with unrealistic proportions, leading kids to have unrealistic expectations for their own body image.  Thus one facet of eating disorders, where even skinny girls still perceive themselves as overweight.

Social media has complicated the issue with the rise of blogs and websites that encourage eating disorders.  These websites, often called “Pro-Ana” for anorexia promotion and “Pro-Mia” for bulimia, aim to support kids with this behavior by putting a positive spin on it, providing “thinspiration.”  They post tips on how to vomit, how to dose laxatives most effectively, how to think about food to make it less appetizing, and most darkly, how to hide this behavior from parents.

Like we mentioned above, teens rarely seek help for eating disorders.  Often they hide it so that no one interferes with their weight-loss efforts.  However, these behaviors can be life-threatening: 10% of anorexics will die if untreated.  Anorexia became a much better known illness after the famous singer Karen Carpenter died of heart failure at age 32 as a result of her weight loss.  Eating disorders can cause dehydration, heart arrhythmias, low blood pressure, slow heart rate, and low temperature.

Thus it’s important to be vigilant for the signs of eating disorders.  If your teen seems to be getting skinnier and skinnier, get her seen.  But some signs are often passed off as healthy activities, like dieting and exercise. Other signs can be attributed to teen “phases,” like moodiness and wanting to be alone.  Physical symptoms include always being cold, dizziness and fatigue, and headaches.  Starvation also leads to thinning hair, brittle nails, dry and discolored skin, and loss of menstrual cycles.  Like we mentioned above, red flags are peculiar eating habits, like only eating at certain times, wanting to eat alone, or not eating with everyone else at restaurants or holiday gatherings.

These are difficult illnesses to treat.  The sooner you recognize your teen’s eating disorder and get her evaluated, the more successful the treatment, and the likelier you’ll be to save her life.   

Stressed Teens, Stressed Parents

The parents brought their teenager into the Emergency Department because she was acting bizarrely.  The normally cheerful, outgoing girl was suddenly sullen, irritable, and lashed out at the slightest provocation.  She also seemed paranoid, suspicious of everyone around. Usually ready to hug, she now acted afraid of any contact.  During my physical exam her eyes darted back and forth, and she flinched when I reached out with my stethoscope.

The onset of mental illness can seem sudden.  In medical school they called it “the psychotic break,” where previously well teens become paranoid or delusional, often when faced with new stress, like moving away to college. This break was thought to herald life-long illness like schizophrenia or bipolar disorder.  However, it turns out that most teenage psychological troubles have a slower, more subtle beginning; and if treated early, can have a happier ending.

Seemingly dramatic changes in behavior are often preceded by symptoms that are missed or denied by teens or parents.  These include weight loss and drop in appetite, plummeting grades, chronic abdominal pain or headaches, irritability and combativeness.  These can easily be dismissed as normal teen “phases,” which they often are. Unless they’re not.

Other signs that your teen is coping badly are…having to cope.  Profound stress can push your teen to depression or other maladjusted behaviors.  Are parents divorcing or having other troubles, like infidelity?  If you as a parent think you’re stressed by the situation, it’s as bad or worse for your kids.  Love and security that they counted on their whole lives has now blown up.  Many divorcees state that they wouldn’t have divorced if they’d known what it would do to their kids.  Other profound stressors include moving; a parent’s job loss or other economic hardship; and death of a loved one, like a friend or close grandparent.  If your kid’s facing these issues, be ready to get help.

The more distressing symptoms of mental illness, like our girl above, are clearer signs that it’s time to get help now.  These include alcohol and drug use, sexualization or being sexually abused, eating disorders, or paranoia and hallucinations.

It’s no fun dealing with angry parents who make their teen’s mental illness a battleground.  Often they bring their kids to the Emergency Department demanding that they be drug-tested, to “win” the fight over suspected abuse.  In the most recent instance, after I told a mom that we could not legally force a drug test on a teen, she stormed out of the ER, yelling that it was her right to know.  Fortunately, the teen stayed behind, and we had a good talk about her drug use, her depression, and how she could get help.

Having proof that your teen is using drugs won’t make him or her snap-to.  Looking back, I could have handled the situation better by asking the mom, “how will a positive test help you and your child?” and explore the issue from there, rather than shut her down with the law.  If the girl’s behavior already made mom worried that she’s abusing drugs or alcohol, that behavior is often evidence enough that she needs help, better than a drug test.

Like we discussed above, symptoms of depression or other mental illness can be subtle, or not-so-subtle- weight loss, plummeting grades, chronic headaches and abdominal pain, drug use and promiscuity.  Now that you’re properly scared, where to get that help?

If you belong to a major denomination church, clergy and staff often have training and offer competent counseling.  Your child’s doctor should have a list of mental health services, and some even do counseling and anti-depressant prescribing themselves.  School counselors also should know their cohorts in the community.  You’ll want a counselor that partners with a psychiatrist or other provider who prescribes.  Anti-depressant or mood-stabilizing medication often helps get teens through a bad patch, and keep them steady as they learn new, healthier habits with thinking and interactions.

If you find yourself getting angry at your teen’s behavior, when they’re combative, sullen, or just plain lazy, take a step back.  Maybe they’re not acting this way to piss you off, maybe they’re crying for help the only way they know.  Laziness may just be laziness, or that inability to get off the couch could be depression.  Don’t take it as a personal affront, take it as a call to action.  

AIEE! I’ve Hurt My Eye

This week’s guest columnist is Dr. Irena Liang, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

It’s a pumpkin-decorating party, and the carving tool seems safe.  The edge is serrated, but the tip is blunt and it’s plastic, not metal.  But when you turn your back, your 8 year-old girl screams “OWW!”  She’s got her hand over her right eye, and yells, “I poked myself in the eye!  I can’t see!”

In the Emergency Department, the doctor sees a defect in the cornea, that clear dome in front of the iris and pupil.  If it’s a hole, he explains, that’s serious.  He calls the eye surgeon, who recommends starting IV antibiotics, and she’s on her way in.  Your girl may need surgery.

Eye injuries can be worrisome.  Often it’s just a scratch that heals fine, but sometimes eye pokes can lead to vision loss. The simplest injury is a scratch to the cornea, called a ”corneal abrasion.”  This means the cornea is scraped on it’s outer layer. These hurt so much that it’s hard for the child to open her eye.  They require pain control and infection prevention.  We’ll prescribe an antibiotic ointment that soothes the scratch and stops infection, and advise ibuprofen or tylenol. If not cared for properly, sometimes abrasions can become ulcerated and leave a permanent scar on the cornea, which impedes vision.

Another simple injury is the subconjunctival hemorrhage.  This is when the white of the eye gets poked, and blood pools in the outer layers.  It’s essentially a bruise of your eyeball, but the tissue is so thin and white that it’s bright red, unlike the usual blue bruising of skin.  These heal fine, though it takes a week for the blood to reabsorb.

If the eyeball is penetrated, this is serious.  Surgery may be necessary to save vision, with possibly some permanent vision loss anyway.  Even the other eye could be endangered, a phenomenon called sympathetic ophthalmia.  When one globe is penetrated, the immune system sees the eye’s interior as foreign, attacks the injured eye, and attacks the good eye as well.  Unchecked, the child’s immune system can damage both eyes.

Toddlers are explorers.  Unfortunately, many families keep poisonous substances under the kitchen sink, where toddlers go.  They grab the cleaner or dishwasher pod, open it, and poof or squirt it in their eyes.  Screaming ensues.

Chemical burns to the eye, like the poking traumas we mentioned above, can have serious consequences.  They initially impact the cornea, that clear dome in front of your iris and pupil, and burn it, causing intense pain.  Left unchecked, they can penetrate the cornea and damage deeper eye structures.

First things first-wash it out!  This is hard with toddlers and even older kids, but it’s crucial to stop the damage.  Often it takes two people, one to hold the child and another to hold the eyelids open and pour in lots of water.  After that initial wash-out, head to the Emergency Department.

In the ER, we put numbing drops in the eye to make further wash-outs less miserable.  Then we wash with saline solution multiple times, because chemicals can hide in the lacrimal sac, a tear-collecting reservoir between the corner of the eye and nasal bridge.  After one wash-out, chemicals can squirt out of that sac back into the eye and cause further burns. After this is over, we refer to the eye doctor to assess the extent of injury.

Blunt eye trauma- punches in the eye, or blows to the face with a ball, are easier.  These often don’t injure the eyeball, because it’s protected by the eyelids and brow.  Simple bruising, black eyes, and swollen eyelids are treated with ice or cool compresses, and pain medicine like Tylenol. Check your child’s vision. Blurry vision needs an eye doctor, since the shock wave from blunt injury can damage structures important for seeing.

Eye “foreign bodies,” like sand or eyelashes, can cause intense pain, and lead to corneal abrasions like we discussed above. Though they usually don’t cause serious damage, they really irritate!  If you know it’s something simple like dirt, sand, or an eyelash, washing the eye out often removes the object.  If you can see it, sometimes you can dab it out with a cotton swab.  If pain continues after removal, or your child has blurry vision, come on in! 

Thanksgiving

Sometimes I wonder what I’d be like if I was born in 1800.  I’d be crippled, since I have an arthritis requiring regular medication.  Once the arthritis affected my eyes and without medication, I might’ve become blind.  Then one time a mosquito bite on my calf got infected, my knee swelled up, and it took surgery and a month of antibiotics to clean up.  In 1800 the cure for this infection, to save the patient’s life, was a mid-thigh amputation.  Without anesthesia.

Modern medicine gives me lots to be thankful for, not being a one-legged, blind, crippled guy.  In the late 1800s anesthesia was invented, so patients didn’t have to be strapped down and shriek through their operations.  Also at that time aseptic technique was discovered, so that patients wouldn’t get infected during surgery.  Before that, surgery was a last ditch effort to save people, since many died from bacteria introduced in surgery.  Then in the 1930s, antibiotics were invented, another breakthrough that made today’s whole Scott possible.  Finally, the 20th century brought anti-inflammatory and non-narcotic pain medication.  In the 1800s the only pain medications available were opioids like laudanum, which was opium dissolved in alcohol.  That would’ve made me a one-legged, blind, crippled narcotic addict.

My pediatric patients have lots to be thankful for as well.  When I was a kid, if a child developed leukemia, the most common pediatric cancer, he was certain to die within months of diagnosis.  Today, leukemia has cure rates above 90%.  The majority of my cohorts who had cystic fibrosis, sickle cell disease, congenital heart defects, extreme prematurity, were dead by the time I had my fifteenth birthday.  Today most of these kids will live into old age.

Finally, in 1900, one in ten babies died before their first birthday due to infections like diphtheria, tetanus, and, pertussis.  One in three were dead before age 5. Thanks to improved living conditions and vaccinations, these deaths are rare.  During my own 26 year career, the invention of  meningococcus, pneumococcus, and H. Flu vaccines have emptied pediatric wards that were once filled with kids with meningitis and blood infections.  Modern medicine has kept me whole, and countless of my own patients.

What if there was an apocalypse, and technology reverted back to the way things were in, say, 1800?  The best-selling book, Station Eleven, explores what life might be like if a flu epidemic wiped out the majority of the world’s population, and civilization collapsed.  The book jacket come-on asks, “What would you miss most?”  Coffee?  Electric lights at night?  Recorded music?  Air-conditioning?

If this sounds like science fiction, don’t get too comfortable in that thought.  In 1919 the Spanish Flu epidemic was unimaginably huge.  One in four people on the planet got sick.  Millions and millions died.  In some towns, so many were sick that there weren’t enough able-bodied to bury the dead.  Today, when things go bad with water supplies after hurricanes in parts of the world, there are still cholera and typhoid epidemics.  One bad virus could turn the whole world into post-Katrina New Orleans, with few left to keep the lights on, bury the dead, and maintain order.

The movie Contagion, with an all-star cast including Gwyneth Paltrow, Laurence Fishburne, and Matt Damon, tells a more likely scenario.  In this film, the flu epidemic wipes out a lot of people and whole cities are quarantined, with resulting movie mayhem.  However, the CDC and government keep a lid on things while struggling to isolate the virus and develop a vaccine.

So this Thanksgiving, be thankful for the good things modern medicine has given us.  Like we discussed above, medical advances have kept so many more children alive than a hundred years ago- kids with infections, cancers, sickle cell disease, cystic fibrosis, and extreme prematurity.  Don’t let thanksgiving become complacency either. Though we rarely see kids with diseases we vaccinate against- meningitis, pertussis, polio- doesn’t mean they’re not out there, waiting.  Make sure your kids have their vaccines.

When I worked in the Philippines in 1998, where many don’t have the luxury of vaccination, I saw two kids die of tetanus.  One was an un-vaccinated teenager from a rural village.  He had stepped on a sewing needle, which inoculated him through his foot.  He died a slow death by asphyxiation, as his chest wall muscles spasmed and wouldn’t allow him to breath.

Be thankful for vaccination! 

Is There A Doctor In The House?

This week’s guest columnist is Dr. Meighan Anderson, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

She’s 10 years old.  She has asthma and eczema, but hasn’t seen her regular doctor in a year- her pediatrician retired and mom hasn’t found a new doctor yet- life’s so busy!  Yet the girl has had several asthma flares requiring Emergency Department visits. The itching from her eczema is also making life miserable, with sleepless nights and scaly skin.  Visits to walk-in clinics have yielded treatments that haven’t worked.

Many kids don’t visit their regular doctor enough.  When they get sick, Urgent Care clinics are so convenient.  Sometimes the family’s moved and not found a new doctor locally.  Sometimes their doctor has retired, or doesn’t take the family’s new insurance.  We also hear a lot of “he’s never sick, he hasn’t needed a doctor,” in the ER.

Having your own doctor is more important than many realize, especially for kids with chronic conditons like our 10 year-old asthmatic.  For kids with these issues, only their doctor has reliable records of what has already been tried, what worked and what hasn’t.  Office-based doctors are better trained and more experienced with these conditions too, rather than Urgent Care or ER providers, whose focus is acute illness.    Finally, office doctors are where to go for vaccinations, school physicals, and specialist referrals.

The first step to find a doctor is your insurance.  If your child has medicaid, only certain practices accept that, though most pediatricians take some medicaid patients.  If you have private insurance, that company will provide a list of accepting doctors.  Office location is important too- shorter trips from your home are helpful with busy lives.  Then you need to decide what kind of doctor to pick.  If your child is newborn through teenage years, a board-certified pediatrician is best.  If your kid is a late teen, soon to be 18 years-old, a Family Practice or Internal Medicine doctor is better, since they can take care of him into his adult years.  They take care of parents too!

“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul.  Although the two cannot be separated.” -Plato

Though Plato wrote this over 2000 years ago, it’s still relevant.  Above we discussed finding your child a doctor- insurance accepted, location, and specialty (Pediatrics, Family Practice, Internal Medicine).  But is the physician right for your child’s body and soul?  And your soul too?

Cultivating the doctor-patient relationship is important to successful care.  One of the  determinants in this is a practice style called “shared decision making.”  This is where you and a doctor negotiate what is possible for care, rather than the doctor dictating what you should do, and you being expected to follow blindly.

What does shared decision making look like?  In some cases, there isn’t much sharing.  Technical issues are decided by the expert- the doctor.  For example, your child has a sore throat.  It could be a virus and resolve in a few days, or strep throat, requiring an antibiotic.  A strep test is done, it’s negative, and the doctor doesn’t prescribe an antibiotic, because it won’t help and may have side effects.

But what if your child always has a sore throat and it seems allergic?  With chronic illness like allergy, where lifestyle affects your kid’s illness, shared decision making is a must.  Should you go to an allergist, or would this be too much trouble, or does the thought of skin pin-prick allergy testing freak you both out?  Should you try some anti-allergy medication first?  Which one- inhaled, sprayed in the nose, or swallowed liquid, or a pill?  Which will your kid tolerate, and which is most effective?  Can you afford to tear up your carpet and put in hardwood floors for better dust control, and what about the smokers in the house?  Will they quit, can they quit?

All these questions should be explored with your doctor.  What is doable, what is best for your child, what can you and your kid tolerate, to optimize your child’s care?  Together you all decide on realistic goals and expectations.  In the old days, the doctor was always the boss.  These days, to deliver the most effective care, sometimes she’s boss, sometimes you are, often you’re co-captains of the team 

Scary Times

When I was a kid, instead of handing out store-bought candy to trick-or-treaters, my mom made halloween cookies, iced to look like jack-o-lanterns, with raisins for eyes and a grin.  The neighborhood kids loved them- “Mrs. Hamilton’s cookies!” they’d yell.  I could eat a dozen myself (as if she’d let me). The cookies had to be eaten right away.  Otherwise they’d get smashed by other goodies in the treat bag. Then successive generations of kids, who didn’t know mom and my family as well, became leery of cookies made by strangers.  By my teen years, mom had switched to packaged candy.

Halloween fun has been undermined by fear; not the exciting fear of ghosts and skeletons, but unnerving fear of poisoned treats, or with needles inserted.  Parents are afraid to let kids out into a neighborhood where unsavory strangers may lurk.  A generation ago trick-or-treaters flooded the streets.  These days, not so much.

Many halloween fears are unfounded.  Reports of candy tampering are quite rare.  In previous years some hospitals offered to x-ray candy.  However, no hospital ever reported finding metal in treats.  Given the hassle of families going to the hospital, radiology departments tied up with this extra service, and the low yield of found objects, no one bothers anymore.

The damage to neighborhood trick-or-treating volumes has been done.  But in response to these fears, some good things have happened.  Parents accompany trick-or-treaters more.  Some churches, schools, and families hold halloween parties, where kids’ safety is assured.  My church has a trunk-or-treat party, where parishioners scatter their cars about the parking lot, and kids go from trunk to trunk to gather goodies.  Keeping a closer watch on kids these ways, knowing what goes into their bags, isn’t a bad thing at all.

But what about those elementary school kids, too old to want to be watched, yearning to be out with their friends, away from hovering parents?  Young enough to still love dressing up and collecting free candy- what about their trick or treat?

After my kids got home from trick-or-treating, they’d shout “Candy Market open!”  The three of them would sit in a circle, still in costume, empty their bags onto the floor, and begin bartering.  My oldest daughter didn’t like chocolate, and her younger brother and sister did.  So the horse-trading would begin- so many skittles for so many m&ms, does a Laffy-Taffy equal a Butterfinger, etc.

Halloween is supposed to be fun. Choosing and making costumes weeks in advance, the anticipation of halloween night, is part of the joy.  Then the night itself: roaming the neighborhood at night with friends.  Parents often enjoy halloween too, delighting kids with hand-outs, chatting with neighbors, maybe dressing up and having their own parties.  And of course for the kids, the big bonus: a bagful of free candy.

We discussed the perceived hazards of Halloween above- candy poisoned or spiked with sharp objects, and creeps lurking in the dark.  Though these dangers are actually rare, trick-or-treating has taken a hit.  It’s still safe to send your kids out into the neighborhood, but be aware of the real hazards.  The most important concern is getting hit by a car.  Kids are hard for drivers to see at night.  They’re small and often wear dark costumes.  And excited children run in and out of the street as they go from porch to porch.

Thus kids should travel in packs, to make them easier for drivers to see as well as having safety in numbers.  Costumes should have visibility aids- reflective tape or shiny parts (metallic stars on wizard costumes), and kids can carry flashlights (or light-sabers).  Another hazard is not of candy that’s been tampered with, but stomachaches from wolfing it all down in one go.  Parents should encourage their kids to ration their goodies.  It’s more fun, and better for them, to make the treats last for weeks, instead of just one night.

The true fix for halloween fears are having better neighborhoods for trick-or-treating.  Get to know your neighbors.  Have a pre-halloween neighborhood meet-and-greet, to plan for a safe trick-or-treat, and make halloween a block party.  Talk to city hall about blocking the streets, or having signs and monitors to slow traffic.  Welcome kids visiting from neighborhoods where it’s not so safe.  Finally, inspect your kids’ treats when they get home, if only to allay your worries.  Then, let the Candy Market begin!

When Ankles Go Bad

This week’s guest columnist is Dr. Danielle Fuselier, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

It’s the time of the year for leaves to change, pumpkin lattes to be served, and fall sports- and ankle injuries???  Yes! With sports comes consequences of inadequate summer conditioning, over-aggressive drills when the season starts, and new cleats with their fresh, turf-catching studs.  Ankle sprains are one of the most common injuries we see in the Pediatric Emergency Department, and not just in athletes.  With kids getting fatter and exercising thumbs more than legs, more non-athlete ankles are giving out too.

What are ankle sprains?  Ankle and foot bones are bound together with tough, fibrous bands called ligaments.  Sprain is when those bands get jerked so hard they begin to tear.  The “inversion” injury is most common, when the foot is wrenched inward so the victim ends up standing on the outside of the foot.  Then he goes “yowch” and hops around.

Ligament injuries come in three grades: Grade 1 is simple pulls, where ligaments are only bruised by the force.  Grade 2 is partial tears; Grade 3 is full tears, with complete joint instability.  Ankle bones can break too, with strong enough force, like when stepping in a hole while running, or landing wrong when jumping in basketball.  Also kids’ ligaments are often stronger than the bones they’re anchored on, making fractures even more possible.

When do children need x-rays?  If the ankle hurts when squeezed where fractures are most likely, or if the child cannot walk on it at all, then x-rays are necessary to look for breaks.  The degree of swelling doesn’t help decide.  Swelling happens with both ligament and bone injuries, so a more swollen ankle doesn’t mean fracture.

The best treatment for ankle injuries is, of course, prevention.  Athletes should have careful, supervised stretching before and after work-outs.  Conditioning should increase gradually, avoiding over-exertion, when fatigued muscles that support joints give out.  Kids with frequent ankle injuries should have velcro or lace-up braces, or be taped before practice and games.

Your 10 year-old Tim Tebow was throwing a pass when tackled.  Unable to walk on his ankle, he’s brought to us.  After the x-ray, parents often ask, “is it broken, or fractured?”  This question makes us pause and scratch our heads, since in medical terminology, fracture IS a broken bone.  We’re not sure what people think the difference might be.

If a bone’s broken, the child gets a cast, crutches, and a referral to Orthopedics, who  make sure the bone heals properly.  Occasionally, ankle fractures are so bad they need surgery.  Either way, that’s it for the season- it takes a month or two for fractures to heal.  We’ll write the child an excuse for PE and sports until the orthopedic doctor clears her.

If the ankle is sprained, the injured ligaments usually heal in a week or so.  Caring for sprains is actually more work for the parents and patient than fractures, because there’s more things for them to do, remembered by the acronym RICE.

R is for Rest.  Parents need to limit kid’s walking for the first days.  Occasionally rest means crutches, so the child can get around school and home without putting weight on the ankle.  Don’t leave the doctor’s without that PE excuse!  I is for Ice.  Wrap a bag of ice or a cold pack on the swollen part to decrease pain and swelling.

C is for Compression, with an ACE bandage or velcro brace, wrapped from toes to lower leg.  This minimizes swelling and gives ankles some support. E is for Elevation: sprained ankles swell and throb, so propping them up on pillows or footstools will decrease swelling and throbbing with gravity assistance. 

Finally, don’t forget pain medicine (maybe the acronym should include an M, like MR. ICE instead of RICE).  Sprains and fractures hurt, so don’t skimp on ibuprofen (AKA Motrin or Advil), which is better than acetaminophen (Tylenol).  Both ease pain, but ibuprofen also decreases inflammation in the injury, which eases swelling too.

Like we said above, prevention is the best treatment.  Get your kids off the couch and running around outside, so that they self-condition those legs.  Feed them less junk  they don’t get overweight and strain those ankles.  And don’t push the Tim Tebow thing- kids should condition in their own good time. 

Wheezing Through The Ages

Asthma has been with us for millenia.  The ancient Greek physician Hippocrates, inventor of the Hippocratic Oath, first used the term (from the Greek aazein, “to pant”). The Greeks had treatments- adding ephedra (an epinephrine-like drug) to red wine, and smoking stramonium, an atropine analog.  They weren’t entirely on the ball though, thinking that adding owl’s blood to the wine helped too.

Asthma has become more common in children in recent decades.  This is because of changes in kids’ environments, and because of the Hygiene Theory.  Hygiene Theory posits that since children’s lives have become cleaner, more infection-free, their immune systems attack their own tissues, having nothing else to do.  Also, it seems that when kids had intestinal worms from contaminated food, the worms put out substances that kept the immune system quiet.  This protected the worms from immunity, while lessening immune aggravation of the kid’s lung tissue too.  Now, no one’s advocating giving children tapeworms to lessen their asthma.  Yet.

The environmental issues are more clear.  Modern housing emphasizes energy saving with better sealed doors and windows.  This means less fresh air circulates into the house through those leaky portals.  Thus kids breathe more house dust, which irritates lungs.  People also open their windows less and make air conditioners and heating systems, which accumulate and circulate dust and other irritants, do more work.  Kids also spend more time indoors than out with TVs, computers, games, and phones; thus breathing that dusty indoor air more.  Less exercise clearly worsens asthma- kids need exercise to prevent it.  This may seem counter-intuitive, since exercise can sometimes trigger or worsen individual asthma attacks.  However, in the long run, more active children have fewer attacks.

These are clues to prevent asthma in children, and prevention is the mainstay of treatment.  Once kids start having asthma it’s a lot of trouble- they visit Emergency Departments for attacks, and sometimes get hospitalized.  They miss school, and parents miss work.  Occasionally kids end up on life support in the Pediatric Intensive Care Unit, or die.  Makes tapeworms sound better and better.

Continuing our asthma history lesson from above, asthma theory took a weird turn in the early 20th century, with Sigmund Freud’s theories of the subconscious mind.  Since anxiety attacks were known to trigger asthma, some over-enthusiastic Freudians believed that all asthma was psychological; even when patients had audible wheezing, that high-pitched whistle from deep down the throat. They thought that whistling was generated subconsciously as a tiny scream for help from the patient’s buried anxiety. 

Fortunately, in the 1940s and ’50s, physiologic understanding of asthma prevailed.  That understanding holds today, that asthma comes from two glitches in the airway.  First, the muscles that control airway diameter overreact to noxious stimuli like dust, allergens, and viruses.  When those muscles contract, they narrow airways to keep out the irritants. But doing that keeps out the air too.  Second, after too much stimulation, the airways become inflamed, causing swelling into the passage, and excess mucus production.  With airways narrowed by muscle contraction and swelling, and clogged with mucus, no wonder it’s hard to breathe.

Asthma treatment is two-pronged.  First, we use medicines inhaled as a mist, like albuterol.  Albuterol breathed into the airways relaxes the muscles lining them, opening the passages up.  Second, we use steroids, which decrease inflammation and mucus production.  Steroids have minimal side effects.  Sometimes when people hear steroids they think “anabolic steroids,” the kind that some athletes take to build muscle mass.  These aren’t the kind we use for asthma- kids aren’t going to bulk up, grow beards, and have rage attacks.

The most important treatment for asthma is prevention.  Like we mentioned above, regular exercise prevents asthma.  As kids exercise less these days, asthma has become more common.  Since individual asthma attacks can be worsened by exercise, some parents restrict their asthmatic kids’ activity.  However, over the course of childhood, regular exercise actually lessens asthma.  Also, like we said above, kids should get outdoors more to breathe fresh air, instead of dust-laden indoor air. 

Children can take medicines to prevent asthma attacks as well, particularly for air-borne allergen sensitivities, like to molds and pollens. Those kids can play outdoors too.  Talk to your doctor about treatment plans, prevention medication, and exercise plans for your child.  Asthma’s another good excuse to get your kids away from their screens and into the real world.