When Seizures Attack!

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

I saw my first seizure while at a family reunion.  I was eating with teenage cousins when one of them suddenly stopped eating and said “I feel kinda weird.”  Then her eyes rolled up to the back of her head, her arms began jerking, and she slid out her chair onto the floor. After a few seconds of shocked silence, we all began shouting at once, moving furniture away from her, and fumbling with phones to call 911.  Her body stopped shaking after a few minutes, and then a few minutes after that she opened her eyes.  “What’s going on?” she slurred, her head rolling around to see us all standing over her, “Whatchya all looking at?”

I didn’t know much about seizures then, but that was before medical school.  When the brain functions normally, it’s cells communicate with each other using tiny electrical impulses.  Our brain coordinate and controls these impulses to do things like think, talk, and walk.  During a seizure the impulses go haywire, firing randomly and excessively.  The patient goes unconscious, and muscles sometimes twitch from faulty nerve signals coming from the brain.

Seizures are scary, especially for parents of a seizing child.  The good news is that the vast majority of seizures are benign.  Patients typically recover from a seizure pretty quickly.  Kids breathe adequately during a seizure, though this can be hard to perceive with all the shaking and foaming at the mouth.  Kids don’t swallow their tongues- that’s a myth.  The only real danger from seizures is if the child’s alone in a bathtub or pool, or a teenager seizes while driving.

Epilepsy is a diagnosis where a child has regular seizures.  One common type is the Absence seizures, typically in elementary school-age kids.  These are super-brief seizures, just a few seconds, where the child appears to be just staring and day-dreaming, but is actually unconscious.  Then they come to before they have time to lose muscle control and fall out of their chairs.  Other kids have full-blown “tonic-clonic” seizures, like my cousin above.  Fortunately, anti-seizure medication controls most epilepsy.

Fast forward 10 years from that exciting family reunion.  I was on my first shift in the Pediatric Emergency Department at Lafayette General.  The paramedics brought in a teenager who had a seizure at school.  The vice-principal who came with her reported that she had suddenly closed her eyes tightly, and her arms began shaking.  The girl (we’ll call her Tina) remembered shaking, and classmates talking to her.  However, despite her best efforts, she couldn’t open her eyes or get words out.  The episode lasted about 2 minutes, and she felt fine immediately after.

This wasn’t Tina’s first seizure.  She had already seen a neurologist.  Her MRI showed normal brain structure, and her EEG showed normal brain electrical activity.  The neurologist diagnosed Psychogenic Non-Epileptic Seizure, or PNES.  Unlike epileptic seizures, with their haywire brain electricity we discussed above, these manifest from extreme psychological stress.  Patients often aren’t unconscious because their brain cells aren’t misfiring.  If they do go unconscious, it’s from passing out, not brain malfunction.

PNES starts with post-traumatic stress and developmental issues.  Post-traumatic stress stems from disturbing things like bad car accidents or abuse incidents.  These kids also have poor coping and communication skills. When faced with difficult memories or tense situations, their brains go into a kind of protective mode, walling off the unpleasant circumstances and directing the emotional intensity to physical symptoms like trembling and fainting.

PNES can be difficult to treat.  It requires combinations of therapy and medications like anti-depressants or mood-stabilizers. It also requires lots of patience from parents, therapists, and schools.  After all, these are teenagers!  With thorny problems!

A final word about the most common seizure in the Pediatric ER- febrile seizures.  These are brief seizures in infants and toddlers with fevers.  Like epileptic seizures, these are scary for parents, but benign for the kids.  Most toddlers have only one in their lives, and outgrow them by age 6.  Like epileptic seizures, kids breathe adequately during the seizure and their brains aren’t injured, and aren’t being “cooked” by the fever. The majority of fevers are from viral infections that pass in a few days on their own.

Vaping Is Cool, Until…

My nephew called at 9 pm- he had had a fever the night before, woke up drenched with sweat, couldn’t stop coughing, and then had slept all day.  He also felt crackling in his lungs when he breathed.  He couldn’t finish a sentence without coughing, and sounded weak.  I was out of town and couldn’t see him myself, so I said “Get to the Lafayette General Emergency Department.”  Later my colleague Nick texted me- it was pneumonia alright, and my nephew was being admitted for IV antibiotics and observation. One thing particularly worried Nick- my nephew had been vaping.

Vaping?  As far as I knew, the dangers of vaping were largely theoretical.  Sure vaping liquid contains nicotine, but lung injury?  Well, this August I learned that my nephew was on the front line of an emerging epidemic in teens and adults who vape. The victims develop coughing, shortness of breath, fever, vomiting, and chest pain.  One of the sneaky things about the illness is that though the patients look awful, their chest x-rays look normal. It takes a CT scan to show the extent of the lung damage.

Also sneaky- the perception that vaping is safe, that it’s just flavored water vapor. First, most vaping fluids contain nicotine, one of the most addictive substances known to science. Kids get hooked, and often transition to the next nicotine fix- cigarettes.  Data is emerging that vaping is a “gateway” to real smoking. Nicotine also harms brain development, which is still ongoing until age 25.  Users can have trouble with memory and learning.  Finally, vaping transmits lung irritants and cancer-causing chemicals.

My nephew’s episode was a wake-up call for me to now start talking to teens about vaping, and quitting, just like with cigarettes.  It’s also a wake-up call for parents to talk to their kids about its dangers.  And they should have his talk before the kids are eye-rolling teenagers, inured to their parents’ advice.  Children need to hear these messages while they’re still young and impressionable.  It’s certainly cheaper and easier than trying to quit later with drugs and therapy, and a lot better for them.

I love Penn and Teller, the magicians.  Their tricks are great, but their crass sense of humor really kills me. I once saw them on Broadway, where they did an illusion with cigarette smoke blowing out of a painting and wrapping itself in all kinds of artistic shapes.  As Penn lit up to start the trick, he turned to the audience and said, “Now kids, cigarettes are bad for you, so don’t start smoking….unless you want to look really cool.”

The joke is, of course, that all kids DO want to look cool, but smoking isn’t the way.  Unfortunately, society continues to view smoking as attractive. Hollywood film noirs with moody characters must have them light up a cigarette, their faces wreathed in smoke.  Even worse, in 1988, the tobacco manufacturer RJ Reynolds began the Joe Camel campaign, a cartoon camel that “coincidentally” appealed to children and teens.  Cigarette sales to minors shot up $470 million per year.  Internal documents revealed RJR’s VP of marketing saying the “young adult market…represents tomorrow’s cigarette business.”  Hook them on highly addictive nicotine, and they’re customers for life.

This insidious thinking now fuels the vaping trade.  As we discussed above, vaping is often perceived as harmless- it’s only flavored water vapor, right?  Wrong. Besides kid-friendly flavoring, vaping liquid contains nicotine.  It also contains other cancer-causing chemicals and lung irritants, leading to the current epidemic of Emergency Department visits of teens and young adults gasping for breath.

The latest sneak attack is the JUUL (pronounced “jewel”) E-cigarette.  Their website claims their “mission” is to “improve the lives of the world’s one billion smokers by eliminating cigarettes.”  In reality, one JUUL pod has as much nicotine as 20 cigarettes.  Also, its nicotine comes in a form that’s less harsh in the throat than other e-cigarettes, removing a last possible deterrent to vaping.  Add yummy flavors like mango and cool mint, and they’ve got a whole new generation hooked, laughing all the way to the bank.

Warn your kids not to be tools of this industry, using the guise of cool, caring, and safe to sell them an early death. Warn them before they’re teens, when they’re still young and impressionable.  Before the new Joe Camel tells them differently.

Curing Asthma, With A Fish?

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

My great-grandmother Regina Thomassie, born in 1897, lived in the small farming town of St. Amant, Louisiana.  Because doctors and medications were scarce, she used many home remedies.  While her hot toddies and thrush salves have stood the test of time, her asthma treatment has been, well, superseded.  She would first have the asthma patient inhale over steaming hot coffee and then sip it- fair enough.  But then she sent the patient out to catch a fish, then breathe into its mouth, to transfer the asthma to the fish.

Luckily for both humans and fish, our treatment of asthma has improved beyond trout and coffee.  Asthma is an over-reaction to things inhaled from the environment, like dust, viruses, smoke, cockroach droppings, and other allergens.  The muscles in the airways constrict to keep out the offending agents.  Unfortunately, too much constriction also keeps out the air!  After more irritation, the airways become inflamed; swelling and producing mucus to wash away the irritants.  This swelling and mucus production further clog air passage, and breathing becomes labored.

To prevent airway inflammation (and visits to the Emergency Department!), we have several tools. One is daily inhaled steroid to keep the inflammation and mucus down.  It’s important to use this medicine every day before your child is sick, even if they feel great.  If you begin the medicine when your child’s already coughing and wheezing, it’s not strong enough to fight inflammation, only to prevent it.  Another daily prevention medicine is montelukast (Singulair), which also inhibits inflammation.  Again, prevention means using this every day, before your child gets sick!

The best prevention is avoidance.  Dust is the most common airway irritant that triggers asthma, and is partly why asthma is so bad in winter.  When kids are trapped indoors in school or by bad weather, they breathe more indoor dust.  Dust is hard to avoid, requiring minimal carpeting, curtains, and bedding, which collect and hold dust; and lots of mopping. Cockroaches are also hard to avoid- it’s Louisiana after all!  So keep your exterminator busy.

Back to my great-grandmother Regina Thomassie from above, who treated asthmatics by having them transfer their asthma to a fish by breathing into it’s mouth.  During the  20th century when she practiced, more effective asthma treatments were developed. Injection of adrenaline, the hormone responsible for our fear reaction, proved effective in relaxing muscles in constricted airways, opening them up.  For eons humans have known the effects of adrenaline: when confronted by a sabre-toothed tiger, the human would develop a racing heartbeat, muscle tremors, and wide-open airways, to prepare for a foot race with its predator.  About when Regina was born, 1897, scientists isolated the compound, and by 1914 had demonstrated its usefulness in asthma.

Today’s mainstay of asthma treatment, albuterol, acts like adrenaline but with less agitation.  Albuterol relaxes muscles in airways that have constricted to keep out irritating agents like dust, smoke, and viruses; with less tremoring and racing pulse.  Adrenaline, a.k.a. epinephrine, lives on in other important treatments: injected for severe allergic reactions (the “epi” in your epipen), cardiac arrests, and severe asthma attacks.

Another mainstay of treatment, steroids, was developed in the 1940s.  Steroids decrease inflammation, like the airway swelling in asthma.  As discussed above, supersensitive lung tissue in asthmatics is easily irritated by dust, pollen, smoke, and viruses. Steroids soothe this irritation, decreasing swelling that narrows airways and occludes air passage.  Mythbuster: steroids don’t work faster when injected. “Cortisone shots” don’t take effect sooner than pills or liquids.  In the Emergency Department we give it to kids orally, unless they’re breathing so hard they can’t swallow. Then it’s given IV.

Of course the best asthma treatment is prevention; don’t get an attack!  Besides avoiding asthma triggers, it’s important to get flu vaccine every year.  Flu virus is particularly hard on asthmatics, is highly contagious, and the season is coming fast.  Get your asthmatic that vaccine!

Another important, often overlooked, prevention is exercise.  Getting kids outdoors and moving not only decreases dusty interior air exposure, it somehow makes lungs stronger.  Though it seems paradoxical, given that exercise sometimes triggers asthma, in the long run (get it?) activity makes kids less susceptible to attacks.

Avoid The Spots, And Worse

How epidemics happen: first, a vulnerable population. Then bring into that population a highly contagious infection.  Recently that’s measles.  Unvaccinated kids are often in clusters where not vaccinating is culturally popular- like Washington State and southern New York.  Then someone visits from another country with spotty vaccination, carrying measles.  It’s highly contagious- carriers cough in a room, and mucus particles stay in the air for 2 hours.  During that time, an unvaccinated kid enters, breathing in those particles.  A week or two later, she starts coughing, has a high fever, pops out in a spotty rash all over.  However, she’s already been shedding virus to other kids 4 days before breaking out herself!  How do you keep the lid on a virus like that?

Of course, vaccines.  When epidemics happen, the sheen is suddenly off having unvaccinated kids, and clinics cannot keep up with vaccine demand.  It’s hard for public health officers not to crow “I told you so!”  We don’t advocate vaccinations because it’s cool, and certainly not for secret payoffs from pharmaceutical companies; the companies couldn’t care less.  Vaccines are such a financial dog for them that in the 1980s, Congress had to intervene so they wouldn’t stop making the stuff.  They’d rather be making scads of money on Viagra and other drugs they advertise.  When’s the last time you saw ads for vaccines?

Non-vaccinating is frustrating for pediatricians because to us, who “live the data,” the benefits are so clear, the risks so minimal.  Throughout our careers, we read the studies, debate the statistical design, and see in practice how effective vaccines are.  When non-vaccinators say “I did my research,” they didn’t pull the data, do their own statistical analysis, and find study design wanting; they read some cranks on the internet.  Like climate scientists, we who know the actual numbers are reminded of Senator Daniel Patrick Moynahan’s words: “Everyone is entitled to his own opinions, but not his own facts.”

The consequences of this are life-and-death.  Doctors who counsel parents have been sued, even when warning parents on not vaccinating. If the child then contracts a fatal, vaccine-preventable illness, the parents argue in court, “But he didn’t tell us our child could die!”  Your child could die.

Once at a party a mom came up to me and whispered, “So what’s the real truth about vaccines?”  As if we kept quiet, I’d confess about the piles of money drug companies are paying us pediatricians to administer unnecessary vaccines.  It was a little exciting- for the first time in my life someone thought I was part of a conspiracy!  Cue the James Bond music!

Unfortunately for my income, the conspiracy theory about vaccines is a myth.  As we mentioned above, vaccines are the least favorite things for pharmaceutical companies to make. The profit margins are slim, the insurance burden is great, and they make lots more on the medications you see advertised on TV.  If they made so much money on vaccines, why aren’t they running ads for them?

And what about those corrupt researchers?  I’ve met many researchers, and can attest that few do it for the bucks.  They’re nerds and careerists who’d rather make associate professor than make money.  They live for clean data, elegant study designs, and the admiration of their colleagues when they publish a good paper.  They’re nice folks who do good science to save kids’ lives.

How can we get non-vaccinating parents to understand?  For years the American Academy of Pediatrics has advocated not kicking them out of practices.  The strategy is to see the kids, gain the parents’ trust, and teach them the importance of vaccination.  If the parents still don’t listen after some time, then the doctor can release the patient from their care, since the parent-doctor trust is broken.

A recent editorial in the AAP newsletter advocated a more aggressive approach.  The author evokes the great Indian leader Mohandas Gandhi, quoting him that we should “cling to the truth,” and in all ways stand up for it.  This means pushing for stricter laws on vaccination and school participation, and boycotting antivaccine businesses.  Picketing, striking, and even fasting are tools to show our seriousness.  This includes keeping non-vaccinated children from practices, schools, and extracurricular activities, where they could infect others.  We don’t want to punish these kids for their parents’s folly, but we don’t want other kids to catch life-threatening illnesses either!

Babies Going Nuts

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

Peanuts are great.  From Snickers candy bars to PB &J sandwiches, they’re tasty and healthy.  But as those with peanut allergies know, sometimes they cause a range of troubles, from itchy rashes to life threatening throat swelling and shock.  For years doctors have cautioned parents from administering peanut products to infants to avoid “sensitization,” where your immune system becomes responsive to an allergen.  However, there’s new evidence that maybe we’ve had it wrong.

I recently saw an 8 year-old girl in clinic who has a severe peanut allergy, and needed a refill of her Epipen.  The Epipen is a spring-loaded injector for when she might accidentally ingest a peanut product.  Then the nearest adult (parent, teacher, babysitter) would stick the pen on her thigh, push the button, and inject epinephrine, a fast-acting allergy antidote. During the visit I thought, “What a stress for her parents!”  Peanuts are in a vast array of food products.  The food labels spell this out, but who reads every label, particularly 8 year-olds?  A friend offers to share the wrong granola bar…

Food allergic reactions, including to peanuts, have been increasing in the population.  But now there’s a way to prevent such allergies for the coming generation.  In 2015 researchers concluded the LEAP Trial (“Learning Early About Peanut” allergy, not standardized testing!). LEAP examined infants ages 4-11 months at risk for allergy development (those with eczema or known food allergies), giving half the infants doses of peanut.  The other half got none.  Results: infants given peanut early had an 81% less risk of developing peanut allergy.  A follow-up study of these kids, LEAP-On, showed that the benefits persisted 12 months later.

Based on these studies, the American Academy of Allergy, Asthma, and Immunology recommends that infants 4 months and up be allowed to experience the wonders of this ground nut. If your infant is high-risk for food allergies however (having severe eczema or already known food allergic reaction), the Academy recommends your child be tested first, and have peanut product introduced in an allergist’s office under controlled conditions.

In the spirit of the LEAP trial, Dr. Hamilton conducted his own peanut experiment, on his feisty little poodle Milou.  Rest assured, no animals were harmed during this study.  In fact, the American Kennel Club states that peanut butter is good for dogs, as long as it doesn’t contain the artificial sweetner Xylitol.  He smeared peanut butter (non-chunky, to avoid choking hazard) on Milou’s palate, and proved his hypothesis: Milou licked and licked and licked his snout, for a recorded 47 seconds, amusing Dr. Hamilton no end.

Which raises the question: how to introduce peanut to an infant, as recommended by the LEAP Trial?  In the study, early peanut exposure in infants’ diets greatly reduces the chance of developing peanut allergy.  Certainly don’t give your baby whole peanuts, a choking risk.  Straight peanut butter isn’t safe either, as infants may choke on its sticky thickness as well.

Best is to dissolve a small amount of peanut butter, about 2 teaspoons, in cereal or formula.  Alternately, 2 teaspoons of peanut flour or powder can be mixed in yogurt or applesauce. Give the first spoonful, then wait several minutes to make sure baby doesn’t have a reaction.  No rash- chow on!  Continue feeding peanut product three times per week.

Again, like we said above, there’s babies who require a medical evaluation before starting peanut in their diet.  Kids at moderate or high risk for allergies need to see a doctor first. These are infants with moderate to severe eczema, or have already had allergic reactions to other foods.  Needless to say, don’t make peanuts the first food you introduce.  Start with the usual hypoallergenic foods, like fortified oat, barley, or multigrain cereals, followed by pureed fruits, vegetables, and grains.

High risk babies can certainly benefit from peanut introduction, but they should be tested to see that they don’t already have peanut allergy.  Then they should have it started under controlled conditions.  This means in an allergist’s office, with careful dosing, and allergy antidotes at hand.  So it may seem scary, but as the LEAP trial showed, early peanut exposure may prevent your child from developing a life-threatening allergy down the road.  Mr. George Washington Carver would be proud.

Packing For School Survival

When I was in third grade, one classmate, Jack, was incessantly bullied.  Jack was heavy-set and wore thick glasses.  Even worse, when he got teased, he shrieked at his harassers, rewarding them with a show disrupting the whole class.  The teacher seemed unequipped to deal with Jack and his teasers, wringing her hands every time Jack was set off.  This went on for weeks before Jack moved to a different school.  40 years ago episodes like this were rare, and few teachers knew what to do.

It’s time to get the kids ready for school- uniforms, backpacks, notebooks, etc.  It’s also time to get kids ready in their heads.  I was always excited for the new school year; September and fall weather still make me happy, but I loved school.  Many kids don’t, and dread another year of bullying, isolation, and drudgery.  The unluckiest kids are those starting a new school, becoming “the new kid” without friends.  Also unlucky are those with underlying anxiety, mood, or behavior issues.

When those psychologically vulnerable kids get bullied, particularly if they are new in school, sometimes these kids become suicidal.  They begin to think that anything is better than this, even death.  Suicide is on the rise, including Lafayette parish.  Our suicide rates are comparable with those of New Orleans and Baton Rouge.  This fall more unhappy children will come to our Emergency Department, their parents seeking help before it’s too late.

Thus it’s time to get your child back into counseling, before the offices also become flooded with the September rush of stressed kids.  Sometimes kids who are on anti-depressant or mood stabilizing medication stop them over the summer, because things have been stable.  First, you shouldn’t stop these medications without talking to your doctor.  Going “cold turkey” on them can be medically or psychologically dangerous.  Second, with school starting, now is the time to really be on them, before the perfect storm of depression, isolation, and bullying begins.  Finally, good mental health starts with getting enough sleep.  Time to walk back bedtimes until your kids are going to bed around 8 pm, for a 6 am wake-up.

Willie Geist, co-anchor of the Morning Joe show on MSNBC, discusses parenting in his book Good Talk Dad: The Birds And The Bees…And Other Conversations We Forgot To Have. Sometimes when his kids behaved badly, Willie would take them to the local New York Police precinct.  He’d made friends with the desk sergeants over the years, and enlisted them to scare his kids straight.  Playing their part, the officers would stare down at the child and in stereotypical Brooklyn accent, say something like “Hey, whaddya wanna act like that for anyways?”  This got them to behave, for a little while at least.

This episode highlights opposite poles of parenting styles.  One end theorizes that kids need respect for authority, and a little fear of adults helps them behave.  The other end is parents who feel that children need to learn behavior themselves, with the parent as co-raiser with the kid himself, rather than the all-knowing authority.  In this scenario, the parent is more friend than disciplinarian.  Willie Geist gets to have it both ways, delegating the fearsome adult role to his local cops, while remaining his kids’ friend.

Some think the increasing child depression and suicide that we discussed above is due to this more recent “child-centered” parenting, and a waning of the older, sterner method.  The nicer parent style lets kids make mistakes, and then maintains their self-esteem when they fail.  The kid learns from mistakes without the emotional trauma and depression that might ensue from failure (as the theory goes).  The older method holds that kids aren’t the emotional center of the universe, that there’s people more important than them (like parents and other adults), and the sooner they learn this the less disappointing life will be.  Some ego bruising is a good thing in this model, since recovering from failure leads to emotional resiliency.

I’m with the old model.  As a perennial little league disaster, I spent a lot of my childhood feeling like Charlie Brown, not measuring up.  I rarely got an award for achievement.  Perhaps this has given me emotional stability in a career where death and tragedy are constant worries, and occasional outcomes. If this parenting style doesn’t suit you, perhaps look to your local police precinct for help!

Choosing a Pain-Free Diet

I had my first “old coot” moment, when grampa yells at the TV when he sees something he doesn’t like.  For me, it was an ad for Miralax, a laxative.  It depicted a young cheerful woman in athetic clothes saying “I choose Miralax!” for her apparent sluggish bowel issues.  I shouted, “WHY NOT CHOOSE FRUITS AND VEGETABLES?”  Of course, she wasn’t listening.

Constipation can be quite painful for children.  We see them in the Pediatric Emergency Department with stories of doubling over, crying out with pain spasms.  They’re usually  better when they arrive, but it’s still disconcerting for parents.  Contipation actually is the most common diagnosis for abdominal pain visits to the Pediatric ED, ahead of stomach viruses and appendicitis.

Constipation is now a common problem in kids, given decreased fiber in their diets.  Fiber is plant carbohydrates that our digestive system can’t break down.  That fiber holds on to water and keeps poop soft and squishy as it passes through our guts.  When your body wants extra fluids, it tries to suck water out of your colon, drying out your stool.  Without enough fiber, your poo gets dried out, moves slower, gets harder, and harder to pass.  If lots of hard poo is moving too slow, painful cramps ensue.

Thus the fix to constipation: eat more fruits, vegetables, wheat breads, bran cereals, all having a high fiber content.  Miralax is simply an artificial fiber substitute- why not eat the healthier thing?  For kids, this means training them to like these foods.  The typical kid can take 10 tries of a food to learn to like it.  This takes persistence on the parent’s part, and is ruined if they get candy, cookies, chips, or fast food as an alternative.  Those foods are designed and manufactured to taste good on the first try, spoiling the child’s chances to learn to eat right.

Drinking more fluids and more physical activity also prevent constipation.  When kids sit around playing video games, their guts sit around too, not moving things through as much, and stool has more time to get dried out.  Active kids stimulate their intestines more, and have less constipation.

Once in residency I had a 10 year-old boy with constipation so severe he was admitted into the hospital.  He had terrible pain, and the parents thought he hadn’t stooled in weeks.  He also had anxiety issues so bad that he wouldn’t tolerate enemas or rectal exams, the quickest way to diagnosis and relieve constipation.  We thus decided on rectal exam under sedation, and do so in the xray suite so we could look at his insides, to rule out other causes for his pain and apparent blockage.

As soon as the sedation started, he relaxed his anal sphincter, and liquid stool poured out of him.  The diagnosis was instantly clear- he’d been purposefully holding in his poo, and it was liquid from all the laxatives he’d been given.  Unfortunately for the Radiology Department, he leaked so much that it ran all over the xray table, through every seam, dripping out the bottom.  They had to completely dismantle the table to clean it, and that room was out of commission for days.

Above we mentioned the diet reasons why kids get constipated- low fiber, inadequate fluid intake, and not enough activity.  But there’s sometimes psychological reasons as well.  Sometimes kids have a hard stool that hurts.  They decide, hey, I’m not doing THAT anymore!  Next time they get the urge, they withhold pooing until the urge passes.  After doing that enough, the urge gets too strong, and they have to go.  By that time the stool is so big and dried out that it’s another painful job, reinforcing their desire not to do it.  The constipation process becomes self-feeding.

Toddlers also can decide to withhold pooping during potty training.  Some kids just don’t like taking down their pants and sitting on that oddly-shaped thing we call a toilet.  It’s much easier to just go in their diaper.  Parents often try rewards, sometimes punishment, to encourage the kid to use the potty.  Willful toddlers may fight back the only way they can- with their anal sphincter.  Some psychologists say that any child can be potty-trained by age 2; others say wait until they show signs they’re ready, like watching their parents use it.  I think the latter, having seen many toddlers get constipated during potty training.

Under A Cajun Sun

Last Sunday, due to church in the morning, work in the evening, and grass long enough to hide large rodents, I mowed the lawn in the middle of the day.  I was ready- I did each part of the yard when shaded by trees, wore my sun helmet (a wide, airy hat like mail carriers wear), and took frequent cooling and hydrating breaks indoors.  Going in for one of those breaks, I took off my helmet, and yelped when I burned my hand on it’s top.  It was HOT!

Heat injuries in children are increasing.  As the planet warms, there’s lots more opportunities for kids and teens to get dangerously overheated.  Also, kids are getting more obese, and bigger bodies generate more heat and shed it less efficiently.  And while the invention of car seats has saved kids’ lives in car accidents, they also make kids less noticeable and more easily forgotten, to be left trapped in hot cars.

What happens when you’re in the heat?  First, you sweat, and water evaporating off your skin takes heat with it.  You also turn red as blood brings heat to your skin surface, to radiate it away.  However, these mechanisms don’t work so well on hot humid days.  If it’s too humid, sweat won’t evaporate, but just accumulate on your skin, keeping your heat with it.  And if it’s as hot out as it is inside your body, there’s nowhere for the excess heat to radiate out to.  Finally, it takes time to “acclimate” to heat, where your body learns to sweat and radiate more efficiently; the typical teenager needs 10-14 days of outdoor work to get used to it.

If you cannot shed heat well enough, your core temperature begins to rise, and organs begin to cook.  “Heat exhaustion” is when early signs of heat injury arise.  As your brain heats, you get headaches, become easily confused, and have nausea and vomiting.  You get dizzy and fatigued from dehydration.  Muscles begin to cramp.  Then comes “heat stroke,” where the victim begins to stagger when walking, is delirious, may have seizures, before lapsing into a coma.

I experienced heat exhaustion myself once on vacation. While in North Carolina, I went running with my marathon-competing brother Pat.  I was fit enough to keep up, but didn’t consider that I always exercise indoors.  I wasn’t acclimated to heat like Pat, who trains outdoors. Half way through, my bald head (say it isn’t so!) began to cook in the sun.  I started having a headache, worsening fatigue, muscle pain, and nausea.  We cut home and I spent several hours in the a/c pouring cold water on my head, walking around to evaporate sweat, and slugging down gallons of fluids.

As we mentioned above, two groups of kids get heat injury: exercising teens, and small kids in hot cars.  If children or adolescents show signs of heat exhaustion like I did, it’s time to treat.  Get the child out of the heat: indoors to a/c, or at least into shade.  Strip off hot clothes and equipment (i.e. football pads and helmets).  Cool skin with cold wet towels, or ice baths with a cold towel over the head.  Hydrate with cold fluids.  If kids show signs of heat stroke- staggering, confusion, vomiting- get them to the ER.

To prevent heat exhaustion in athletes, they need to acclimate.  This takes 10-14 days, and should be gradual and safe.  Work-outs should be early morning or late evening when it’s coolest.  Avoid hot equipment like in football, lacrosse, and baseball catching, for the first weeks of practice: shorts and t-shirts only, helmets and pads later.  Players need frequent hydration breaks in the shade, with coaches vigilant for signs of injury.

Car seats have saved thousands of lives.  However, now that kids aren’t sitting in laps, they’re easily forgotten.  Children are often quiet in car seats.  Then when arriving at the store or work, you forget to take them out.  It doesn’t take very long, or even a very hot day, for a trapped infant or toddler to die.  Even on mild spring days, the sun can heat car interiors dangerously, even with cracked windows.  So never leave kids in cars, no matter how quick you think you’ll be.  Set alarms or other reminders when buckling your child in, to remember to take them out after the drive.

Summer Terror

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

It started as a beautiful summer day- blue sky, hot grill, everyone visiting.  The kids were having a ball too, playing and swimming.  Then someone screamed- a toddler was at the bottom of the pool.  One party-goer jumped in to fetch the boy, another started CPR when he was lain on the concrete.  After some rescue breaths, the boy began to breathe, and was waking up when the ambulance arrived.  In the Emergency Department we admitted him for observation and he did fine, though the parents couldn’t quit crying.

“Submersion injury” comes in many severities.  Some kids fall in and are snatched out so quickly they barely know what happened.  Other kids are discovered too late and die.  In between are children who are resuscitated just in time, like our boy above, or survive but suffer some degree of brain injury.  How can these tragedies be avoided?

First, at pool parties you should designate an adult whose only job is to stay sober and monitor the kids.  It’s easy to become engrossed in conversation, help with the food, accept a cold beer, and lose track.  It doesn’t take long for toddlers to get out of sight either!  Losing track is even more problematic by lakes and rivers where the water is murky, and seeing lost children at the bottom and thus getting them out in time is pretty much impossible.  If they disappear, they’re gone.

The best way to avoid child drownings is not to have a pool.  Second best, the pool should be fenced on all 4 sides, meaning no patio door access.  The fence should be unclimbable, with a kid-proof lock.  If you’re by a large body of water, bring a playpen or other enclosure for the tots.  Knowing CPR is important to prevent drowning death after the patient has been submerged.  Most 12 year-olds are capable of learning and performing CPR.  Finally, although swimming lessons improve swimming ability, there’s no data that swimming lessons actually decrease the risk of drowning.  The American Academy of Pediatrics doesn’t recommend them for drowning prevention,

Kids can have wacky ideas about what’s hilarious, which parents DON’T AT ALL find amusing.  One day I thought it’d be funny to float face down in the pool and not respond when my mother called me.  She yelled and yelled, and when a family friend went to retrieve me. I picked my head up and smiled like nothing was wrong.  She was too freaked out to punish me, and only now as a parent do I realize how cruel that joke was.  I have since apologized.

Child drowning is often even more subtle than my ill-advised joke.  In particular, infants and toddlers, not knowing the danger when falling into a pool, sink to the bottom without making a sound.  They don’t thrash or scream.  Older kids too, when swimming and run out of gas, can slip under before they can call for help.  Therefore, as we said above, a sober adult dedicated to watching the kids helps prevent tragedy.  Also as we said above, the water in lakes, rivers, and oceans is murky, and hides drowning children.  You won’t see them after they sink, and thus they’ll be gone for good.

If a child is submerged, parents and bystanders need to be prepared to save a life.  One study showed that 14 out of 18 victims resuscitated by bystanders survived the event. This means knowing CPR.  It’s also clear that waiting for EMS to arrive without starting CPR seriously degrades the chance of survival.  If the child’s heart and breathing aren’t restarted by the time of arrival at the Emergency Department, the game is up.

So learn CPR.  Find a course near your at the American Heart Association website.  There’s almost weekly courses in the Lafayette area.  Every year around March the local AHA puts on the Be A Heart Starter event at the Cajundome, where over a thousand people learn CPR in one day, for free.  Children as young as 12 can learn the skills of CPR, using an AED (Automated External Defibrillator), and the Heimlich maneuver.

Drowning is preventable.  Through use of dedicated supervision, fences and other barriers, throwable floatation devices, and CPR, you may avoid losing a loved one this summer.

When Bears Attack!

As a Pediatric Emergency Physician, I’m calm in medical emergencies.  But good at one kind of emergency doesn’t translate to all emergencies.  One summer my family was hiking in Grand Tetons National Park.  The path ran along a lake, and nearby boaters began to shout, “There’s a bear coming towards you!”  We should have turned back, but someone nearby said, “My husband knows bears, he encounters them all the time.”  Since most bear encounters are fine, there were 10 of us in this group (bears are intimidated by numbers), and we DID want to see a wild bear, we strode on. I also had a can of Bear Repellant spray on my hip.

Soon enough, a brown bear came loping down the trail.  “Okay,” said our ‘bear guide,’ “everyone in the water.”  We stepped aside into the shallows of the lake, me ending up between the bear and everyone else, struggling to get the can off my belt.  Finally, it jerked free, I accidentally hit the trigger, and a 20 foot spray shot out towards Yogi.  He ambled on, unmindful of us.  “You weren’t supposed to spray unless he came at us,” chimed my daughter.  “I didn’t mean to,” I mumbled, embarrassed that I wasn’t more cool facing wild beasts.

Emergency situations are scary.  By definition, they’re life-threatening; we naturally get shaky when in danger.  Also, emergencies are rare, so we don’t get any practice knowing what to do. They can require unfamiliar skills, like CPR, or getting bear spray off your belt with trembling hands.

Everyone should have some idea how to handle common emergencies, particularly for their kids.  The three leading causes of death in kids are car crashes, firearm injuries, and drowning.  The best emergency preparedness is avoiding the injury in the first place: seatbelts and car seats, no cell phones while driving, swimming lessons, have a sober kid-watcher at pool parties, and locking up guns with ammunition locked up separately.  But if something bad does happen, having taken CPR and a first aid course really helps.  If kids are around grandparents or other elderly relatives, teach them how to dial 911, and be able to tell the dispatcher their address, and who they need (Fire, Police, or Ambulance).

On September 11, 2001, John Pelletier was the manager of Corporation Service Company’s office in the World Trade Center.  At 8:46 am he heard a rumble and saw flames from the tower next door.  Though the PA announced that their building was fine, he thought otherwise and ordered his office evacuated.  His 100-plus employees were on their way down the stairwell when the second plane struck his building.  If they’d stayed, they would have been trapped above the impact site, and perished.

Survivors of that day recall co-workers waiting for Emergency personnel to get them. In mass casualty situations, like hotel fires and airplane crashes, it takes time for Police and Fire to get to the scene and rescue people, and whoever waits for them may be too late.  For those who can run- run!

Above we discussed people’s unreadiness to respond to emergencies, because they happen so seldom.  No one gets to practice what to do.  So when you’re on a plane, do the practice. Read the safety pamphlet, watch the demo, identify your nearest exit, and rehearse in your mind: unbuckle, move to the exit, open the door.  When staying in hotels, find your nearest exit, go out it and down the stairs.  It’s good exercise, it’s fun to explore, and it may save your family’s lives.  Rehearsing prepares you to evacuate when necessary; those who wait do so at their peril.

We also already discussed being ready for personal emergencies.  Again, for kids this means preparing to avoid, or deal with, their most common threats- car crashes, firearms injuries, and drowning.  Buckle them  into their car seats or seatbelts.  Many times I see kids hurt in crashes who didn’t buckle up because they were “just going down the block.”  If the car is moving only 15 miles per hour and crashes, the child’s impact will be equal to a 15 foot high fall.

Firearm injuries often happen when exploring kids shoot themselves or playmates accidentally.  Lock up guns unloaded, with ammuniton locked up separately.  To prevent drowning, get kids swimming lessons, and swim where there’s life guards.  Finally, make sure kids know how to dial 911, tell the dispatcher who they need (Police, Fire, Ambulance), and their address.