‘Tis The Season Of The Barking Cough

It was a case of Physician Heal Thyself, or in this pediatrician’s case, Heal Thine Own. One midnight in Baltimore, I was on duty in the Pediatric ED when my wife called: our son awoke struggling to breathe, such that he couldn’t even talk.  Miles away, I could only help over the phone.  I gave the standard pediatrician’s advice for croup : take him outside, keep him upright.  His breathing subsided, everyone calmed down, and I called in a prescription to the 24 hour pharmacy.  Croup can be scary, yet easily managed.  This week’s guest columnist, Dr. Leslie Sizemore, a family practice resident at the University Hospital and Clinics here in Lafayette, explains:

In the fall physicians prepare for the typical fall and winter illnesses. Everyone thinks of influenza virus (“the flu”) but we also worry about RSV, mycoplasma (“walking pneumonia”), common cold, and the ever recognizable croup.

What is croup?  Croup starts like any cold- dry cough, runny nose, hoarseness, and sometimes fever.  The characteristic “barking cough” comes about 12-48 hours later. The barking lasts about 3 days but the rest of the cold may take around 7 days to resolve. Sometimes croup comes on suddenly at night, with a previously well child awakening with the barking cough and shortness of breath.

Croup is caused by inflammation at the top of your windpipe, called the trachea, just below your vocal cords.  When these pipes get inflamed, they swell and the breathing space gets narrower.  The smaller space compresses the air during cough, making that strange cough like a barking seal.  If the swelling worsens, the child gets stridor, which is a high pitched whistling sound when breathing in.  When the airway is narrow enough to make stridor, kids really starting struggling to breathe.

We see croup mostly in the fall, October being the peak month.  This coincides with a peak in parainfluenza virus, the most common cause of croup.  Croup is mostly seen in kids age 6 months to 3 years, and is unusual beyond age 6.  Viruses that cause croup are spread by close contact, just like any cold.

Most cases of croup are mild with occasional barking cough, hoarseness, and maybe a little stridor when crying.  It is the more severe cases we worry about, when the swelling of the windpipe gets worse.  Then the child has that whistling stridor sound even at rest. These children need to get seen immediately.  If the airway gets too narrow the child may no longer be able to breath.  The good news is that less than 5% of kids with croup get put in the hospital, so these bad cases are rare.

How do we treat this nasty illness?  Since it is caused by a virus, we all know that antibiotics won’t help, since they don’t kill viruses.  We treat the symptoms while the child’s immune system gets rid of the virus.  We treat the airway inflammation with anti-inflammatory medicine- steroids.  This can be done in two ways: the child can be given a one-time shot, or be given three days of a liquid steroid by mouth. We all know which one the kid would prefer!

If the child is having stridor, we give them a breathing treatment with a medicine called epinephrine.  The breathing treatment, or nebulizer, is that pipe commonly used by asthmatics that turns medicine into a mist that is inhaled.  But instead of the albuterol that kids with asthma need, we put in epinephrine.

The epinephrine relaxes the muscles that line the windpipe.  We give this medicine only in the Emergency Department, not at home.  This is because the child needs to be watched for several hours after the treatment.  Sometimes kids who get the epinephrine treatment have “rebound,” where the stridor comes back within an hour, sometimes coming back worse.

For the other croup symptoms, you treat them like any other cold.  Give Tylenol or ibuprofen for fever and throat soreness.  Run a vaporizer by the bed for moist air to lubricate those inflamed airways.  Prop up the child’s head to help minimize gagging on secretions.  Give plenty of fluids, and in a few days your child should get better and go on about his business, no longer imitating a barking seal.




Rockabye Baby. Safely.

We see a lot of little babies in the Emergency Department when they get their first colds. They cough and are congested, have noisy breathing, gag and hack on mucus, and sleep miserably.  When I talk to the parents about what to do, I ask, “So where does baby sleep?”  I usually get a sheepish look and a guilty smile and mom admits, “with me.”

Then I take the opportunity to talk about sleep safety and Sudden Infant Death Syndrome (SIDS).  I talk about how baby should sleep on his back and be in his own crib or bassinet, how sleeping in bed with others is a smothering risk.  The parent often says that when baby is sick, they bring him in bed with them so they can watch that he is okay. Yes, I go on, that seems to make sense, but is the exact wrong thing to do with a sick baby.

October is SIDS Awareness Month.  The CDC, the American Academy of Pediatrics, and many other experts are getting the word out- keep baby safe!  SIDS happens when babies suffocate while sleeping.  They smother when they are face down in thick bed clothes or regular mattresses.  They smother when in parents’ bed by getting their faces stuck up against heavily sleeping adults, or when they slip between the mattress and a wall. Napping with babies on couches is dangerous too- there is even less room for the adult and a clear space for babies’ faces, and the cushions are even softer and easier to smother in.  Babies can also smother in their own cribs if there is too much soft stuff with them- thick blankets, sheep skins, stuffed animals, pillows, or bumper pads.

When babies gets their faces into something too soft to breathe through, they suffocate. And babies under 6 months old cannot rescue themselves.  They do not have enough arm control to push away from a smothering situation.  They can’t do a push-up when face down on a thick mattress, blanket, or pillow.  They can’t roll over purposefully yet. Their brains and nervous systems aren’t mature enough for such maneuvers.

What about our mom from above who brings her congested baby into her bed to watch him? If she is watching baby, doesn’t that protect him from smothering?  Unfortunately not. Too often “watching baby” becomes “sleeping with baby.” You’ve seen the old comedy routine in movies or on TV, where the character must stay awake to watch something, only to be overcome by sleep, and then be caught snoozing.  Well, this happens in real life when mom and baby are warm and snug in bed together.

This is one of those cases where what seems better is shown by science to actually be worse.  Statistics show that sharing the bed with babies is much more dangerous, particularly when they are sick.  So how do you watch baby without sharing the bed? Pull that bassinet up next to your bed!  That way baby is safe in his own crib, and you can watch him from your bed.

Here are the rules then, to prevent SIDS.  As above, baby sleeps in her own bassinet or crib. Baby sleeps on her back, face up.  Baby sleeps on a firm mattress that is specifically designed for babies.  Baby should sleep dressed in a onesie, so no pajamas shirts can ride up over her face.  If you must put a blanket in bed with baby, make it a thin one that is tucked in at the bottom of the bed, again to minimize the chance of it riding up over baby’s face.  And definitely no pillows, stuffed animals, or bumper pads. These things make baby’s bed cute, but they also are suffocation risks.

Some moms try to compromise on baby position by putting their babies on positioners or “boppy” pillows.  Unfortunately, the safety of these has not been established.  So play it safe with baby, keep baby in his own bed with minimal padding.  Put baby to sleep on his back.  You and baby may be more restless on a given night, but in the long run you both will sleep much more soundly.  And safely.





Whaddya Mean “It’s Just A Virus?”

Some parents are disappointed with the diagnosis “virus” and not getting antibiotics. The only two times in my career a parent has outright yelled in my face were when I didn’t prescribe antibiotics. Today’s guest columnist, Dr. Seth Koster, explains viruses and when antibiotics are needed.  Dr. Koster is a resident at the University Hospital and Clinics here in Lafayette.

A lot of parents aren’t sure what to expect with their first child.  Did he just cough?  He sneezed twice, is that bad?  Do I need to go to the doctor?  Some things are common, yet seem complicated.  Let’s talk about some common conditions that are usually a virus that get better with a little TLC, and some “red flags,” things that need to be checked right away.

I think my kid is wheezing, should I bring her in?  Many parents hear baby make funny sounds, and call it wheezing.  Sometimes the sound they are trying to describe is the rattling of nose congestion.  True wheezing that we worry about is a whistling, gaspy tone in the lungs.  Either way you would be safe calling your doctor for a next day appointment if the wheezing doesn’t get better.  But if your child seems to be breathing fast or is having to pull in breaths, then he needs to be seen right away.

The vast majority of colds and coughs are viral.  Even with true wheezing, this is usually a virus and not pneumonia, and antibiotics won’t help.  Hundreds of viruses cause coughs and runny noses and wheezing: adenoviruses, rhinoviruses, enteroviruses, and many more.  Antibiotics do not kill viruses.  What kids with these need is supportive care, meaning fluids and fever and pain medicine.  If they get really sick with wheezing and shortness of breath, they may need IV fluids, breathing treatments, and observation in the hospital.

My child is pulling at his ears.  Does she need antibiotics?  Most of the time “ear pulling” is not from ear infection.  Kids pull on their ears when they are stuffy from congestion, if they have a headache, or some kids just play with their ears.  If the child is not fussy and doesn’t have fever, they don’t have to see the doctor.

What if she has fever-rush her to the Emergency Department?  No.  Ear infections may hurt, but that can be controlled with ibuprofen or acetaminophen (Tylenol) for fever and pain.  Over 70% of ear infections are viral and don’t need antibiotics.  That being said, if your child is having ear pain and fever, see your doctor.  After an exam the doctor can decide if antibiotics or pain drops will help.  But ear pain is rarely an emergency that can’t wait until tomorrow.

My child is vomiting, what to do?  Whether vomiting needs to be checked out by the doctor depends on how much and how long.  Some kids are brought in to the ER when they vomit only once or twice, or only for a few hours. However, that is not enough time for a child to get dehydrated, and most will quit vomiting soon after.

A simple “stomach virus” is usually not serious and will resolve in 1-3 days.  If the child vomits, wait an hour for his stomach to settle, then start clear liquids (gatorade, dilute juice, pedialyte), sipping slowly.  After the child has stopped vomiting for about 6 hours, you can start bland foods.  No fast food.  If your child has a fever, ibuprofen or acetaminophen will help with that. For most stomach illnesses antibiotics will not help, and even make vomiting and diarrhea worse.

So when does your child need to be seen?  If she is having worsening belly pain, that is worrisome.  If your child is vomiting all day or is vomiting blood or dark green, bring them in.  If your kid is having diarrhea for more than a week, that is one of the few times an antibiotic may help, since that may be a bacterial illness and not a virus.

Your child will get sick, there’s no avoiding it.  You usually don’t need antibiotics to treat them.  Most of the time your kid just needs rest, fluids, ibuprofen, and TLC.




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.