What The Heck Is Measles Anyway?

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

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

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

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

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

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

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

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

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

 

Is That Measles???

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

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

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

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

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

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

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

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

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

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

Ear Pain in Merry Olde England

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

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

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

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

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

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

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

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

 

 

 

Oh no! I think I broke my kid’s arm!

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

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

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

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

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

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

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

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

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

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

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

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

 

 

 

 

 

 

Call Poison Control! 1-800-222-1222

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

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

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

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

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

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

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

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

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

Baby Fall Go Boom

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

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

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

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

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

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

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

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

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

My Parents Versus My Dentist

I will always remember my childhood dentist, Dr. Tarentino.  I will especially remember his eyes, boring down into my mouth as intensely as his drill.  Though my parents were smart people with advanced degrees in Theology, they could be remarkably naive about personal health care.  As a toddler I loved to walk around with a bottle in my mouth, and they let me. Since milk was expensive and filling, they substituted Kool-aid for my habit.  Thus my memories of Dr. Tarentino, his eyes, and the scream of the drill.

We non-dentist doctors see lots of tooth problems in the Emergency Department.  There are too many kids out there with bad dental hygiene, which leads to cavities, which leads to tooth pain and infection.  Yet only a few minutes per day of tooth care prevents such misery.  First, supervise your kid’s brushing.  Many parents tell their kids to go brush their teeth, and minutes later the child reports- job done!  But how good a job?  When kids are left alone to brush, they often just do a couple of strokes on a couple of teeth before moving on.  From an early age, be there to watch your kids brush every time, insuring that they get all tooth surfaces, brushing gently instead of scrubbing like they were taking off old paint.

Start tooth care at an early age.  After all, your kids get teeth in the first year of life.  Get them used to brushing as soon as they have teeth, again, gently!  You don’t want it to hurt and make them hate brushing.  If it is a habit when they are so young, it gets ingrained as a habit for the rest of their lives.  Bring them to the dentist early as well- as young as age two. Then they learn that the dentist can be fun and every dental visit won’t mean pain.

Unlike my parents, avoid that sugary diet.  We all have bacteria in our mouths, no matter how much brushing and flossing. Dental hygiene keeps down that bacteria that hurts our teeth.  Sugars in our diet feed that bacteria, which turn that sugar into acids which burn into our teeth.  Those burn holes are cavities.

It always seems that the tooth pain cases come in at night.  The lights are down, the house is finally quiet, there are no more distractions for a kid.  WIth the quiet of bedtime comes the realization that something has been hurting- ouch, its my tooth!  The child cries and the mom finally has time to notice that the side of the child’s face is swollen. They rush into the Emergency Department with their tooth infection.

However, dental infections are not sudden emergencies.  By their very nature, they are slow-growing illnesses.  It starts with a cavity.  Over weeks and months, the mouth bacteria that started the cavity chew deeper into the tooth.  The cavity finally gets deep enough to infect the gums.  The infection causes inflammation, swelling, and terrible pain in one of the most sensitive parts of the body.

Actually, dental infections don’t start with a cavity.  They start with bad mouth care. As we mentioned above, unsupervised brushing, along with not flossing and too much sugar, allow mouth bacteria to get out of hand and begin to eat into the child’s tooth surfaces. Tooth infections also start with children not getting enough flouride in their diet. The American Academy of Pediatric Dentistry is very clear on the science- communities with flouride in their water save lots of money and anguish not having to care for so many rotten, painful teeth.  In places where the water is not flouridated (Louisiana), the AADP recommends flouride supplements for children.  In other words, Louisiana children should take flouride just like they would take any other vitamin.

Back to my parents, who let me toddle about with a kool-aid bottle in my mouth and thus support my childhood dentist’s practice .  My parents were wonderful people who did more good in the world than I can ever hope to approach.  They raised three happy successful boys. Just don’t follow their lead in their third son’s dental hygiene.

 

 

 

The Ugly Truth About the Runs

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

Emma comes home from school and tells her mom that her belly hurts and she doesn’t feel good.  Mom tells here to lie down and rest and she will feel better.  About 30 minutes later Emma yells for mommy!  When mom walks in she finds vomit in the bed, all over the pillow and sheets.  Mom grabs Emma and runs to the bathroom where Emma starts to vomit again, now with diarrhea.  After a day or two mom brings Emma to the Emergency Department because Emma has no energy and cannot eat or drink.  Emma is diagnosed with Gastroenteritis.

Gastroenteritis is commonly known as “the stomach bug,” “stomach virus,” or even more simply “virus.”  Sometimes people use “rotavirus” to mean all vomiting and diarrhea viruses, though rotavirus is just one of many viruses that cause these symptoms.  Viruses are microscopic chemical machines that invade the body.  They enter the body by the mouth through contaminated food or when the victim puts a contaminated hand in the mouth.  The viruses burrow into the body’s cells, take the cells over, and start the fun.

The signs and symptoms of gastroenteritis start about 1 to 3 days after the virus enters the body.  It takes that long, what we call the “incubation period,” for the virus to spread and take over enough of your stomach and intestines to start the symptoms.  Thus if Emma touched an infected doorknob at school on Thursday and a few minutes later played with her lip, she could expect to start acting sick by Friday or Saturday.

What can Emma then expect?  Watery diarrhea, vomiting and nausea, fever, headache, and fatigue.  Usually kids will vomit for the first half-day, then have diarrhea for a few days more.  However, it can be normal for symptoms to last 7 to 10 days!  Parents should seek help when the child has lots of pain, bloody diarrhea, or is dehydrated.  Parents should watch for worsening pain, increasing sleepiness, no urine for 12 hours, dry mouth, sunken eyes, no tears when crying.

Sometimes when we tell a parent a diagnosis like Gastroenteritis, the parent gives us a skeptical look.  How can we know just by looking- shouldn’t we run some tests?  Well, the vast majority of illnesses are diagnosed from the medical “history.”  The history is simply the story of your child’s illness.  When did he start getting sick?  How much did he vomit and have diarrhea?  Was he around other sick kids or family?  How is he acting now?  Is he making urine?  Then the doctor uses the physical exam to confirm what she thinks is the diagnosis, and further assess for signs of dehydration or more serious illness- dried out mouth, decreased circulation, tender stomach, patient responsiveness.  Tests are only necessary if the doctor is concerned about serious dehydration or a more serious illness that is masquerading as gastroenteritis, like appendicitis.

How is gastroenteritis treated?  The most important management is preventing dehydration.  Most gastroenteritis is mild and can be treated at home: pedialyte and breast feeding for infants, dilute juices or sports drinks like Gatorade or Powerade (Gatorade G2 is particularly good) for older kids.  If your child cannot stop vomiting or has worsening dehydration, she might need IV fluids.

Here are some home instructions for parents:  After the child stops vomiting, feed with only clear fluids as above for six to eight hours.  This lets the stomach settle before trying solid foods.  Ease back into eating after about 6 to 8 hours of the fluids; the stomach may not be ready for food or milk before then.  Avoid fatty or seasoned foods and let your child get plenty of rest.  The first two days of vomiting and diarrhea are not good times to rush your child back to school.

Most importantly, teach your kids to prevent getting Gastroenteritis.  Teach them to wash their hands after using the bathroom and before eating.  Teach them not to put their hands in their mouth so much. When they do get sick, keep them home for to rest from school. Loving care at home is the best medicine.

 

 

 

The Dark Side of Fluffy and Rover

It really wasn’t the boy’s fault.  He was playing in his yard when a stray dog wandered over. The dog jumped up and bit the boy on the side of his face. The dog fled and Animal Control couldn’t find it.  Rabies is in the area and there was no way to know if the dog was rabid without capturing and quarantining it. So we had to assume the worst, and start the boy on the rabies vaccines.  The vaccines aren’t so bad- no worse than regular vaccines.  But the rabies immunoglobin, a medicine to prevent the rabies virus spread, must be injected right into the wound.  It was not a good night for the boy or me.

Dog and cat bites make up plenty of pediatric ED visits.  Usually it’s a neighbor’s animal or the family pet at fault.  Occasionally it is a stray.  When a child gets bitten, there are lots of medical problems to address.  The most obvious worry is the wound itself.  Kids explore with their faces and hands and want to touch and look closely at any animal. If they get too close and the animal feels threatened, it protects itself by lashing out with tooth and claw. The resulting face wounds sometimes leave scars that even plastic surgery can’t hide. Then there is the worry about infection.

There are three infections that dogs and cats can transmit.  The biggest worry is rabies. Rabies is a virus that wild animals get by biting each other.  Rabies attacks the brain, makes the animal go mad and bite other animals (and thus pass the virus on), and then the animal dies.  It is very rare for any animal, or human, to survive rabies once the infection takes.  The next concerning infection is Pasteurella, a bacteria for which we give antibiotics.  The only face laceration I remember getting infected was from a dog bite, though the child was on antibiotics.  The third infection is Tetanus.  This is another good reason to be sure your kids are vaccinated because like rabies, tetanus often kills.

The newspapers recently ran a story from Oregon about a 22 pound cat named Lux who attacked his family.  The seven month old baby pulled Lux’s tail, so Lux swiped the baby in the forehead with his claw.  Then he got so aggressive that he trapped the parents in a bedroom until police arrived.  Even more concerning, the family is keeping the cat, getting it “therapy.”  Now, cats are carnivores, meat-eaters who are hard-wired to hunt, kill, and eat.  Some are nicer and more family friendly than others, but I doubt that any therapy will help Lux and a baby get along.

My point is not to give cats a bad rap as pets, but to illustrate safety issues.  The first thing is to not have a pet with a toddler.  Toddlers are explorers.  When they explore things they touch them, peer at them, and grab and pull on them.  Dogs and cats are often patient with such behavior, but not always. You can’t know when the ancient purpose buried in their DNA (defend, hunt, kill, eat) will come out with such treatment.  Wait until your kids are school age before getting a dog or cat.

Another safety concern is fencing for dogs- to keep them in, or out.  Fences keep your dogs and kids in and away from the neighbors. They also keep other neighbor’s dogs or strays out.  Also, pick a dog breed that is less aggressive.  Terriers, pit bulls, chows, and breeds like them are more aggressive and more difficult to train.  Poodles and retrievers tend to be safer with kids.  Veterinarians can help you pick a breed and tell what behavior to look for in an individual dog.  Finally, teach your children how to treat pets and other animals. Pets are not play-things or wrestling partners.  They need to be played with in appropriate ways, and need to be trained to do the same with your kids.

Feel free to get a pet: dogs, cats, and humans have been great companions for thousands of years.  However, dogs and cats have been hunters for even longer- treat that knowledge, and them, with respect.

 

Ah Choo! My Child Always Has A Cold!

This week’s column is from Dr. Susila Shanmuganathan, a family practice resident at the University Hospital and Clinics here in Lafayette.  

Another runny nose?  Don’t they know this is an Emergency Department, and cold viruses are hardly an emergency?  When we finally interview mom though, her frustration comes through.  Her child has been sneezing, rubbing her eyes and face for weeks, and mom is fed up.  The kid coughs all night and none of the cold remedies have touched it.  Maybe its not just a virus that should have gone away weeks ago.

Does your little one always have the sniffles?  Is she constantly rubbing her eyes and wiping her nose?  Your child may have Allergic Rhinitis, also known as seasonal allergies or hay fever.

Allergic rhinitis is a common problem in infants and children.  The symptoms can vary, the most common being a clear runny nose, sneezing, and itchy red eyes.  Kids may have dark circles under their eyes (“allergic shiners”) or a crease across their nasal bridge caused by constantly wiping their noses upwards (the “allergic salute”).   Children may also have a cough that is worse at night.  These symptoms are often worse at certain times of the year when there are more pollens and other allergens in the air.  Some people have allergies to year-round, indoor allergens like dust, pets, and molds.

So what the heck is an “allergen?”  What is pollen exactly?  Allergens and pollen are tiny bits of plants or animals that are so small they cannot be seen.  Often they are so small and light that they float through the air.  When they get up some kids’ noses or in their eyes or in their lungs, the kids’ immune systems react against the allergens and try to flush them out. The body makes extra mucus and tears to wash them away.  The body also makes sneezing and coughing to blow the allergens out.

Allergies can be a real burden.  All that itching and sneezing and coughing- it really irritates. It’s harder to play, it’s harder to pay attention in school, it’s harder to sleep- life is a lot less fun!  So what can you do to control these symptoms?  First, there is no need to get frazzled.  There are some simple things you can try at home before visiting your doctor or allergist.  The easiest thing is to avoid exposure to allergens that seem to make your kid worse- pets, dusty areas, certain plants.  Look for weather reports with pollen counts. If the day’s pollen counts will be high, avoid outdoor activities.

For medicines, you can start with an over-the-counter antihistamine like loratidine (Claritin) or cetirizine (Zyrtec).  Though you can use these medications on an “as needed” basis, it may actually be nicer for your child to use them every day so you don’t end up chasing symptoms.  It’s best to start these medicines right before your child’s allergy season and use them every day throughout that season.  As stated before though, some kids have year-round allergies and need to be on medicine every day all year.

If your kid needs better medicine than those, see your doctor about nasal steroids such as Nasonex, Flonase, or Nasacort.  They are a little more trouble to use, but they work better than the antihistamine syrups.  If those don’t cut it, then it is time for allergy testing to better find out what allergens to avoid.  Your child may need more medicine, or allergy shots. Many parents worry that their child won’t tolerate getting an injection every week.  It’s a judgement call between the parent and the allergist: sometimes the shots are a whole lot better than living with constant itching and sneezing and sleep deprivation.

But remember, there are simple things you can do at home and symptoms to look for before you worry and head to your doctor or the ER.  Avoid the pet dander and pollen.  Try the first-line antihistamines.  Although our kids might love animals and the outdoors, sometimes it may take their breath away…Ah choo!