The Elixir Of Life- Blood!

We read about these things in our books, but when they happen for the first time it’s a surprise.  The parents rushed their 8 year-old girl into the Emergency Department.  She had been riding her bike, turned the handlebars too sharply, and tumbled off.  When she fell down the end of the handlebars speared her in the belly.  Soon she was pale and weak.

Examining her, the only mark was a quarter-sized bruise just above her belly button.  But she certainly was pale, and when I sat her up, she said “I can’t see,” like she was passing out.  Laying her flat, she suddenly could see again. She clearly was fainting from blood loss, and I had read about the “handlebar-spear” as a risk for internal injury.  While my nurse started the IV and slapped on the monitor leads, I ran and grabbed a second nurse, “I need blood and I need you to hang it!”  Next I called a surgeon, and my girl was off to the OR.

Lots of kids need blood.  Some are injured, like our girl above.  But also kids with cancer need blood products too.  The most common childhood cancer is leukemia, which affects bone marrow.  Bone marrow manufactures blood, and leukemia crowds out the good, blood-making cells with cancer cells, and those kids thus need transfusions.  Some chemotherapy drugs also impair marrow function.  Children (and adults) who have heart surgery also need lots of blood, to keep up with surgical losses and to feed the heart-lung bypass machine.  Occasionally premature babies need blood transfusions too.

Where does all that blood come from?  You!  Blood doesn’t come from a pharmaceutical factory, but from donors, in our area and across the nation.  Our local blood bank, United Blood Services keeps that vital stuff coming. UBS is a non-profit, charitable organization that provides this crucial resource.  There are UBS centers across the country, and one on Bertrand Drive here in Lafayette.  Their blood-mobiles fan out across Acadiana, going to charity events and churches, schools and universities, stores and work places, to collect blood from volunteers.

Giving blood is easy, except this one time for me: I was in medical school, and there was a blood drive in the cafeteria.  The night before, I had been on call in the hospital, too busy to eat or sleep.  I came to the drive pale, hungry, and exhausted, but ready to do my part.  Giving the blood wasn’t bad, but after they put the bandaid on, I saw that they had free cookies and juice.  I leaped out of my chair, bellied up to the table of goodies, and started chowing down.

Suddenly, I couldn’t see.  “Gee, that’s weird,” I thought.  Several blood drive staff noticed that I was more pale, had stopped chewing, and was staring off and starting to sway.  While I was still puzzling over my vision black-out, they helped me back into my chair before I fainted completely.

Soon my body began to send more blood to my brain and my vision returned.  I learned an important lesson on donating blood- get up slowly after.  Your body needs to adjust to losing a pint.  Also, start eating slowly, sitting down.  When you’re eating, your body shunts blood to your digestive system to absorb all those nutrients.  If the dipstick is low, there may not be enough blood to go around, and it’s harder to pump it up into your head when you’re standing.

Giving blood is easy (for well-rested non-medical students), and it’s important!  Like we discussed above, lots of kids in Acadiana need blood to save their lives: accident victims, kids with cancer, children who need heart surgery, and the occasional premature baby.  Donations are down in Acadiana, with the oil down-turn.  Fewer people have an hour to spare to donate.  Companies that once sponsored blood drives have laid off employees that used to be donors.  The employees that are left have to work harder and fear taking company time to donate, not wanting to be labeled a slacker and lose their jobs too.

Donations are down, but need isn’t.   Donating is voluntary, and a really good deed.  You might even get a t-shirt or a chance to win a prize.  And I still like free cookies and juice too.

Is Anything Really Toddler-proof?

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

9 pm: a frantic call from my sister. She was in the kitchen warming a bottle for her infant, went back into the kids’ room, and found her 2 year-old daughter with her purse. Diet pills were scattered about and a half chewed one in the girl’s mouth.  Though the daughter wasn’t showing any signs of distress, my sister sure was!  She wailed through the phone, “What do I do?”

This is a classic accidental ingestion, and a serious concern for parents.  In the 1970′s, the Consumer Product Safety Commission mandated that medicines be sold in child-resistant packaging. This requirement has saved countless lives.  Also in the past 50 years the advent of Poison Control Centers has reduced deaths among children who get into medicines.

Fast forward to now, we still see children in the Emergency Department with ingestions. In 2014, the 55 U.S. Poison Control Centers provided telephone guidance for nearly 2.2 million people, mostly for children under age six.  Many more come to the ER. This begs the question: why, with “child-proof” containers, are kids still getting into these things?

One big reason is the proliferation of medicines in households.  Many adults are on 2 or more prescription medications, and most also have over-the-counter medicines like Tylenol and cold relievers.  Parents try to store them in high cabinets, but they sometimes miss pills in purses or left on counter tops.  Adults who are sick or have sick children may keep medicine close at hand to be convenient for the next dose.  Abundant medicine within reach becomes a field day for curious toddlers.

How can parents prevent children from ingesting these things?  First, pick a safe storage spot that kids can’t see or reach.  Know that any medicine or vitamin can cause harm, even those without a prescription.  Put medicines away after every use- never leave them on a kitchen counter or child’s bedside table- children sometimes try to help parents by taking the medicine themselves.

Putting medicines in high cabinets is often not enough.  I know one ex-toddler named Brian who would go exploring in the middle of the night.  Once at 2 am his mom heard noises from the kitchen and found him standing on the counter (having pushed the stool over as a ladder), and was getting a hammer out of the cabinet above the refrigerator.

Knowing Brian’s abilities, his father installed hook-and-eye latches on the house doors so he couldn’t get out.  Some nights later the parents heard more noises and found him wandering outside anyway.  He had used a broom handle to push the latch up, and out he went!  Soon all the cabinets in the house had locks, and the door latches had spring-loaded catches that couldn’t be jimmied from below.

Like we discussed above, toddlers sometimes get into medicines and accidentally poison themselves, despite having those medicines in high cabinets.  Many children have super-toddler abilities like Brian. Fortunately, most medicines have safety caps that click to tell you they’re closed safely.  Some are so toddler-resistant that adults have a hard time getting them open- this is good!  But sometimes adults have so many pills, and have such a hard time with child-proof caps, that they put their medicines in a weekly pill organizer. These are NOT toddler-proof, and should be treated with EXTREME CAUTION with kids around.

Never tell kids that medicine is candy to get them to take it. Instead, explain that taking medicine is for feeling better. If kids are told it’s candy, and then they see grandma taking “candy” from her pill organizer, where to you think they’ll go next?

Sometimes we have guests in our homes, especially during holidays. There’s hustle and bustle, and lots of curious, exploring kids.  Discuss medication safety with your guests. Help them keep purses, bags, and coats with medications out of reach.

Finally, before you find yourself in a toddler-ingestion situation, be prepared with Poison Control’s phone number handy.  It’s 1-800-222-1222.  Put that in your house and cell phone.  Before you run to the ED, they can advise about whether you need to go in, call 911, or not worry.

Take care with household medicines and kids.  Because nothing is really toddler-proof. 

Don’t Get Chopped In Your Own Kitchen

My family loves the cooking show “Chopped,” where contestants make dishes using “mystery basket” ingredients, their creations judged by famous chefs.  The prize: $10,000.  Though it’s interesting enough to see how creative the cooks can be, the show injects more drama by queuing up exciting music when someone burns an ingredient or drops their food on the floor.  But the really big artificial moments come when someone cuts themselves, or starts a fire on the stove.

Kitchens can be dangerous, particularly for kids.  Ovens and stoves stand ready to burn little hands.  Microwaves produce boiling liquids to spill.  There’s broken glass, raw meat, sharp knives, poisonous powders and liquids under the sink, blenders and garbage disposals.  Since parents spend lots of time preparing meals and kids want to be around them and everyone is getting something from the refrigerator, it’s a high-traffic area where collisions happen.  Watch Chopped and note how chefs warn each other when passing; they know it’s dangerous bumping each other with pans of hot oil.

Yet kitchens are places for families to get together.  Ideally, parents and kids meet there at breakfast, and discuss what-happened-today at dinner. Parents can monitor their kids’ homework at the counter.  Also, kids want to help with food prep- if weren’t entertaining, they wouldn’t have cooking shows!  Kids want to learn skills like chopping and baking. And of course, they want to eat!

It’s important then to teach food safety.  First is frequent hand-washing.  Most illnesses are contracted from hand-to-hand contact. In the kitchen hands are touching raw meat, dirty vegetables, raw eggs, which can carry illness-inducing bacteria.  And people are always touching their faces and licking their fingers, putting those germs into their bodies.  Everyone should be washing hands after handling raw foods, before forgetting and inadvertently infecting themselves.

Kids should learn to wash dirty utensils and cutting boards too.  Keeping clean in places like the kitchen and surgery is like a kid’s game, where the bad guys (bacteria and viruses) are invisible, and you have to work a certain way to not get contaminated. Change or wash knives after cutting raw meat or vegetables.  Use only plastic cutting boards for meat- bacteria-laden meat juice soaks into wooden boards and stays.

I use my microwave a lot, but I hate others having them.  Sounds selfish, but the most common kitchen injury I see is kids burned when taking food out of the microwave. Usually mom is in another room; the child heats soup or noodles, opens the microwave’s big clumsy door, and someone bumps into it.  Screaming and blistering burns ensue.  If the child gets splashed on the face or hands it can be disfiguring.

Kitchen safety is something that is taught- kids aren’t born knowing ovens are hot, microwave doors are big targets, and dishwasher pods aren’t edible.  My mom loved to tell the story about my genius brother who, when she explained that the red stove was dangerous, he had to touch it for himself.  Yow!

After modeling kitchen cleanliness like above, next show kids how not to get hurt. Teach about the dangers of hot liquids, stoves, and ovens, and those damn microwave doors. If you have a gas stove, kids need to learn not to turn them on unknowingly, and about fire hazard.  People often store poisons under the sink- cleansers, dishwasher detergent, rat poison.  Dishwasher pods look particularly appetizing. If you have babies and toddlers, install toddler-proof locks on the cabinet doors.  Even better, put those things high and out of reach.

Kids want to handle knives.  They should learn basic rules like always cutting away from themselves, and not holding food being cut in their other hand. Knives should be used slowly and carefully- no hurry when slicing!  Leave the high-speed dicing to the cooking shows.

Finally, supervise kids when using blenders, garbage disposals, and snow-cone makers. It’s a life-long disability when kids lose fingers by reaching in these machines while they’re running.

Everyone needs to learn how to cook and to be safe in the kitchen.  We all learned cooking from our parents, and I’m proud of my son when he makes gumbos and stews, or when my daughters bake a cake.  It’s a joy to be together in the kitchen.  But teach them not to get Chopped.

Bumper Cars For Kids

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

Juice in one hand, 2 year-old in the other, 15 minutes late for work.  I buckle my girl into her car seat, off to daycare.  After the second curve, screaming came from the back.  In the rear view mirror I saw only feet, sticking up in the air!

I pulled over and found my daughter and her seat upside down, a confused look on her face.  What happened?  Someone had borrowed the car seat and forgot to re-buckle it when putting it back in my car.

Summer travel season is approaching, so everyone needs a reminder on car seat safety: road injuries are the leading cause of preventable deaths in children in the United States.  “Preventable” is an important word in that statistic, because 71% of those deaths would be avoided with proper child seat use.

And “proper” seat use is another important caveat, since 4 out of 5 car seats are used incorrectly, with an average of three mistakes for every seat!  Car seats are complicated things to buckle and position; ask anyone who has tried.  But it’s your kid’s best safety device, since car crashes are her most likely way to die.  Some important tips:

-Know your car seat!  Read the manual!

-Rear-facing seats: for newborns until age 2, or until the child reaches maximum height and weight for that seat (read that manual!).  Most bad crashes are head-on, and rear-facing supports baby’s heavy head.

-Forward-facing seats: when your child has outgrown the rear-facing seat.  Some seats are convertible, from rear to forward-facing.  Your child should stay in this seat until he maxes the seat’s height and weight (manual!)

-Booster seat: used with the car’s standard lap and shoulder harness, to position the child so that the adult seatbelts give maximum protection.  A child sitting in a regular seat would have the shoulder harness resting on his neck (very bad!), and the lap belt over his belly instead of his hip bones.  Boosters avoid this, and are for kids age 4 to 7 years.

Once we saw a case where a car had been hit by a truck.  The driver cried to the firefighters that her baby was in back, but they couldn’t see baby because the car was so crumpled.  They heard no noise from inside and feared the worst.  It took 45 minutes to cut away the roof and find baby in her car seat, sleeping quietly, clutching her stuffed rabbit.  When we examined baby in the ER, she was completely unscathed.  Hooray for car seats!

The backseat is actually the safest place in car crashes, and kids of all ages should be back there, not in front.  It’s not convenient, but it’s safer, and it’s the law.  Follow the rules every time, even for short drives.  Inconsistency with restraint use confuses children, again is illegal, and we see many injuries with unbelted kids when ”I was just going down the block!”  All kids under 13 should be in the back seat; airbags in front can kill younger children.

Shoulder and seat belt use: when kids are 80 lbs. and 4 feet 9 inchest tall, they can go in booster seats, at about 8-12 years old.  When using regular seat belts, the lap belt should fit snugly across the thighs, not on the groin or belly.  The shoulder belt should lie on the mid-shoulder, at least two inches from the neck.

Correct installation: to tell if you have strapped the car seat in properly, use the “tug test,” tugging the seat from side to side.  It shouldn’t move more than an inch.  The “pinch test” ensures that the seat’s shoulder straps are snug on the child; you shouldn’t be able to pinch a fold in those straps when she’s buckled.  Young infants should have their seats in a semi-reclining position; if baby is too upright, his heavy head could fall forward and pinch off his airway.  Most seats have a built-in level on the side to show the proper recline.

If you get a used car seat, be absolutely sure it hasn’t been in a crash.  Replace ones that have been in a crash, are broken, or expired.  Throw them away, don’t give them away!

Finally, always wear YOUR seat belt.  Be a good example, and stay alive for your children!

Modern Adventures for Kids

In 2008, New York City mom Lenore Skenazy was shopping with her 9 year-old son.  They rode the subway, and that day he begged her to let him ride home alone.  Ms. Skenazy decided it was time for some independence and let him.  He returned home safely and was ecstatic with his feat.  But when Ms. Skenazy wrote about it in a newspaper column, she set off a storm of controversy.

Some called her the “world’s worst mom,” and child protection agencies took note.  Others praised her for not being afraid to give her child freedoms not allowed by  “helicopter parents,” so-called because they hover over their kids’ every move.  Ms. Skenazy recently completed a reality TV series where she coached such parents on letting their kids ride bikes or slice vegetables, to give the kids some independence.  The show’s title: World’s Worst Mom.

In the Pediatric Emergency Department, we often roll our eyes at what some kids are allowed to do- ride 4-wheelers or use the microwave.  But we only see the kids who get hurt; scads of kids use microwaves without spilling boiling water on themselves, and jump on trampolines without breaking something.  The key is teaching children to do these things safely.

Before Ms. Skenazy let her 9 year-old ride the subway alone, she had coached him on reading subway maps and identifying uptown versus downtown trains.  It’s the same with kids doing any risky thing, like riding bikes or 4-wheelers.  There’s rules and training before setting your kid loose.

Of course, learning to ride a bike requires teaching; kids can’t just get on and ride.  But the safety stuff requires more parenting- teaching the rules of the road and enforcing helmet use.  When my son wanted to ride to his friend’s house miles away, we went riding together to show how to stay on the right side of the road and cross busy streets safely, and to be sure he knew the way.  And we had him call when he arrived so we could relax.

When I was eight years-old, they built a hospital near my house.  Construction sites are as good as Disneyworld to a child: piles of dirt to play on, and those big yellow machines!  Fortunately the workers took the keys out of the bulldozer; otherwise we would have fired it up and gone for a spin.

One day I ran across the site and into a mud patch.  It was deep enough that I sank to my knees, stuck.  Remembering the quick-sand scenario in movies, I was scared that I might sink more.  I yelled to my buddy, but he stood helplessly at the edge of the patch, no rope or stick handy to save me.  Since no other rescue was likely, I decided I had to save myself and began to slog my way to a big rock nearby.  Three or four heaves in that direction and I was able to hug the rock and haul myself out.

Parents worry about letting their kids out into the world.  If my folks had known about that deep mud, would they have let me go to the site?  Perhaps not, but back then things seemed safer.  There wasn’t 24-hour cable news, needing to fill a whole day with attention-grabbing stories to scare parents.  Every child abduction in the country now gets breathless attention.  Before cable and internet there were only brief TV news programs and newspapers; no space to report every child tragedy in the nation.

In reality, back then children were actually less safe.  Crime was rising in the 1970s and 1980s, peaking in 1993.  Now there is 50% less crime than when I was a kid.  In addition to a more dangerous environment, kids went out without cell phones or bike helmets.  So the world turns out to be pretty safe for kids; the odds that your kid will be kidnapped or seriously hurt are very tiny.

And children yearn for freedom.  They want to explore, push boundaries, and be proud of their accomplishments.  Lenore Skenazy’s boy was beside himself with joy at going home alone on the New York subway.  While many think that’s extreme, even the FAA lets 14 year-olds fly gliders solo.  Makes a bike ride across town seem pretty tame.

RSV- Don’t Panic?

This week’s guest columnists are Drs. Brian Allen and Chris Fontenot, Family Practice residents at University Hospital and Clinics here in Lafayette.

Winter- the season of holidays, travel, and people congregating indoors. Friends and family share hugs, gifts, food, and germs.  Just as common as sharing good tidings and Mardi Gras are those three letters that strike fear into parents: RSV.

RSV, or Respiratory Syncytial Virus, is the most common cause of a condition called Bronchiolitis.  Bronchiolitis is an illness in babies and toddlers where the smallest airways in the lungs get inflamed, decreasing oxygen delivery to the bloodstream. Worsening inflammation causes a “whistling” sound as the air squeaks through those narrowed airways, a.k.a. wheezing.

Anyone can get RSV.  For people over age 2 and adults, it’s simply a cold.  Only babies under age 2 get bronchiolitis.  Even then, if your kid has RSV, don’t panic. Most babies have only a cold as well. RSV is rampant from November through April, particularly in January and February.  Also know that kids don’t stay immune to RSV: some unlucky babies get it twice in a season!

The basic symptoms of RSV are runny nose and congestion, cough, fever, and decreased appetite.  Babies with colds can have trouble feeding, because clogged noses make it hard to suck the bottle or breast, and breath.  More concerning signs of RSV, when we call it bronchiolitis, are rapid breathing (breathing 60-80 times per minute), wheezing, and worsening feeding.  Kids may have “retractions,” where the skin over the ribcage sucks in as they tug in breaths. Infants may grunt with every breath. Children with grunting, retractions, fast breathing, or worsening drinking need attention immediately.

RSV is highly contagious.  It travels on water droplets that are coughed, sneezed, or breathed out.  The virus lasts up to two hours after landing on surfaces like furniture and counters, where others can unknowingly touch, pick it up, and infect themselves.

“Your child tested positive for RSV” is a painful phrase for parents.  Parents ask, “Are you sure,” and “Will she have to stay in the hospital?”  The answer to “Are you sure”, weirdly, doesn’t matter!  As we alluded above, RSV isn’t the only virus to cause bronchiolitis, that condition with coughing, fever, wheezing, and  congestion- many others cause it too.  We don’t recommend testing most kids for RSV, since whether the test is positive or negative, what’s important is how your child is handling bronchiolitis, not which virus caused it.

The mainstay of treatment is “supportive care.”  The first support is hydration.  It’s important that children drink plenty, to keep mucus moist, thin, and easy to handle. When an infant or toddler can’t drink because of congestion, they begin to dehydrate.  Their mucus gets dried and sticky and gums up their already inflamed airways.

Breast milk or formula are best, but extra clear fluids can help.  Pedialyte is a good option for infants; its designed to hydrate babies if they can’t handle milk.  Babies tend to vomit with bronchiolitis when they gag on mucus and have upset stomachs from swallowing it, and Pedialyte is easier to absorb than milk. However, Pedialyte tastes a little too salty for older children, so these kids can hydrate with dilute juices and sports drinks.  If a kid just won’t drink, he may need admission for IV fluids.

Breathing also needs support.  Bedside humidifiers and nasal saline may help hydrate and thin mucus.  Elevating the head helps noses and upper airways stay clear too. When babies starts to struggle to breathe like we discussed above, need oxygen and other respiratory support, it’s time for admission.  Unfortunately, nebulizer breathing treatments don’t help.  Breathing treatments are often prescribed with bronchiolitis since the symptoms look like asthma, which treatments do help.  However, multiple studies have shown that nebulizers for bronchiolitis are a waste of time and money.

Finally, keeping your child isolated is important for others to not get RSV- it’s highly contagious, and the cough and “viral shedding” last for weeks.  No daycare until baby is fever free and coughing much less.

So don’t panic if your child has RSV. Like we said above, most kids will just have a nasty cold, only a few need hospitalization.  Fever medicine, fluids, patience, and TLC usually take care of it.

Is Chapped Lips An Emergency?

One of last year’s fun news stories was a 911 call from a man whose cat wouldn’t let him in his house.  After a three hour stand off, and after the police and 911 operator finished laughing themselves silly, an officer was dispatched and apparently talked the cat down.

Similar absurdities happen in Emergency Medicine.  Once when I worked in Baltimore, a mom brought her child in for chapped lips.  Thinking that no one would come to the ED for such a minor thing, I searched for the “hidden agenda,” some underlying worry explaining mom’s thinking.  Like if her Uncle Frim had lip cancer and she feared her son had it too. However, after an exhaustive history, there was no such issue: her son simply had chapped lips.

It’s sometimes difficult telling the public when to call 911 or not, and when to bring kids to the Emergency Department or not.  We want to encourage people to get emergency help so they don’t blow off potentially serious issues.  On the other hand, we don’t want the Emergency Department and EMS systems clogged with non-emergencies.

Most pediatric ED visits are not emergencies, but families come for many reasons. First, parents get scared for their kids.  They love their kids and when they get sick or hurt, parents sometimes rush for help rather than call their doctor for advice or wait for an appointment.

Often parents can’t get their kid seen in the office that day.  An appointment for next week doesn’t help when your child won’t stop vomiting, or needs x-rays.  Sometimes when the parent does call for advice, the mom is told to go to the ED, rather than office staff taking time to talk the situation through, giving advice that could keep the child home.

Sometimes when a child gets sick or hurt, a doctor’s office or school is worried about caring for a potential emergency.  They aren’t used to emergencies and don’t want to miss something, or get sued.

Almost daily we see kids in the Emergency Department who were in car crashes, seem fine, but the parents want them “checked out.”  You can’t fault this reasoning; they care about their kids and are worried.  However, when the “crash” involves cars backing into each other in a parking lot, and the child was strapped into a car seat, maybe an ED visit is overkill.  Unless the lot has cars speeding into their slots like the Indy 500 pit stop.

Too often the ED is used as a walk-in clinic, rather than for true emergencies.  The point of this blog is to inform you about what real emergencies are, what can wait to see the doctor, and what you can take care of at home.  So let’s review common issues appropriate for the ED, and things that are not emergencies.

Kids who are short of breath, tugging to breathe, belong in the ED.  Of course bring any children with possible broken bones, cuts that need stitches or won’t stop bleeding, or severe pain. When kids get lethargic (difficult to arouse), they need to get seen.  However, there are gradations of cuts and limb injuries, and lethargy: kids with fever get lethargic, but recover with anti-fever medicines.  If it isn’t obvious if it’s an emergency or not, call the doctor’s office.  If they can’t help, go to the column in this blog to the immediate right side of the page.  Click on your issue to read specifics about what is an emergency, and what can be handled at home.

Things that are commonly not emergencies: fever, coughing, rashes.  Fever doesn’t hurt kids- it doesn’t cook their brains and is rarely associated with seizures.  The height of the fever doesn’t correlate with how sick the kid is either: a child with a 104 temperature isn’t sicker than a child with 101.  Coughing also isn’t an emergency- kids cough when they get colds and if they aren’t otherwise short of breath, it can wait.  Again, see the column to the right.

This is a busy time of year for the Pediatric Emergency Departments, so use common sense when deciding to visit.  Use your doctor’s call line, or this blog when in doubt.  But if you still can’t decide, bring your child in. Better safe than sorry, but you can leave the chapped lips at home.

ADHD Or Just Bad Behavior?

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

Is your child ”bouncing off the walls” or “just won’t listen?”  Pediatricians and family physicians see lots of kids with behavior problems.  Parents or teachers often want to know if this is ADHD (Attention Deficit Hyperactivity Disorder) or just bad behavior?

ADHD is a hot topic.  Some claim that ADHD is only bad behavior from ineffective parenting- “she just needs a good spanking!”‘  On the other extreme, some kids receive ADHD medication who don’t need it. Regardless if you believe ADHD is real, here are tips on helping kids act better.  Kids who don’t have ADHD respond to these tips; kids who do may respond less consistently, but will still be happier and better behaved.

Spanking?  Many ask, to spank or not to spank?  A bigger question is why are you spanking?  If you do spank your child, avoid doing this in anger.  Only spank for behavior that’s dangerous, like running into the street, not for something small. Explain why you’re punishing. He may not understand right away, but kids get more than you think and will eventually catch on.

More importantly, reward good behavior.  Positive reinforcement is MUCH more effective than punishment.  Saying things like “Thank you for being so quiet,” and “You did a good job picking up your room” is great behavior modification. Every kid (and adult!) likes praise, and kids will work to earn more.

Don’t be sarcastic, or make fun of your child.  Young children are sensitive, and cutting remarks and mean-spirited teasing hurt feelings.  Pre-teens and teens don’t like that either.  If you are unpleasant to your children, they will grow up thinking that it’s okay to be abused and to abuse others

Build family traditions.  Many households lack structure or traditions.  Do something together!  Go to a park or to church every Sunday, or have Friday night pizza as a family. Kids look forward to these things- it’s something to do with mom and dad. Also keep extended family in mind and make time for them.

Keep a home routine, or “rhythm.”  Chaotic homes make chaotic children.  Some kids who seem to have ADHD just aren’t used to having to sit still and follow along; they never learned how at home.  We know it’s especially important to have a routine home life for children with autism or ADHD, but every kid behaves better and is happier with structure.

Keep the same bedtimes.  Don’t let kids stay up later with phones or watching TV-that’s cheating!  Eat meals together at regular times. Give your children daily and weekly chores. Even kids as young as 5 years-old want to help, and should start picking up after themselves.  Be realistic though; the seven year old shouldn’t be shingling the roof.  5-6 year-olds can clean rooms, 8-9 year-olds can help with dishes and take out trash, and 13 year-olds can mow lawns and babysit younger siblings for short periods.

Expect your children to RESPECT others.  Respecting adults and peers is important. The Golden Rule, “Treat people as you want to be treated,” even very young children understand.  This is the South- we expect ”yes sir” and “no ma’am.”  Doing this will help your kids earn respect in turn. 

Set a good example by respecting others in speech and action.  Your child should never hear you curse.  If (or when?) you do mess up, be honest with your children and tell them you expect better from yourself, and them.

Don’t argue with your kids, or ask them “why” they did something.  If they misbehave, punish them appropriately and briefly explanation why they acted badly.  Asking them why makes it personal, as if they are bad inside and not just simply making a mistake.  If they argue with your reasoning, don’t engage them in the argument.  As Dr. Hamilton used to say to his kids, “This isn’t an argument, this is simply how you should act.”

The most challenging child can benefit from these tips. Try them out; if you don’t make progress with difficult behavior, you’re not alone!  Talk with your doctor or school counselor.  They can help you with behavior techniques, to help your kids be the best they can be.

Can Hospitals Make You Sick?

It’s tough to care for friends.  My friend Jennifer had delivered her third baby.  My patient was baby Julia, who had a rough start, needing oxygen for the first days of life.  Jennifer was exhausted from labor, delivery, and worry.  But the fourth day I had good news: “Julia can go home today!,” I said.

Jennifer burst into tears.  Puzzled and a little freaked out, I asked  “What’s wrong, Jennifer, what did I say?”

“How come Julia can’t come home?” she sobbed.  I then understood that Jennifer had simply mis-heard me.

“Sorry if I wasn’t clear, but Julia CAN go home,” I explained, and Jennifer recovered.  Whew!

Parents and children often feel vulnerable in hospitals.  A recent article in the BBC News Magazine discussed how hospitals sometimes make you sicker, instead of being places of recovery.  The article stated that of patients in the US admitted to hospitals, 20% have to be re-admitted within a month.  For some reason those patients weren’t healed in the first try.

Hospitalization can be stressful, rather than purely healing.  The most obvious stressor is that your child is sick enough to be admitted in the first place.  You’re worried, your kid’s scared, and she’s tired and hurting.

Hospitals also cause sleep deprivation, just when you need your sleep the most! Patients are awakened all night for vital signs and medications.  When the patient tries to nap in daytime, interruptions continue: morning blood draws, doctors’ rounds, staff and families chattering away in halls, food carts rumbling back and forth.  It’s hard to get even three to four hours of uninterrupted sleep.

There’s also pain, which of course kids hate- needles for blood draws, IVs, and procedures.  Finally, the food: it’s hard to serve hundreds of meals on several floors, hot and delicious, and few hospitals have mastered this. Then they take away your food if you have a procedure- must have an empty stomach for anesthesia!

So how can you make your child’s hospital stay safer and more restful?  First, hospitals have been doing their part.  Since a 1990 government report on hospital-acquired infections, Lafayette General and others are policing doctors, nurses,and techs on hand washing.  Hand sanitizer stations are now all over.  Programs to reduce IV and other catheter infections have made infection rates plummet.

Surgeries have new rules for safety.  The news used to carry stories of surgeons amputating the wrong leg.  Comedian Dana Carvey (who played Garth in the Wayne’s World movies) was also in the news after his heart surgery. In 1997 he had bypass surgery for a blocked heart vessel.  Unfortunately, after cracking his chest, the surgeon bypassed the wrong vessel.  So Carvey had to undergo a second open heart surgery. Hospitals now have protocols to ensure that we operate on the right patient, on the right part, at the right time.

There’s lots you can do to make your child’s hospitalization safer too.  First is to have a patient advocate.  For kids, this is usually the parent.  However, some parents are overwhelmed by their children’s illness and care- tests, medications, therapies, when can we go home, when will my child get better?  Then parents need their own advocate to help sort it all out.

The most important thing an advocate can do is remind staff to wash their hands. And their stethoscopes.  Second is to make sure everyone introduces themselves, and keep straight all the players.  Who is the nurse, the doctor in charge, the specialist?  Third, be sure the right therapy is happening to the patient.  What’s this medication you’re giving, what’s it for?  Why this test or procedure, how necessary is it?  Lastly, an advocate can prevent sleep interruptions, like making a sign for the door requesting minimal wake-ups. And the sign should say “please keep quiet in the hall!”

Hospital care is complicated, and not without risk.  Hospitals like Lafayette General are doing their part.  But patients and parents need to do their part too, like Dr. Kate Granger. Though Dr. Granger was a doctor, when she became a cancer patient she was treated impersonally, until she started a twitter campaign to get doctors to simply introduce themselves.  You shouldn’t have to go that far, but making a sign for your child’s door is a great start.

Put Me Back In Coach!

Dave was the quarterback for my college fraternity’s football team.  Though it was flag football, Dave got knocked down a lot, and several times hit his head on the ground.  For days he would act confused, repeat questions over and over, and finally recover. He graduated to go on to fly Navy jets and finally got a helmet to wear!  Dr. Blake McDonald, a Family Practice resident at the University Hospital and Clinics here in Lafayette, discusses concussions this week: pay attention!

Concussion is an injury caused by a blow to the head.  This injury impairs neurologic function: concussions interfere with coordination, thinking, emotions, and sleep.  They eventually heal, but it takes time.

Concussions aren’t bleeding in the brain or skull fractures- they aren’t detected by CT or MRI scans.  They can be measured by neuropsychological tests, where the patient interacts with a computer program or a paper-and-pencil test.  In other words, concussion is a functional injury, not a structural one.

Concussions are a big problem, bigger than statistics report.  About 144,000 people per year visit ERs for concussions, but one review estimates that there may be up to 3.8 million recreation and sports concussions per year in the U.S.  And that doesn’t include injuries in grade school and middle school athletes.

Football is the riskiest sport for concussions in high-school boys, soccer and basketball for girls.  Rugby, ice hockey, cheerleading, and lacrosse also probably have high concussion rates, but their data are limited since these are often club activities rather than official school sports.

Headache and impaired coordination are the main physical symptoms of concussion. Loss of consciousness is another physical sign, but this only happens in 10% of concussions- you don’t have to be knocked out to have a concussion!

Concussions also affect cognitive function- the ability to think and remember. Kids with concussions have trouble with homework, concentration, and thinking clearly.  Memory is also impaired- a concussed child may not remember what happened for some time before and after the injury.  Some kids have short term memory loss, asking the same question over and over.

Besides causing physical symptoms and thinking deficits, concussion can affect emotional stability.  Concussed kids are often tearful and depressed.  They can be emotionally “labile,” meaning one minute they are acting silly, the next minute moody. Kids with concussions sleep a lot.  This worries parents who have heard not to let head-injured kids sleep.  But sleeping late and napping with a concussion is part of normal healing.

So how can we help concussions heal?  Management involves avoiding activities that slow natural recovery.  This means allowing time for physical, cognitive, and emotional recovery, and not worsening things.  Even the NFL now recognizes that if you send an athlete back out who has impaired coordination, concentration, and thinking, they stand a greater chance of getting more hurt.

Cognitive and physical rest are the mainstays of management.  Cognitive rest means staying home from school.  Upon return, concussed kids may need shorter school days and reduced work.  They may need more time for assignments or tests.  If headaches return, the child may need to be out of school longer.  Videogames and computers can worsen symptoms too.

To be allowed to return to full school work or sports, the child must be symptom-free- no headaches, normal coordination, no trouble thinking or remembering, no more fatigue or depression.  This can be a problem with motivated athletes who hide their symptoms to stay in the game.  Coaches, teachers, and parents need to be vigilant.  If a kid hits her head and then seems impaired, the approach is simple: “when in doubt, sit them out!” Coaches and trainers should be aware of sideline tests for concussion to detect impairment.

When kids do return to school or sports, they need a “graduated” increase in intensity.  This means slowly increasing class work and home work.  In sports, it means slowly increasing physical intensity, then adding complexity (like adding drills and plays), then scrimmaging, then full play.  Worsening symptoms during that time mean “back off!”  

Though there’s been much prevention talk about mouth guards, better headgear, altered sports rules, the best tools to prevent and treat concussions are education and recognition- for athletes, parents, coaches, trainers, teachers, administrators.  And doctors and nurses too!