Gumbo On Call

When my wife was in college, years before we met, Saturday mornings boys would knock on her door: “Make us a gumbo!” This was in Wyoming where gumbo was rare, and she and her roommate, also from Lafayette, were popular for their cooking. And  after a night of partying, apparently gumbo was what was needed. Bleary-eyed themselves, the girls set the conditions: “Go to the store, get a chicken and some sausage, and we’ll see.”

Cooking is an important skill kids should learn. This winter there’s no better indoor activity. They’re home from school more, and it’s sometimes too cold to play outside. Eating home-cooked food is healthier for the whole family too, rather than eating take-out or processed food from a box. Of course, if the parents are lousy cooks, maybe kids should learn from another family member. My mom was an average cook, but an excellent baker, so that’s how I turned out. My wife’s mother was solid in the kitchen, and so is she. Now my son is a better cook than I, having his mom to teach him gumbos and etouffees.

Learning to cook goes hand-in-hand with learning which foods are better (fruits and vegetables, low fat, high fiber). Children are also happier, stronger, less sick, and less overweight when they eat three meals per day: breakfast, lunch, and dinner. Some kids  don’t like breakfast; their stomachs and heads aren’t awake before they go out the door to school. However, children learn better with fed brains, so get them up earlier to eat something, like at least half a banana, a small muffin and a glass of juice. Some other kids don’t like to eat at school, where many get their breakfast and lunch. These kids should take food with them- granola bars and fruits to keep them going.

We see lots of issues in the Pediatric Emergency Department due to poor diet. Constipation and gas pains result from low-fiber foods. Not eating three meals daily contributes to headaches, fatigue, and depression. Snack-filled diets cause obesity, leading to leg and back pain, among other problems. Gumbo to the rescue?

On the TV show Chopped, four chefs compete to make gourmet meals from “Mystery Baskets,” with time limits to cook each course. The baskets contain regular ingredients like fish or lamb, but also whacky items like gummy worms. It’s fun watching the chefs try to make tasty food as time ticks down. Then they stand there as judges critique their dishes and decide who gets “chopped.” Pressure really ratchets up when a chef slices himself with a knife, and precious seconds waste away while his wound is dressed.

Kitchens can be dangerous places for kids. There’s knives and whirring blades in blenders, pots and microwaves full of boiling liquids, and lots of traffic to bump children into these hazards. On Chopped chefs call “behind you” to each other as they pass, lest they collide and get burned. Few teens yell “behind you” when going to the fridge while parents are dicing vegetables.

However, like we discussed above, it’s important for children to be there, where they learn the life-long skill of cooking and families hash out the day’s events, and other important life issues. Besides learning how to feed themselves in a healthy way, kids also need to be safe when kitchens get frantic like on Chopped.

The most common kitchen injury we see in the Pediatric Emergency Department is burns from microwaved liquids. Those big, clumsy microwave doors are targets for passers-by, bumping the child who’s retrieving a bowl of hot noodles, scalding her in the face, chest, and hands. When this happens, immediately remove burning clothes and run cold water on to stop the burning process. Better still, closely watch kids when they use microwaves.

Knives injuries are second. Kids should learn how to use them, but with supervision, ensuring they cut away from themselves. It seems obvious to not hold the object you’re cutting in your hand, putting it on a cutting board instead, but it wasn’t obvious to that kid we saw last week. A final checklist for toddlers: keep pot handles and electric cords out of reach, and lock cabinets with poisoning hazards like detergents. Kids shouldn’t get chopped in real life.

Residency During The Pandemic

This week’s guest columnist is Dr. Hanh-My Tran, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

I recall one elderly patient I took care of in the ICU. He had COVID, which in turn caused multiple organs to fail. Inflammation was killing his kidneys, his liver, and his lung capacity. After two weeks on the ventilator he continued losing ground, and his family agreed to switch from life-saving measures to comfort care for the end. The worst part: I had to tell the family that visitors weren’t allowed. Coronavirus is rampant enough, and no one wants other family to get sick, maybe die, and compound the tragedy. I gowned up in full PPE, took in an iPad, and Facetimed the family. Devastated, the children and grandchildren said their goodbyes, crying in the camera.

This last year of residency was supposed to be seeing more patients, honing procedural skills, and broadening my experience with different diseases. Instead, my fellow residents and I have learned to tackle a pandemic. Early on we were designated for more adult floor and ICU shifts to shore up personnel for that first surge. As the attending doctors and hospitals have gotten more efficient at COVID care, we’ve resumed a mostly normal schedule.  In pediatrics, we’ve not had anything near our usual volume of patients, since with COVID precautions kids have been pretty healthy, not passing colds to each other. But kids have suffered other ways.

As adults, we tend to understand what stressors make us feel overwhelmed, angry, sad, anxious, and depressed. Children learn how to respond to stressors as they grow and develop. COVID has forced them to grow up a little faster this year. Isolation, social distancing, and fear of family and friends getting sick are taking their toll.

Anxiety and depression are rising in children and teens, and counseling services were scarce in the best of times. So besides your own stress, watch your kids for the subtle signs of depression- changes in mood and appetite, unusually defiant behavior, self-isolation. Respond to these sympathetically now, so your kids can learn to cope too.

I have a condition that weakens my immune system, so I follow guidelines on COVID prevention religiously. I’m always masked, wear PPE with patients, and of course wash my hands until they’re red and raw. But COVID-19 is highly contagious and sneaky, and I contracted it nonetheless. My first symptom was fatigue, but since residency is a 60-70 work week, that wasn’t abnormal. I had no fever, cough, or trouble breathing. However, my partner got sick with cough, fever, and aches, and tested positive. He works from home, so he probably got it from me. “What’s mine is yours, what’s yours is mine” didn’t  have that poetic ring when I tested positive too.

The worst part for me was the loss of taste and smell for two months. I l dropped weight, but don’t recommend COVID as a weight-loss plan. No taste or smell takes a lot of fun out of life, and is a major depressor in affected patients. However, both my adults and children in clinic have drastically gained weight since COVID started. Trapped in the house, they’ve increased snacking and eating. Physical activity is also down, with limited school, sports, and outdoor time. Obesity has been escalating globally, and is now an epidemic within the pandemic!

Overweight kids have more trouble looming than just achy feet. Obese kids become obese adults, and have a head start on the attending heart disease and cancer risks. They also get sleep apnea, joint pain, and diabetes. High blood pressure in children, and thus risk of future strokes, is also rising. “Curing” obesity is harder than treating cancer. Medical attempts at weight loss lag behind cancer cure rates.

As we discussed above, more children have depression and anxiety due to the pandemic, and obesity compounds depression. Feeling achy, being bullied, and social isolation are a trifecta of misery. The lessons are clear: keep your kids to routines: three healthy meals daily, limited and healthy snacks, regular bed-times. Get them moving! Less screen time!  Besides masking and distancing, you’ve got to fight Coronavirus at home as well as in public. For our kids’ futures, it’s a battle we must win.

Long Dark Winter

Yesterday my wife and I were walking our dog on a grey, wintery day. Though only 45 degrees, it was a damp chill that felt like 39, what my wife’s Cajun family calls “dat wet cold.” She was grumbling about it, having grown up in Lafayette and hating winter. I reminded her that we met in Maine, regularly walking and skiing in worse cold and snow, with even shorter days and longer nights. “So this isn’t so bad, right?” I offered. Her response to my profound wisdom: “I wanna go to the Bahamas.”

Unlike my wife, grey winter days make me happy. I grew up in New Jersey, which like Maine, has long dark snowy winters. But winter has it’s own fun: as kids we got “snow days” off of school when the roads were too slick for school buses. Unlike days off for hurricanes where you must shelter, snow meant having snow-ball fights, sledding, and cross-country skiing in the woods. You’d come home wet and cold, peel off the soggy clothes, and have hot chocolate before a roaring fire. Some pundits are predicting a “long dark winter” of COVID. They seem to think, like my wife, that long dark winters are a bad thing?

Winter is typically difficult for kids’ health. Cooped up indoors with each other at home and school, children pass around cold viruses, influenza, and RSV. Those cough/congestion viruses in turn can cause asthmatics to have attacks, and some babies can wheeze from RSV. Kids with skin conditions like eczema will have flairs with prolonged exposure to cold dry air. They’ll itch, scratch, and have crusty flaky rashes.

At least we in Louisiana have shorter winters than most of the country, given our early spring warmth and longer days of light. Kids (and adults) will get outside sooner. Also,  schools’ protocols for mask-wearing, distancing, and alternating attendance has cut down not just COVID, but those other viruses that make kids sick on the regular. And the vaccine’s coming! So stock up on skin moisturizers, your kid’s asthma medication, and get those flu shots. There’s light at the end of the long dark winter tunnel.

I grew up cross-country skiing, but hadn’t been for 20 years since moving to Lafayette. Last March my wife and I went to Quebec with friends to try it out again. Three days of going up and down hills, the old reflexes were working, and I didn’t fall down once.Then that last day, skiing back to the lodge, they were cheering me in! I threw up my arms in triumph, lost my balance, and POW!  Nordic Scott eats snow.

As I mentioned above, long dark winters don’t get me down. However, this time of year when the days are shortest, the nights longest, and it’s grey and cold, many people get depressed. Add the post-Christmas blues: the holiday’s over, no fun between now and spring. Finally, with COVID, we can’t get together to share the misery like usual, under threat of life-threatening illness that we could catch; or worse, give to loved ones.

Depression from COVID issues is real. Isolation brings loneliness. Fear oppresses as friends and family get sick, some fatally. There’s nowhere to escape- any vacation spots you might visit are risky. Finally, most of us are poorer to some degree. Nothing takes the fun out of life like poverty and money worries.

Teenagers particularly get depressed easily. Puberty often makes them hyper-emotional, hyper-sensitive. If there’s depression to be had, they’re buying in! It’s thus a good time to keep an extra eye on your teenager’s mood. Are they more sullen or argumentative? Are they isolating more in their rooms? Are grades slipping? If so, ask them if they’re depressed or suicidal. Don’t tiptoe around the subject: asking if they’re  suicidal won’t put the idea in their head, and you need to know if they are. Not being proactive could prove fatal!  If you get the usual eye-rolling at your over-protectiveness, then good.  Better to be over-cautious than making funeral arrangements.

Meanwhile, stay positive. Spring and vaccines are coming. When the sun shines, get out of the house and get some sun on your faces. Do some charity- helping others often makes kids and adults feel better. The long dark winter will soon be past.


My Big Fat Cajun Wedding

On December 8, 1990, I got married. It was my first trip to Louisiana, and my staid protestant family met my new loud, fun catholic in-laws. Like the movie My Big Fat Greek Wedding, my stiff northeasterners got swallowed up in merry-making, and had a blast. First, the rehearsal dinner speeches started with the restauranteur welcoming everyone with a dirty joke. Wary looks were exchanged, but fortunately none of my family understood his thick Cajun accent (enhanced by a few drinks). Except it had something to do with ducks and condoms.

For our 30th Anniversary this month, there’s no Big Fat Events. COVID in Acadiana’s hospitals is up to apocalyptic volumes, added to our usual winter big numbers of patients. This new bump started with pre-Thanksgiving gatherings. For example, some parents rented party buses for Homecomings, finding the distancing, outdoor events planned by schools too nerdy. Those unmasked teens spread the virus to each other, then on to their families. Then Thanksgiving happened, and it’s a bump on top of a bump.

Fortunately for children, they aren’t getting as sick as adults with Coronavirus. There’s some coughing and fever, maybe a headache, and recovery in a few days. Many fewer children get as gravely ill as adults do.  Unfortunately, Emergency Departments, Intensive Care Units, regular beds, and even ambulances are clogged by the sheer numbers of very sick, even dying, grown-ups.

It doesn’t seem to be the schools’ fault. They’ve been careful with their protocols,  enforcing mask-wearing and distancing. It’s parents not following the basic containment rules: teaching kids to wash hands and wear masks properly (cover BOTH nose and mouth). Their violation of distancing rules in allowing, even arranging, spreader events, has been responsible for the current calamity. Maybe enough of them and their elderly parents have gotten sick now, that we’ve all learned our lesson.

So please, from all of us working at hospitals, please plan a Quiet Christmas: no parties, no big family events. Just you and your kids at home opening presents, virtual church, and grandparents at a distance, preferably on facetime. Thus we can have as merry a Christmas as possible.

Another event during my Big Fat Cajun Wedding 30 years ago was the Thursday Gumbo. My family of stiff protestant Northeasters wondered, what’s “A Gumbo?” A gathering? Brown soup? But they were swept up in the milling, laughter, and noisy chatter, and even calling for seconds on the brown soup. I get misty-eyed watching the video; so many of our parents and family have passed on.

Also when I watch that video, I first wonder “Why is everyone so close together?” Then I remember: oh, that was life before COVID. Hopefully, no one’s planning any Big Fat Events for this Christmas. Too many friends and family have been in the hospital, in ICU, or died, to risk making more Christmas tragedies.

As mentioned above, Coronavirus cases have ramped up since October, with too many kids and adults having big risky gatherings. Acadiana’s hospitals are clogged with cases, adding to the usual winter high volume. Being careful, not succumbing to “COVID fatigue”, is key to survival. It’s a sneaky virus, being so contagious and spreading through asymptomatic kids and adults. We’ve got to cinch up on the mask-wearing, distancing, and hand-washing; to get through the next few months as the vaccine rolls out. Fortunately for us in Louisiana, we get to go back outdoors in February or March. My unlucky Northern family will still be shoveling snow.

As for vaccine safety, I’m not worried; I’ll happily start mine in the next few weeks!  The vaccines have been carefully studied and well-scrutinized. Mythbuster: there’s no microchips in the injection. Nanotechnology is amazing, but just isn’t there yet, so don’t worry that Government will track you through the vaccine. Like they want to watch me anyway: “Hey, look, Scott’s driving to work. Now he’s napping. Wow, he’s mowing the lawn.” If they really wanted such information, it’s much cheaper and doable to spy on us through our phones.

So again, plan a Quiet Christmas. Fewer people, no parties, fewer presents. Just you and your kids at home, and visit other family on-line. That way next Christmas can be a happier one, with no melancholy watching of this year’s videos.

Texas Vacation

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

“Dad, pull over!”  Driving across West Texas is a loooong drive, the view unbroken flat nothingness. When I was 11 years-old, that drive got even longer. Relatives we had just visited apparently blessed me with gastroenteritis- I suddenly had gurgling guts. Yes, the lone prairie holds no romance for me, no visions of cowboys strumming guitars by campfires; just the memory of many rest stops.

Most vomiting and diarrhea illnesses, “gastroenteritis” in doctor-speak, are caused by viruses we catch from one another.  It usually only lasts a day or two, but it can last a week in some unfortunate kids. Sometimes when parents see large volumes of diarrhea pouring out of their child, they get scared. They’re worried, of course, about dehydration. Still, most get through even a week of misery without needing IV hydration in the Emergency Department. As long as your child’s drinking and not vomiting, she’ll typically absorb enough fluids to keep up with the, um, output.

How do you know if your child is hydrated?  If their mouths are moist, they make tears when they cry, and they pee at least once or twice per day, then they’re okay. If your kid’s mouth is getting dried out inside, he’s moaning but not crying tears, or hasn’t urinated for 12 hours, get checked out. Sometimes with babies and littler kids, there’s so much diarrhea that you can’t tell if their making urine.  In that case you have to go by  tears, mouth moisture, and energy level.

If your child’s only having diarrhea and not vomiting, anything they’ll drink is fair. We used to say don’t give milk with diarrhea, or avoid certain foods, but now we say “feed through” diarrhea.  The sooner your child’s on his regular diet, the sooner her guts will get “back in balance.”  Good things to eat are bland starchy foods easy on the stomach. Certainly avoid heavy greasy foods, like fast food, and high sugar liquids like straight juice or soda. Too much sugar acts like a laxative, and we certainly don’t need that!

Fortunately for my “trail of tears” diarrhea experience across Texas, I didn’t vomit. My 4 year-old patient Eden wasn’t so lucky. She vomited for 4 days before her parents decided she wasn’t okay. What did their home smelled like!? To her parents’ credit, she tolerated some fluids at first; but later spewed so frequently that the tiniest sip wouldn’t stay down. When her tears stopped, despite crying with stomach cramps, they came in.

The majority of gastroenteritis (a.k.a. stomach virus) can be managed at home. Like we said above, if your child urinates once or twice daily, has a moist mouth, and makes tears, he’s okay. If he’s becoming progressively more listless, has a dried out tacky mouth, stops making tears, has sunken eyes, and hasn’t urinated in 12 hours, you’re losing ground.

Some parents panic at one vomit.  After all, it’s gross, and dramatic- all that wretching and cramping!. Fortunately, most kids only vomit once or twice, and then settle down and tolerate fluids. The best strategy to keep kids hydrated is go slow. Don’t force them to drink right after they hurl- it takes an hour or so for stomachs to calm down. Then start with small amounts of clear fluid.  An ounce or two of dilute juice, like apple juice cut half-and-half with water, is a good start. If that small amount stays down, half an hour later give some more.

After a few hours, you can increase fluid volume.  Some parents worry that their child is starving, and start foods right away too. Rest assured, your child won’t waste away going a few days without food. Don’t give solids, or thick fluids like milk, for at least 6 hours after vomiting- kids’ stomachs won’t handle that freight. But if they’re tolerating fluids after that long, then small amounts of bland, starchy things are okay- crackers, toast, bananas.

In these COVID times, we’re hopefully now all aware that clean hands prevent Coronavirus from spreading. The same goes for stomach viruses. Make sure you and your kids wash hands after using the bathroom. One sick kid per household is enough!

Under Pressure

Today’s guest columnist is Dr. Jeremy White, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

“Not the table!” I shrieked, peering through my fingers at the slow-motion tragedy unfolding before me. It was my first night ever babysitting, for some family friends’ two-year old daughter. Mom and Dad had no sooner backed out the driveway for their night out, before WHAM!  Gracie had tripped and smacked her petite nose on the sturdy dining table. She didn’t cry at first, even giggled a little, until she saw blood on her hands.  Deep gasp….

Parents, kids, and even babysitters sometimes panic when they see bleeding. They can get frantic: when will it stop, that’s so much blood!, can my child breathe? Often the kid has smeared blood all over his face and clothes like a horror-movie victim, increasing everyone’s anxiety. Then when they get to the Emergency Department, most times the bleeding has stopped.

Many nosebleeds result from injuries: football passes gone awry, wrestling matches, or that pesky furniture that “leaps out” at toddlers. No matter how it happens, the mainstay of treatment of any bleeding is applied pressure. For nosebleeds, that means pinching the nostrils closed for 10 minutes. You don’t have to squeeze hard, gentle pressure is enough.

Often we anxiously check too soon to see if the bleeding has stopped, letting go of the nose to have a look. This isn’t really applying pressure. When we say pressure for 10 minutes, we mean 10 minutes on the clock, without letting go to check. Another common mistake is tilting the head back. This doesn’t help stop bleeding; it only allows blood to trickle down the back of the throat, leading to coughing, gagging, and nausea.

When do we need to take kids to a doctor?  Come in If the nose is obviously broken- crooked or dramatically swollen. If the child is in a lot of pain, or the bleeding just won’t stop after multiple attempts of 10 minutes of steady pressure, that should be seen. However, don’t panic. We’ve never ever had a child die of nose bleeds.  Apply pressure, don’t succumb to it!

I’ve been on several annual retreats to the Rocky Mountains with students from my old high school. When we would get off the bus at our destination, some kids would climb down with blood coming from their nostrils. One year six students got bloody noses!  Between the high-altitude thin air and super-low humidity, some kids’ noses just let go.

When kids breathe cold dry air, the inside of their noses gets dried out and can crack. Sometimes those cracks cut into blood vessels and POW!- bloody nose. This explains why we see nose bleeds so much in August, after we’ve been living in air conditioning all summer. That water you see dripping out of an air-conditioner is the moisture sucked out of the indoor atmosphere.

We also see lots of nosebleeds in the winter, when the air’s naturally cold and dry. Kids get more head colds in winter too. When excess snot from those spewing noses dries out and cracks, nasal blood vessels crack too. If your child has frequent nosebleeds, a bedside humidifier can keep nasal passages moist at night, when the air is driest. For allergic kids who aren’t supposed to use vaporizers (they can be mold-growers), saline nasal spray is another option.

Some children have extra-fragile blood vessels in their noses. With repeated bleeds, they get raw patches that don’t heal well. If your child has nosebleeds that keep recurring, then it’s time to see an Ear/Nose/Throat (ENT) specialist. The ENT has skinny scopes for looking inside noses and finding those raw spots. If necessary, the bad patches can be cauterized.

As we said above, children never lose a significant amount of blood, though parents sometimes panic when the kid paints his face, pajamas, and bedroom red. However, it always looks worse than it is. When a child is actively bleeding, gently squeeze the nostrils shut for 10 minutes on the clock, with no letting go during that time to check if it’s stopped. Again, no head tilting back either.  Don’t panic- as we also said above, apply pressure, don’t succumb to it!

Meat-Eating Babies

Baby was starting to walk, holding on to furniture as he toddled around. This time he missed his grip on the coffee table and hit his mouth on it’s edge. The cut on his gums bled an alarming amount, to the parents.  After examining the baby, I reassured them that he didn’t need stitches, and though it looked like he bled a lot- he had smeared blood all over his cheeks and forehead- he didn’t need a transfusion. The parents breathed a sigh of relief, and Dad was even able to crack jokes- “it looks like he’s been eating raw meat!” Everyone laughed, horror-movie baby joining in.

We see all kinds of bleeding kids in the Pediatric Emergency Department. The vast majority of them have insignificant blood loss. The sight of blood unnerves many parents, especially when their children paint their faces and clothes red. Nosebleeds are a common ER visit, with blood “pouring” from kids’ noses. They’ve usually stopped bleeding by the time we see them, and never need transfusions. Mouth injuries, forehead and scalp lacerations also look terrible, but aren’t life-threatening.

Some children do need blood transfusions.  Kids in car or ATV crashes sometimes  injure blood-filled internal organs like the liver or spleen, and need blood.  Occasionally a kid will crash his bike or skateboard into a door or window, lacerate a major vessel in the arm, and need blood and surgery too.

Trauma patients aren’t the only ones who need blood products.  Children with certain cancers need occasional transfusions when chemotherapy, or the cancer itself, impedes their ability to make their own blood. Some NICU babies need transfusions, and patients with Sickle Cell Disease needs lots of blood throughout their lives.

Unfortunately, nowadays blood donations are way down. The Coronavirus Pandemic has kept people away from blood banks, afraid that going will put them at risk. There’s been far fewer blood drives at schools and places of work, as these have been closed.  Now Acadiana’s blood supply, and the national supply, are critically low. Yet people’s need for blood hasn’t diminished.  The message is clear: Do something life affirming, GIVE BLOOD!

I was riding my bike and hit a gravelly patch. That’s slippery for bike tires, and I’d previously taken that turn gingerly.  This time I was a little too fast and cutting a little too tightly. Seeing what was coming, I thought, “Darn, this is going to hurt!” Splat!  I got up, inspected the bloody scrapes on my right side, concluded I was okay, and kept riding. I must have looked a mess though, judging by the alarmed looks on people’s faces.  I got home, showered, dressed my wounds, and went to work, thinking nothing more of it.  Until I was seeing a girl who had been in a car crash. She paused in her account of the crash, eyes bugging out at me- “what happened to your elbow!?”

Bleeding alarms many people, like the parents of our baby above, who smeared blood from his mouth injury all over his face. However, very few skin, mouth, or nose injuries require transfusions. Like we discussed above, there’s children who do- cancer patients, kids with Sickle Cell Disease, traumas, and some NICU babies.

The Pandemic has cut blood donations to critical lows.  People have stayed home, rightfully so. Going out and mixing with others is a risk for catching Coronavirus. But this means they’ve been staying away from blood donation centers and blood drives.  There’s been fewer places to hold blood drives too, with closed schools and businesses.

Other reasons why donations are down: weekly hurricanes!. People have been prepping for storms, riding them out, and then busy with the inevitable clean-up. Donations have been down too because of the lagging economy. Blood drives depend on businesses with full stocks of employees ready to donate. Since the economy has tanked, many businesses closed or are running on skeleton crews.

While blood donations are down, needs are not.  Blood banks, like Vitalant on Bertrand Drive, are super-safe places to visit.  They’ve always been keen to avoid infections; now they’ve gone many extra miles to be sure COVID isn’t a risk for donors.

Want to volunteer for something critically needed, and life affirming? GIVE BLOOD!

When Asthma Attacks

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

I was testing for my karate black belt, trudging through the last stretch of a two-mile run. The morning was cool and crisp, which seemed fine for exercising. Except the dry cold air made my lungs feel raw. Then they began to burn like fire. I crossed the finish line and doubled over, gasping for what seemed an eternity. My mom brought me my inhaler and after a few puffs, the burning eased and my respirations began to slow. A sense of relief washed over me- I could breathe again!

This was an attack of exercise-induced asthma: if I’m ever in a ninja fight, better have my inhaler!  Almost 10% of kids have some form of asthma. Asthma is airway narrowing in the lungs. When airways get smaller, it’s harder to suck air through them.  When the narrowing gets really bad, air begins to whistle through those tight passages, making that wheezing noise characteristic of attacks.

Kids with asthma have lungs that are extra-sensitive to irritants. Many things can irritate the airway lining, like cigarette smoke, cold viruses, pollens and mold spores, and dust.  In my case cold, dry air triggered narrowing. The American Academy of Pediatrics warns that climate change and increasing air pollution contribute to increasing national asthma rates. Severe weather events like forest fires, droughts, heat waves, and hurricanes are becoming more common, and giving lots of kids trouble with their breathing.  Increasing smog, soot, and other particle pollutants from cars and factories aren’t helping.

What does an asthma attack look like?  Mild asthma results in irritating coughing that doesn’t go away in a few days, like a regular cold would.  Moderate attacks cause a feeling of chest tightness and trouble breathing with exertion, like when walking up stairs, playing, or testing for karate.  When kids’ attacks get really bad, they visibly struggle to breathe, panting away with skin puckering between their ribs as they try to tug air in. Older kids may get a little panicky like I did; younger kids will be fussy. Time to get help!

Asthma, and asthma treatments, have been with us for millenia.  The ancient Greek physician Hippocrates (writer of the physician’s Hippocratic Oath) coined the term “aazein,” meaning “to pant.”  The Greeks had some reasonable asthma treatments, like adding ephedra (an epinephrine-like drug) to red wine; or smoking stramonium, an atropine analog. They also had whackier ideas, like adding owl’s blood to the wine too.

Today’s treatment is more science-based.  As we mentioned above, asthma is the lung’s response to irritants like dust, smoke and pollution, cold viruses, and allergens. First, muscles in the airway lining tighten up, constricting air passage to keep out what’s irritating. After continued insult, the airways become inflamed and swollen, further impinging air movement. Finally, the lungs secrete mucus to wash out the irritants. This mucus gets dried out and sticky with heavy breathing, further clogging things up.

The first pillar of asthma care is albuterol, a medication that relaxes the muscles in the airways. Albuterol is breathed in by nebulizer or inhaler. Initial management of an attack is 2 to 6 puffs of the inhaler, with a “spacer” (a wide plastic tube) attached. These puffs can be repeated in 20 minutes if the first round doesn’t ease symptoms. If that doesn’t work, get seen!  While most prescriptions for albuterol inhalers call for 2 puffs, it takes 6 puffs to deliver the amount of medicine in a nebulizer treatment.

The second pillar is steroids. Steroids are anti-inflammatories, to quiet that airway swelling and mucus production. The most common steroid is prednisone, which comes as tablets, or liquids for kids who can’t swallow pills. Prednisone is not an “anabolic steroid.”  Kids don’t grow hair, hulk out, or have “roid rages.” Given in short courses, it’s quite safe. Myth-buster: injected steroids don’t work faster than when they’re swallowed; getting “cortisone shots” is unnecessary (yay kids!).

Have plenty of your child’s medication on hand in the winter when cold air, viruses, and dusty indoor living make it more prevalent. Be aware of outdoor air quality conditions that might trigger asthma, like cane burning, humidity, and high pollen counts. Finally, the American Academy of Pediatrics asks everyone to advocate for pollution and carbon control; to help your child, and the whole world, breathe easier.

Martian Death Flu

Some years the Influenza virus gets a special name for it’s strain, like Swine Flu or H1N1.  When he had his bout with flu, humorist Dave Barry made up his own: Martian Death Flu. He and his wife spent days in bed achy and feverish. “There has been a mound of blankets on my wife’s side of the bed,” he wrote, “I think it might be my wife…the only way to tell for sure would be to prod it, which I wouldn’t do” for fear that poking her could be fatal. Dave, leading a more active lifestyle, attempted to crawl to the bathroom.

Flu season is coming, that winter scourge that lays millions of kids and adults out on beds and couches.  They cough, ache in head, throat and body, and occasionally vomit or have diarrhea. This misery can last 7 days, and medications like ibuprofen, Tylenol, and Tamiflu, only somewhat alleviate symptoms. It’s highly contagious, like Coronavirus. It can be life-threatening for medically vulnerable kids, those with asthma or heart conditions.

Last winter when Coronavirus started in China, many kids admitted to the hospital had combinations of viral infections, like Corona and Flu, or Corona and RSV.  Normally we see children with two contagious infections together in a season, like strep throat and flu or RSV and flu.  Put one of those together with Coronavirus, and it’s a whole new, awful, ball game.

Perhaps this’ll be a better-than-usual flu season, since we’ll be wearing masks, washing our hands more often, and staying distant from each other. However, these aren’t easy for kids, who fidget and horse around, and thus don’t follow the rules. Parents also forget to wear masks or keep their kids apart. We worry about parents organizing birthday parties and sleep-overs, potential Coronavirus and flu spreading events.

When hurricane Katrina was approaching, officials warned that “this is the one” to evacuate from.  Likewise, this year is “the one” to get you and your kids flu shots. Like masks, hand-washing, and distancing, flu shots are one more way to protect children; maybe the most reliable way given kids’ potential difficulty with hygiene measures. Because some kids will get both Influenza and Corona at the same time, a real Martian Death Flu combination.

Bronchiolitis is another winter scourge besides Influenza virus. It also needs a better name, like Dave Barry calling Influenza “Martian Death Flu.” For one, it sounds too much like Bronchitis, an adult respiratory illness. For another, “bronchiolitis” doesn’t really convey the misery infants and toddlers go through. Maybe call it Baby Snot Virus From Hell (BSVH)?  Gunk Hacking Infant Whopper (GHIW)? Slime Scourge?  Phlegm Factory? I could go on for days.

Many people know bronchiolitis by the virus that often causes it: RSV.  Respiratory Syncytial Virus is just one of the viruses causing this syndrome, but it’s the most common, and is highly contagious.  While most kids just get runny noses and fevers,  some babies and toddlers have trouble breathing and need hospitalization for oxygen and observation.  They can also get so congested that they can’t breathe and drink at the same time, thus needing IV fluids for hydration.

Bronchiolitis care is frustrating because there’s no effective treatment to ease symptoms or shorten the course. Nebulizers and steroids used for asthma don’t work for RSV.  We’re left with “supportive care:” riding it out with oxygen, IV fluids, and sometimes more intensive life support.

Like we surmised above with flu, maybe this winter’s “RSV season” will be better than usual. Adults and older kids carry RSV, and with masks, hand-hygiene, and distancing, maybe RSV won’t spread as much. However, the kids who get bronchiolitis- infants and toddlers- won’t be wearing masks much.  Daycares have stayed open, and are notorious places for RSV to pass from toddler to toddler, crib to crib. Not every daycare worker washes hands like he/she should, and toddlers certainly don’t. Even the most obsessive caregivers occasionally let their guard down. They’re only human.

Also like we discussed above, during last winter’s Coronavirus outbreak in China many hospitalized kids were co-infected with Coronavirus and RSV.  Both viruses are highly contagious, and every winter we see several kids who are likewise co-infected with contagions- RSV plus Influenza, Influenza plus Strep throat.  Thus we can expect to see babies and toddlers with both RSV and Coronavirus.  Baby Snot Virus From Hell indeed!  Wash your hands, wear your masks, and for goodness’ sake stay away!

That’s Not A Piggy Bank!

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

The saying “Find a penny, pick it up; all day long you’ll have good luck” doesn’t always apply, especially for one 5 year-old girl in the Pediatric Emergency Department. She was playing with some coins, inspecting them closely, even putting them in her mouth to taste them.  Then one hard swallow, and she felt something wrong, besides being “short changed.”  Uh-oh!

Kids put foreign objects (as we call them) in any place they can- ears, noses, and mouths. Infants and toddlers particularly like to explore with their mouths, being the most sensitive part of their bodies. And sometimes, they swallow stuff.  Luckily, about 80% of foreign objects pass through the gastrointestinal system without difficulty.  The one place they get can stuck is the esophagus, that tube that brings food from your mouth to your stomach.  When this happens, kids have to go to surgery to have the object removed.

Parents usually know when something gets stuck.  School-age kids can report the feeling of the coin lodged in the esophagus.  Parents usually witness the ingestion in infants, but occasionally toddlers aren’t in the room when they swallow something. Even then, a sudden onset of coughing, gagging, and crying alerts parents to what’s happened.  However, twice in the past year in our ER, we’ve seen babies with weeks of coughing and vomiting, and order a chest x-ray to look for pneumonia.  Surprise, what’s that coin doing in there!?

Coins are the most commonly swallowed objects in children.  However, anything they can get down, they will- pen caps, wedding rings, Legos.  Again, most of these pass without difficulty.  In a few days they’ll come out the other end.  However, some things that get stuck are an emergency.  The most common of these is disc or button batteries.  If these stop in the esophagus, mucus moistens them, setting up a current between the + and – sides, and they get hot. If left long enough, they’ll burn through the esophagus, letting contamination into the neck and chest cavities, in turn causing life- threatening infection. The same goes for sharp objects like needles and pins.

When I was 11 years-old, I remember playing with 12 game tokens from the arcade at a local pizza joint.  My 4 year-old sister watched as I counted them over and over.  Something distracted me and as my sister walked away, I now counted 11.  “Mom, someone took my coin!” I shouted.  She answered, “You just counted wrong!”  Then my sister began coughing and drooling.

Like we said above, we don’t always see when a kid ingests a foreign object.  Often though, we get clues like coughing and gagging after something goes missing.  In the Emergency Department, we first do an x-ray.  Most things that get stuck in the esophagus are metallic, like coins or batteries, easily seen by x-ray.. However, x-rays don’t always show softer materials like plastic toys or fish bones. If we suspect those, CT scans are necessary.

Also as we discussed above, most objects pass the esophagus.  They’ll come out the other end in a few days.  Whether you want to confirm it’s passed by “inspection,” that’s up to you. If you don’t see it in your child’s effluence, a repeat x-ray can confirm it’s gone. However, if the thing’s stuck in the esophagus, it needs to be removed.  The child is taken to the OR and a scope is passed down the throat. The object is visualized,  grasped with calipers, and pulled out.  Swallowed objects that need to come out right away- batteries and magnets.  These can cause internal injuries, and even if the child looks okay, need immediate evaluation in the ER.

The best treatment of swallowed objects, of course, is prevention. Infants and toddlers should always be seated when eating.  When they eat while walking, they can stumble and choke on incompletely chewed food.  Houses should also be toddler-proofed for choking hazards.  This means crawling around the entire floor plan on hands and knees, seeing everything at their eye level.  Go anywhere they can go- under beds, into closets, behind doors. You need to do this periodically, not just once, since everyone occasionally drops stuff.  Finally, take a CPR class.  Practicing the Heimlich maneuver with a CPR mannequin makes it a lot easier to do if your child starts choking.