Backache? You’re Only 16!

I just returned from my yearly medical mission in Honduras.  And I thought I had gotten away with it- no missed flights, no lost equipment, no bad stomach bugs for the team.  But the next morning I sat down at work and YOW- my lower back clenched up!  This happens every couple of years for me, particularly when I have been abusing my back.  All week in Honduras I was hauling duffels, riding rocky mountain roads in old pick-up trucks, hunching over hundreds of patients.  The next few days I walked like a crippled cowboy until things loosened up.

Every week at home I see a kid with back pain too; it’s not just for old guys like me. Sometimes it’s a dramatic injury, like the weight-lifter whose back went POP! after dead-lifting 315 lbs, or the cheerleader who fell off the pyramid onto her tailbone.  Sometimes it’s a dancer who only strains a muscle but keeps on dancing, aggravating the injury further.

Teenagers also abuse their backs outside of sports.  They slouch.  They slouch in school chairs.  They slouch in the car. They slouch all day on the couch at home. Then they go back to school and haul a dump-truck load of books in their school bags.

When a teen’s back begins to hurt, sometimes they complain, sometimes not.  They blow it off and continue to strain their spines, or continue their sports.  They may take an ibuprofen or two.  Maybe the ibuprofen works, maybe not, because they only use it sporadically, and they keep on slouching and playing. Eventually they tell somebody and get brought in.

So how to ease that angry back?  For me, it was two ibuprofens around the clock, and my return to Red’s gym was delayed a week.  At work I sat upright in my ergonomic chair, and slept with a pillow under my knees.  And these things are the keys to easing your teen’s back pain too.

Like we detailed above, teens will continue to abuse their backs despite the pain.  Many kids (adults too) do not put two-and-two together when it comes to caring for their spines, or any other joints for that matter.  Their backs hurt, but they still slouch.  Their knees hurt, but they still play basketball or soccer.  They play hurt, and sit hurt too.

Thus is the first clue to taking care of a sore back- stop abusing it!  Take the strain off by sitting upright with feet flat on the floor, thighs flat on the chair, spine tucked against the chair back.  If the chair does not have a lower back, or “lumbar,” support, use a pillow to put a slight arch in your back.  When in bed take strain off your back by sleeping with flexed knees.  That means putting a pillow under your knees when on your back, and a pillow between your knees when lying on your side.  Standing strains the back too, but you can ease it by putting one foot up on a step.

And for goodness’ sake take a break from sports!  I’m all for sports and exercise in kids, but if you’ve hurt something, you’ve got to let it heal.  That means no basketball, P.E., dance, or running.  When professional athletes get hurt, do they keep playing?  No, they go on the Disabled List and start therapy.  No pros want to kill the golden goose, which is their million-dollar athletic ability.

Pain medicine helps.  Ibuprofen or tylenol can take the edge off back pain, as long as you take enough and start caring for your back.  You can ice your back too, just like you’d ice any injured joint.  An ice pack against your lower spine, ten minutes at a time, three times daily, can ease pain and inflammation.

If rest, medicine, and ice don’t make things better, see your doctor.  Some kids who have been abusing their backs for a long time need physical therapy.  Sometimes they need tests to be sure that their pain is not from something else besides muscle strain.  But often, kids just need to sit up straight.  You may only be 16, but take care of your back so that it takes care of you.

 

 

Hey…Stitch This!

This week’s guest columnist is Dr. Frank Betanski, a Family Practice resident at the University Health Center here in Lafayette.

“OUCH!!” (ou-ch); exclamation; a four-letter word indicating urgency and anxiety when children get a cut.  It raises questions with parents that are often confusing and overwhelming: “Does this need stitches?”  ”Should I go to the ER?”  ”Oh Lord, what is THAT??!!”  My mother faced these questions when I returned home from the movie “Edward Scissorhands.”  I grabbed the cutlery and literally started running with scissors.  So let’s discuss the how-to’s (and don’ts) of skin injuries.

First, some terminology:

-Laceration: tear into the skin with blunt force.

-Avulsion: A chunk of skin is removed, exposing a hole in the tissue.

-Puncture: stab through the skin

-Incision: laceration made with a sharp-edged object (knife, glass, scalpel, etc)

You’re thinking: “Thanks for the vocab lesson, doc, but what to do right now with all this bleeding?”  FIrst, apply pressure to the wound with a clean cloth or bandage.  Pressing for several minutes will stop most bleeding.  Remember, constantly lifting pressure to check if the bleeding has stopped will just prolong the bleeding.  Be patient, hold that wound for a good five minutes before checking.  If the cloth becomes soaked with blood, put a new cloth on top of the old one.  Should the bleeding not stop, head to the ER.

Once bleeding has stopped, wash your hands and remove dirt by running water over the wound.  Don¨t scrub the wound yet.  The old faithful hydrogen peroxide can help clean. Peroxide kills germs and can “bubble up” dirt and dead skin.  Only use peroxide once. Multiple uses can poison good tissue and delay healing.  Soaking open wounds in a mix of water and betadine also kills germs. If there is no more bleeding for áwhile, then you can gently scrub the wound with a washcloth if ít has embedded debris.

We see a variety of lacerations in the Emergency Department, and a variety of parental questions about management.  Sometimes the child has a tiny scrape the size of an eyelash, with Dad asking if we should call plastic surgery.  At the other extreme, the kid comes in with a mangled hand that looks like it was attacked by a bulldozer, with Mom wondering if it needs a bandaid.

So when should you bring your child in?  Here are some examples: heavy bleeding that doesn´t stop after 5 to 10 minutes of direct pressure.  Deep (down to fat or muscle layers) and/or longer than one inch.  Large, gaping cuts on the face.  Animal or human bites that break the skin.  Dirty wounds that you can’t get all the debris out. Signs of infection like increased pain, spreading redness, swelling, or drainage.

Many wounds heal themselves without stitches, and sometimes doctors prefer to leave wounds open to heal “from the bottom up.”  For example, we don´t stitch most animal bites, so that the stitches don’t trap infection inside the wound.  We stitch cuts mainly to minimize scarring and improve how the scar will look. Stitching wounds also can stop bleeding, increase scar strength, heal cuts faster, and decrease pain.  Face and forehead wounds can particularly need stitches for the best cosmetic result.  On the other hand, cuts inside the mouth and on the tongue, even deep ones, rarely need stitches. The inside of the mouth heals miraculously, closing big wounds in a few days.

We have many methods to close wounds: stitches (a.k.a. sutures), medical glue, staples, steri-strips (sterile tape).  Glue is good for clean, no-tension incisions.  If the wound cannot be easily closed by gently pushing the edges together, or has shaggy edges, then stitches are better.  Staples are best for areas where scarring is not an issue (inside hair lines). By the way, don’t remove medical staples yourself with an office staple remover.  Paper and medical staples are different animals.  Been there, saw that, saw the scar….

When in doubt, call your doctor, or maybe even send a picture from your phone.  Doctors can often tell you over the phone if a wound needs stitches, but sometimes we just gotta see it for ourselves, to know if we need to…Stitch This!

Addicted To Diagnosis

Last week we saw a 7 year-old girl with eight days of sore throat and fever.  Her parents were frustrated: they had seen their doctor twice, another ED once, had three flu tests and two strep tests and blood tests that were all negative, had two different antibiotics that didn’t help, and still no answers.  She was getting more miserable, with worsening throat pain, continued fever, and now a swollen face and neck.  So, I’d like to take credit for making the clutch diagnosis, but my nurse Natalie beat me to it.  She assessed the girl first and made the call: “It’s mono.”  I went in, saw the girl for myself, and agreed.  The mononucleosis test came back positive.

The parents were overjoyed.  First, Natalie impressed them with her thoroughness: “You were the first to feel her neck glands.”  Second, they felt like we really listened to their story.  Finally, they had a diagnosis, knowing what was wrong and what to expect for the future.  Unfortunately it was more of the same- fever and throat pain. Mononucleosis is a viral infection that causes fever, fatigue, sore throat, and swollen glands.  As a virus, antibiotics can’t kill it- it must run its course, and mono can last weeks. We could only offer a course of steroids.  Sometimes steroids decrease the throat inflammation, pain, and swelling; sometimes not.

This story illustrates how people need answers for their pain and misery.  Ours was the fourth visit the family had in 8 days in their search for a diagnosis.Test after test had been run.  This craving for answers is a natural desire in patients and families and of course in doctors.  We all find comfort in diagnosis- finally to know what is wrong, and what to expect in the future.

Unfortunately, parents’ and doctors’ zeal to find answers can hurt.  A natural inclination when the diagnosis is uncertain is to order more tests, to try more medicines to see if something helps.  But tests have a price.  Too many xrays and CT scans mean radiation, which can cause cancer later in life.  To kids, blood tests mean needles, dread, and pain.  And needles and catheters can cause infections, invading the body with devices that introduce germs where they can thrive.

Starting medicines like antibiotics without a firm diagnosis can also cause harm. Antibiotics have side effects.  They can cause allergic reactions; vomiting, diarrhea, and cramps; and yeast infections.  Antibiotics don’t kill viruses, so giving them in cases like our girl above increases risk for more misery, with no benefit.

Another consequence of needing diagnosis is a phenomenon called “The Vulnerable Child,” where the diagnosis scares the parents into thinking their child is fragile.  This often starts with a benign diagnosis like allergies. The parents are happy to be given an answer, but then believe that their kid is now sickly. They become overly protective. They don’t let him go out to play or do sports. They limit his friends.  He grows up with less fun, more isolation, and less exercise. Though the child’s body is fine, the parents don’t see it that way, even after being told that he is basically healthy.  The Vulnerable Child can start with diagnoses like asthma, prematurity, even simple heart murmurs.

The best way to make diagnoses then, without unnecessary tests and drug trials, is with a thorough history.  Your doctor should get a complete story of your child’s illness, detailed from start to finish.  This takes lots of listening and lots of questions. The doctor then needs to do a thorough physical, looking for all the clues to confirm what the child’s history has suggested.  Doctors make 85% of their diagnoses by history alone; physical exams and tests usually only confirm diagnoses, not make them.

And patience is needed.  It can take time to make a diagnosis; disease can be slow to reveal itself.  Consider our girl from above with the sore throat- first impressions of cold viruses or strep throat are usually right, but it took eight days of treatment failure and negative tests and progressing symptoms to have “mononucleosis” jump out at us. A lot of those tests and the antibiotics could have been avoided.  So, don’t let an addiction to diagnosis get in the way of, well, the diagnosis.

“He Bumped His Head And Went To Bed…”

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

Kids fall and hit their heads a lot.  Though most children with head injuries are fine, some need evaluation in the Emergency Department.  The parent can have difficult decisions to make, while at the same time dealing with a crying baby: Is the brain okay?  Does my child need a CT scan?  Can he nap?  We have all heard the nursery rhyme about the old man who bumped his head, went to bed, and couldn’t get up in the morning.  What about your two-year old, who despite every effort will “fall and go boom?”

The decision is easy for the worst falls.  If a child loses consciousness, has a seizure, vomits repeatedly, has a severe headache, is lethargic or confused, then she needs to be seen.  The doctor can decide if tests are needed, or if observation is enough.  We need to consider the “mechanism of injury,” meaning how it happened and what force was involved.  A child may seem fine after being struck in the head by a baseball, but such high-speed impacts need evaluation regardless of how well the kid is acting.

Here are more criteria for needing to get seen now: car wrecks where the child is thrown from the car, another passenger in the car dies, or the car rolls over.  If he is hit by a car while walking, or while riding a bike without a helmet, that’s concerning.  Kids under two years old need to be evaluated if they fall from over three feet; kids over two, falls higher than 5 feet.  If an infant or toddler under two gets a “goose egg” swelling anywhere but the forehead, that is worrisome.

However, most kids who hit their heads are okay and can stay home.  Kids who fall from their own, standing height, are usually fine.  Kids who hit their heads but are not knocked out and go back to playing are okay too.  Toddlers who run into walls also don’t generate enough force to hurt themselves badly.

Several times per week in the Emergency Department, we see a baby who rolls off the bed or falls from the stroller.   Mom is understandably freaked out- “I just left the room for a second, she has never rolled over before!”  Most falls occur at home and are usually either from falling off beds or other furniture, tumbling down stairs, or from being dropped. Interventions used only weeks ago to keep baby safe are now obsolete due to the child’s developing abilities.  Add to that the distractions of other children, pets, dinner on the stove, and the rest of the household confusion, and stuff will happen.

Like we said above, after most falls the child doesn’t need an Emergency Department visit.  If baby fell from a height less than three feet, then he is probably fine. Further, if he is acting normally, doesn’t have any “goose egg” swelling on his head (except for the forehead- a goose egg there is okay), doesn’t vomit, and is acting well, he is okay.  If you are unsure, call your doctor.  The doctor can help decide if baby can be observed at home or needs to come in.

Many parents believe they must keep their child awake after a fall to prevent coma. However, this is an “old wive’s tale.”  Naps after a minor fall can be restorative and comforting.  If there is a question about how bad the injury was, we do like an observation period where the child is watched for warning signs (severe headache, vomiting, changes in behavior, confusion).  During normal waking hours this is easy. However, if it is nap or bed time baby can go to sleep, but you should wake him up hourly for a few hours.  If the child is alert after waking (as alert as a child who’s just been awakened can be!), then okay.  If she seems overly groggy or lethargic, call your doctor or come in.

Unlike the old man in the nursery rhyme, most kids who bump their heads and go to bed are perfectly fine- they are not old men!  Someone needs to write a new nursery rhyme for kids who bump their heads.

Alternative Medicine?

The child had odd markings on his back.  He was three years old and being seen in the Emergency Department for coughing.  The resident first examined the boy and noted red streaks up and down his back.  The rash looked like it was drawn on by marker.  Or a branding iron.  Concerned that the child was being physically abused, the resident brought me in to look.

When I saw the marks, I breathed a sigh of relief.  “This isn’t abuse.  This is from ‘coining’,” I explained.  The family was vietnamese, and coining is an asian tradition of heating a coin and rubbing it on the back to draw out the “bad humours” causing the child’s cough.  They were not abusing their child, only trying to make him better.

We occasionally see or hear about alternative practices in the ED, what modern medicine now calls “Complementary and Alternative Medicine,” or CAM.  CAM includes traditional practices like herbology, acupuncture, chiropracty, and in Louisiana, the Traiteur. Surveys show that many more people are using CAM therapies on themselves and their kids than doctors hear about.  People are often uncomfortable telling their doctor about such practices, fearing they will be ridiculed for using what many physicians regard as quackery.

However, the line between “modern” medicine and CAM is starting to blur.  As certain non-medical therapies are shown by science to help patients get better, they have become adopted by modern medicine.  Such therapies include diet modification and probiotics, massage in kids with chronic pain, and play therapy for kids in the hospital.  The NIH now has a research section called the National Center for Complementary and Integrative Medicine, to study the validity of these practices.  The American Academy of Pediatrics also has a Section On Integrative Medicine with the same purpose.  In fact, some doctors get extra training in CAM therapies to ”integrate” CAM into their practice.

Now, some alternative medicine seems down right kooky.  Once in medical school, I was watching a woman in labor.  The Labor and Delivery nurse was an older, experienced, no-nonsense professional.  She took a clear history about the pregancy and competently assessed the contractions and cervical dilation.  But then this all-business nurse said to the woman, “We will need some more positive energy for this delivery,” and began to hover her hands up and down over the patient’s swollen belly, murmuring about boosting energy, acting like a wizard from the movies.  The nurse’s sudden change and what she was doing blew my mind.  Was this really happening, in a real hospital?  Was this Labor and Delivery, or the Psych Ward?

As I reflect on this memory now, I have more sympathy for that nurse.  I pray, go to church, and believe God gives me strength for the many stresses and occasional tragedies in pediatric emergencies.  But Christianity seems kooky to my sister-in-law, who is an athiest.  To her the universe is a machine, needing no diety to run it.  My belief in an unseen God and Holy Spirit is just as silly to her as the Labor nurse’s invoking positive energy with her hands.  However, this illustrates why many people use alternative medicine- it fits their belief systems, they are comfortable with it, and they feel it helps.

As we discussed above, scientific medicine is now researching alternative CAM therapies.  Science is powerful- it has given us antibiotics, cancer cures, anesthesia.  Science also realizes that belief is powerful too, and is testing the limits of what we believe will work and what actually will work.  Science has already revealed the danger of some alternative medicines- St. John’s Wort and chelation therapy in autism, for example. Science has also started to show that traditional practices like acupuncture, chiropracty, and massage may have real therapeutic benefits.

So don’t be afraid to talk about “alternative” therapy with your child’s doctor.  The doctor may already know more about these practices than you think.  Your kid’s doctor needs to know about these, to help counsel you about which practices are safe and which aren’t. However, if your doctor starts passing his hands over your child and murmuring incantations, maybe the doctor has gone too far.

 

 

 

 

 

 

 

Nutrition—For Life!

This week’s guest columnist is Dr. Allan Olson, a family practice resident at the University Health Center here in Lafayette.  Allan is 61 years old, yet is on the long and stressful road of residency that makes a doctor.  How does he do it?  For one, he takes care of himself with a healthy diet.  And there is no better time to learn to eat right than as a kid.  Read more:

How can parents have the biggest effect on their children’s health? Providing a safe environment and promoting physical activity top the list.  However, your guidance with the greatest potential involves something we do every day- eating.  Nutrition is a huge opportunity to help your kids feel good and be well prepared for their day. Furthermore, your food leadership will create habits to insure good health for their whole lives.

What foods are best?  Research is showing that whole food, plant-based nutrition provides the maximum benefits for children and adults.  This means a diet consisting of vegetables and fruits and less animal products (meat and dairy).  Avoiding fast food and processed food (any food that comes from a factory) is also important to eat well.  These contain too much fat, sugar, and salt for your body.

For many people this will be a major change in the foods they eat, and it is important to say that such changes need not happen overnight.  The key is to begin selecting foods which consist of plant products that have not been fried or processed, frozen or boxed. Start using these foods in your family’s diet, and eventually meet the majority of your meal needs with them.

Food choices can influence whether kids develop certain chronic diseases.  Childhood obesity has become much more common, as have diabetes, asthma, and constipation. Studies show most obese childen will become obese adults, and can expect to develop adult diseases early in life, like high blood pressure and heart disease.  In other words, obese kids will live shorter and more miserable lives.  While many factors lead to these diseases, food is among the most important causes, and the most effective cure!

Two examples of how diet can influence health and illness:  Many children with constipation are cured when milk is removed from their diet, and fruits and vegetables added.  Some studies show best results when all dairy is stopped.  Know that eating milk and cheese is a matter of choice, not necessity, for children and adults.  We do not absolutely need milk or other dairy in a healthful diet.

Asthma provides another example.  Asthma has become very common in children. Asthmatic airways become inflamed, breathing becomes difficult, and kids wheeze.  Often kids with asthma also have allergic runny noses and itchy skin.  These can be treated with medications, but we are finding that in many children they can be prevented with a plant-based diet.  Specifically, the antioxidants in plant foods seem to both prevent and treat the inflammation in allergy and asthma.

Now food companies have seized this idea and manufacture foods with added antioxidants, touting them as more healthy.  However, studies suggest that antioxidants in processed-food are much less effective than in whole foods.  It seems the whole food must be eaten to get the health benefits, and that natural foods contain other beneficial components besides the antioxidants.

Here are some more hints on diet.  Breakfast really is the most important meal.  Be sure your kids eat it every day, if only some fresh fruit.  Have your kids eat at home as much as possible, at the table with the whole family.  This is an important social time for families, and you can be sure your kids are eating right.

Avoid sugary drinks like soda and other canned or bottled drinks.  Even those which are sugar-free and artificially sweetened are not good.  Sugar-free drinks still do not keep off the pounds!  The best drink is water, though some sports drinks are okay for electrolyte replacement while exercising, or if your child is sick with vomiting and diarrhea.

Finally, eating should be fun!  Invite your kids to help you plan meals based on plants. Include their ideas in selection and preparation.  Make trying new foods an exciting challenge.  Your children may need to try a particular food a dozen or more times before they like it.  Your choices for their diet will help shape their choices- for life!

Kids As Infrastructure?

As I write this, elections just happened yesterday, with of course lots of talk about the economy.  Despite the political fighting, one thing Democrats and Republicans can agree on: government needs to provide infrastructure.  To have a humming economy, you need good roads and bridges, railroads and air transport, to move people and goods.  You need energy and communication.  So why is a pediatrician writing about railroads and the economy?  Because another key part of infrastructure is education, and that’s kids.

The coming generation of workers is as important to the future US economy as good roads and airports.  We will need skilled and educated workers for the high-tech communication, manufacturing, and engineering jobs of the future.  And right now we are on target to getting beat by foreign competition to supply those workers.  While India and China spend less per kid on education than the US, they do volume business.  With hundreds of millions of kids in their education pipelines, they will bring out plenty of crackerjack engineers and scientists.  In a generation, the leaders of innovation, manufacturing, and technology could very well be in Asia, with the United States left as an economic has-been.

Not enough US kids, particularly Louisiana kids, are getting the education they need.  Driving I-10 East towards Baton Rouge will tell you that Louisiana is not spending enough on roads.  Driving past Lafayette High and seeing its building will tell you that education is not getting enough money either. Then read about cuts to Louisiana’s college budgets. We must do better to get every child a good schooling; the US will need every kid, rich or poor, black or white, girl or boy, to stay ahead.

Good education is not just important to Louisiana’s and our nation’s economies.  It is even more important to the kids themselves.  Kids need good educations to get good jobs.  Kids need good educations to climb out of poverty and ignorance.  There are three pillars of happiness- having love, hope, and work.  The quality of hope and work start way back with the quality of one’s school.

At least once per week I see a bright-eyed kid who lives in poverty.  The child is alive with curiosity and intelligence.  As my mom would say, the kid has “a light bulb inside.”  Then I look at the child’s mom.  She is tired.  She has several children and two grinding, menial jobs.  She comes to the Emergency Department though she knows the child’s cough is not an emergency.  However, the doctor’s office was closed when she got off work, or was too busy to see them.  I can guess that this kid is headed for a below-average education in an unhappy neighborhood.  What will happen to that curiosity and intelligence?  It makes me despair.

The magic bullet to cure poverty is education.  Education starts with reading.  When I see a poor mom and child with potential, I take time to talk to mom about reading.  I tell her to read a book to him every night.  Talk to him a lot.  Fill his head with words.  Intelligence and happiness in kids is proportional to the amount and diversity of words they hear in infancy and early childhood.

The next step in education is pre-school and Head Start.  A good program with early reading and classroom socialization readies a kid for success in school.  Key words in that last sentence are “good program.”  Good pre-schools aren’t cheap.  It costs money to pay for the best pre-school teachers, decent books and toys, and a clean, bright, and safe place to have class.

The next steps in a kid’s education are elementary school, high school, and college.  Like in pre-school, good ones cost.  Society, through its government, must be willing to pay the bills.  Nothing good is free and when it comes to quality: you get what you pay for.

Good schools are the infrastructure kids need to succeed in life, and those kids will in turn be the infrastructure to make a healthy society and economy.  Now that the election is over, let’s encourage our new governments to make a better investment in those governments’ purpose- investing in the kids that will be our future citizens.

‘Tis The Season Of The Barking Cough

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

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

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

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

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

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

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

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

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

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

 

 

 

Rockabye Baby. Safely.

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

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

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

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

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

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

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

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

 

 

 

 

Whaddya Mean “It’s Just A Virus?”

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

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

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

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

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

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

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

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

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

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