Dorkapotamus On A Bike

Posted on May 16, 2013 by klfydoctor

Summer is coming. I last wrote about swimming safety, and two more popular summer activities for kids need to be addressed: biking and jumping on trampolines.

Bike safety is nothing new to me. I grew up with a Dad who was a cycling nut, and a safety nut. When I was a kid, helmets for cyclists had not been invented yet. One day my genius brother Pat, future MIT graduate, decided to see how far he could ride with his eyes closed. He got as far as the back of a parked car. After that Dad got us all hockey helmets for riding long distances.

I grew up in a small town, and would ride to and from friend’s houses at night all summer. It was pretty safe, what with no traffic and no crime, but Dad was taking no chances. I had to ride with a head light, tail light, flashing light on the saddlebag, and reflectors front, back and sides. I also had a light that strapped to my leg that shone out front and back. I was lit up like an ambulance.

Dad was a stickler for the Rules Of The Road. We went on a lot of “bike hikes,” 25 to 50 miles each, with the Boy Scouts and as a family. We always rode on the right side of the road. We obeyed all stop signs and traffic signals. We rode single file, to stay out of the way of cars. No one ever got hurt, and we would celebrate the end of the 50 mile ride by splashing into the local river.

I had a ten-speed for distances, but it wasn’t great for riding around the neighborhood with friends and popping wheelies. So my brothers built me a “chopper” bike from junk yard parts, with a ripped-up banana seat and high handle bars. One day a pedal came off and I spilled onto the asphalt. After that, Dad trained us on better bike maintenance. We did not ride when it was wet either, after the day I had sped down a hill, hit a wet patch in a turn, and skidded on my back onto a neighbor’s lawn.

Though I looked like a real Dorkapotamus On A Bike back then, the safety issues still stand. Wear a helmet. Obey the same road rules as a car. Be visible at night. Ride a well-maintained bike. And jump into the river at the end of a good hot day.

Besides biking, trampolines are another fun summer activity for kids. However, we are seeing a lot of injuries from trampolines- broken bones, head and neck injuries, hurt ankles and knees. There are so many trampoline injuries that the American Academy of Pediatrics recently discouraged parents from having one at home.

One of my pediatric nurses thinks differently. He has five kids, and they absolutely love their trampoline. When their first trampoline was blown apart by a hurricane, they mourned its loss for months, moping about, whining that there was now “nothing to do.” This past Christmas he surprised them with a new one, and it was the best Christmas ever. Now that its warmer and the sun comes up sooner, his kids get up an extra half hour early just to get some jumping in before school.

Like bikes, trampolines are fun, but some rules need to be followed. Only one kid should be allowed on at a time. Lots of injuries happen when kids fall on each other, knock each other off, or ”double bounce.” A double bounce, where one kid is falling while another kid is jumping, can generate enough force to break the legs of the falling child.

Trampolines should be on level ground and away from trees and other obstacles. A tilted trampoline will shoot a kid off to the side and on to the ground. Obstacles offer something hard for the falling kid to get hurt on. There should not be gaps between the rubber and the frame for kids to fall through. No one is sure if netting around the trampoline saves kids from injury, but it seems like a good idea. Square trampolines may be safer than round ones because of differences in the physics of the mat.

Like we said last time about pools, not having a trampoline is safest. But like bikes, a lot of kids just have to have one. Like bikes, be sure your kids follow the rules. We in Pediatric Emergency Medicine would like a quiet summer.

Water Safety In The Wettest State In The Union

Posted on May 2, 2013 by klfydoctor

One day the ambulance brought in a 13 year-old who had almost drowned in a local hotel pool. He was awake on arrival, but everyone had a good scare. The pool had a deep end but no lifeguard.

The boy could not swim, the parents told us, but enjoyed bobbing in the shallow end, going to the bottom and then pushing up out of the water. This time he had bobbed and bobbed is way into the deep end until he couldn’t bob up high enough to reach the surface. The boy remembers looking up and seeing his parents helplessly looking back down at him. They could not swim either.

All the parents could do was shout from above: “Get out of the pool!” I guess they could not make the connection that “can’t swim” means “can’t get himself out of the pool.” Eventually a more capable adult jumped in and hauled the boy out.

This story illustrates several points for swimming safety. Water is fun and inviting. If you don’t know how to swim, however, water is deadly when you get in (literally) over your head. Being safe means knowing how to swim. Summer is coming and it is time to sign your kids up for lessons. The Boy Scouts and Girl Scouts have excellent swimming programs. One of the first things a Boy Scout learns is not just how to swim, but how to swim safely. The lessons l learned at Scout Summer Camp stick with me today.

The first safety principal is swim at a pool with a lifeguard. Lifeguards have training to save drowning kids without endangering others. There are too many stories in the news about people who jump in to save a foundering child, and end up drowning too. It takes training and equipment to safely rescue a swimmer in trouble.

Next, swim with a buddy. That way if one gets in trouble, the other one is there to help. It is also just good sense to have someone account for you. Lastly, have flotation devices at the pool. If someone gets in trouble, throwing them a float to hang on to is better than offering your hand. You don’t want to get pulled into the water and taken to the bottom by a panicking victim.

There are two groups of kids that tend to drown more: toddlers in water at home, and teenagers in open water like lakes and rivers. The best way to prevent a toddler from drowning is not to have a pool or pond on your property. Everyone loses track of their little one sometime. It is impossible to prevent. They are natural explorers, and poor listeners (they barely speak English yet!). They are going to get out and into things- the street, the cleaning products, the backyard pool. If you don’t have a body of water at home to fall into, you eliminate the risk of them falling in and not being able to get back out- a pond doesn’t even have to be over the child’s head to be deadly!

If you already have a pool or pond, the next best thing is to fence it on all four sides. No back door access to the pool! The fence should be toddler proof. This means a fence that can’t be climbed, with a lock too high for the toddler to reach. If you haven’t seen that kind of fence before, visit a local hotel pool. They will have one.

Talking to your toddler only helps a little, but talking to your teenager works (somewhat) better. Despite what we all say about teens, they do listen, particularly when we talk directly to them about safety. It helps to talk to them earlier- at ages 10-12, about not drinking while swimming or boating, about not diving into shallow water, about swimming with buddies who are also safe and responsible. Talk to them nicely! Tell them you trust them to do the right thing, but as a parent you have to remind them to be safe. Take the eye rolling and “you’ve told me this a thousand times” in stride. Teens do this even when they are listening.

Drowning is preventable- do your part. Secure any water at home, get the kids swimming lessons, and talk to those teens. Let them get wet this summer, but safely!

More Itching, More Rashes

Posted on April 16, 2013 by klfydoctor

Last week’s blog post on eczema brought to mind two other common rashes we see in the Emergency Department: hives and poison ivy. We see hives a lot because it really does look bad, and is associated with bad allergic reactions. When a kid is covered with itchy welts, especially when they have blotches on their face and around their eyes, parents think about other scary allergic reactions: Will my child start to wheeze and struggle to breathe? Will his throat close up? Will she go into shock?

The good news is that hives, or ”urticaria” in doctor-talk, by itself is not dangerous. If your kid has had hives for an hour or two without any of that bad stuff above, rest easy. The bad allergic reactions- throat swelling, wheezing, anaphylactic shock- happen immediately in an allergic reaction. Hives are also quite common. Most kids have an attack of hives sometime in their childhood, and they get over it just fine.

What causes hives? When a kid comes in covered with itchy welts, the parents have already been racking their brains for causes. What food did he eat? Did we use a new washing powder? Did she get bitten by something? It turns out that most urticaria episodes have unclear origins. In fact, if the kid gets allergy testing after a hives outbreak, most often all the tests are negative. Only if the child has just taken something highly allergenic before the attack, like antibiotics or allergenic foods like peanuts, do we have a possible culprit. For most kids though, there is no obvious cause.

How do you treat urticaria? As you probably could guess, use good old Benadryl. Benadryl is good for the itching, and makes the rash look better. Tylenol is also good for itching and is safe to take with Benadryl. If the Benadryl still is not enough to keep your kid happy, sometimes we add steroids.

More good news about urticaria is that it is short-lived. Most kids are better in 2 to 4 days. Rare cases last longer, and those are the few kids who need allergy testing. Otherwise, if your kids has hives, don’t panic! Give some benadryl, maybe some tylenol, keep them cool and their skin soft. And don’t go too nuts trying to figure out a cause- you won’t!

Poison ivy is another common non-emergency rash that we see in the Emergency Department. It may not be an emergency, but like hives and eczema it sure does itch like crazy, and looks awful. It is red, streaky, and often has pustules and wet, weepy patches. Kids commonly get it on their faces and arms and legs, since these are the places skin is exposed and brushed by the poison ivy leaves.

Poison ivy is one cause of a class of rashes we call “contact dermatitis.” In other words, any irritant that contacts your skin can cause this rash. Other irritants, like poison oak, poison sumac, or any other thing your kid’s skin is allergic to, can cause a break out. Myth buster: many people think poison ivy is contagious, that you can spread the “oil” that causes the rash to others. THIS IS WRONG! Poison ivy and other contact dermatitises are not contagious. It seems contagious when a kid as more and more break-outs on his own body, as if he is spreading it around by scratching. In reality, the kid is just having later breakouts where his body got a lower dose of the allergen.

To treat poison ivy, we use steroids again. Steroids are anti-inflammation medicines, and calm down the skin inflamed by the irritant. Another myth-buster: steroid injection, the “cortisone shot,” does not work any better or faster than steroid pills or syrup. Other treatment for poison ivy includes covering the really raw spots with bandages, and giving Tylenol or ibuprofen for the itch. Poison ivy can take as long as a week to heal.

So if your kid has poison ivy, dress the worst patches and give him or her some Tylenol for the itching. Call your doctor for a steroid prescription and tell his teachers he is not contagious. Tell them you heard it from me!

Is Itching An Emergency?

Posted on April 5, 2013 by klfydoctor

It is discouraging when a parent checks their child into the Emergency Department for a rash. Rashes are rarely an emergency and should be seen by the child’s regular doctor. I often go into these patient’s rooms feeling grumpy: I feel like this parent is misusing the system, coming to the Emergency Department for convenience rather than being patient and waiting to see their doctor. However, when I see the child covered with rash and scratching away, I get more sympathetic. I too have sensitive skin, and itching drives me absolutely nuts. I imagine this little 2 year old guy trying to sleep at night, but his skin is on fire and he is tearing himself up with scratching.

Rashes are rarely emergencies, but on the other hand itching is quite miserable. Itching is particularly bad at night, when the air is dry, and there are no day-time distractions to take the kid’s mind off his itch. The child is trying to sleep, but the itch won’t let him. And this is the purpose of this blog: to give parents tools to take care of these problems at home and avoid a time-consuming and expensive Emergency Department visit.

The most common reason for kids coming to see me for itching is eczema. Eczema is a condition where skin is extra-sensitive. Extra sensitive skin easily itches when irritated. When it itches, kids scratch. When they scratch, they make a rash. Eczema if often called the itch that rashes, rather than the rash that itches.

Eczema is partly genetic. These kids are born with skin that is extra sensitive, and breaks down more easily. Then that sensitive skin gets irritated. Many things irritate eczema skin, like dry winter air or air-conditioned air. Dusty conditions are drying and irritating too. Some soaps are hard on eczema skin, like Zest, Ivory, Irish Spring, and Dial. These soaps are so strong that they wash away the natural oils that skin makes to protect itself. Finally, skin can be irritated by abrasive things like washcloths, synthetic clothes, and things that chafe like jewelry or wet and tight clothing.

These things that cause eczema to flare do two things: they dry, or they rub. And these are the clues to eczema treatment: moisturize, and protect. The first step in moisturizing is to use a moisturizing soap rather than a drying soap. Good soaps are Dove, Caress, and Lever. The next step is using a moisturizing lotion. This should be smeared all over the child’s itchy dry skin three times daily. It is especially important that one of those times to put it on is right after the kid takes a bath and dries off. This ”locks in” the moisture the child’s skin gets from the tub or shower.

To avoid rubbing injury to eczematous skin, have your kid wear only loose fitting, 100% cotton clothes. That way the clothes don’t collect sweat and stay wet, and don’t rub too much. Washcloths often irritate skin too. They scrub at the skin, which damages sensitive skin. Kids with eczema should soap up with their hands or a very soft sponge. Toweling scrubs skin too. Kids with sensitive skin should be patted dry with the towel, not scrubbed.

Eczema is often helped by medicines like steroid creams. Steroids are anti-inflammation medicines, and can calm down inflamed, itchy skin. Steroid creams come in many strengths. The mildest is over-the-counter hydrocortisone. Hydrocortisone will calm down most minor, itchy patches. Medium and high-strength steroids can only be had by a doctor’s prescription. I prescribe medium-strength steroids, which are pretty strong but do not have the potential to damage skin. High strength steroids should only be prescribed by dermatologists, since they can harm skin if used improperly.

Other good medicines for itching are medicines like tylenol, ibuprofen, and benadryl. Tylenol and ibuprofen take away pain, and itching is actually a minor type of pain. Since eczema is an allergy-related sensitivity, benadryl can help with that itch too.

So when your child with itchy skin starts scratching and whining at night, try these things to calm and protect the skin. It that does not work, call your doctor. Eczema is a chronic condition, and chronic conditions should be seen by the same doctor who knows what has worked and what has not. Don’t go to the Emergency Department or a walk-in clinic, because you might see different doctors every time, who won’t know your child’s condition. It is your doctor who will go the extra mile to help your kid with his emergency itching.

Was Rudolph The Red Nosed Reindeer Allergic?

Posted on March 22, 2013 by klfydoctor

When my son got his first ear infection at 8 weeks old, I might have known. Soon after he began having continual congestion. He spent much of his childhood with itchy eyes and nose. Many pictures from that time show him smiling away with a red nose like Rudolph. He lived on Zyrtec and Flovent in the winter months in order to keep the itching and coughing down and to help him sleep and not be miserable during the day. Teenage years came and thank god he outgrew that stuff. Now his biggest medical complaint is a sore pitching arm.

Head allergies are common in kids, though they are sometimes hard to diagnose. Cold viruses and sinus infections give kids a lot of the same symptoms- runny nose, cough, itching eyes and noses. Allergies tend to give kids symptoms a lot longer, but young ones in daycares or schools can have long lasting symptoms too because they catch cold virus after cold virus, one right after the other, so it looks like one continous illness. Chronic asthma can sometimes act like allergies, with continous coughing and chest congestion that doesn’t always wheeze.

So how do you tell the difference between continuous colds, allergies, or mild chronic asthma? Besides the itchy head, does your child get his symptoms with change in seasons? Is there a history of allergies in mom or dad or other relatives? Do obvious allergic triggers like animals or dust seem to make the child sneeze and itch? If it seems like the kid has allergies, one way to make the diagnosis is to try an anti-allergy medicine. Drugs like Claritin (Loratidine) or Zyrtec (Cetirizine) are pretty effective and very safe, so safe that they can be bought over-the-counter. If the child gets better in a day or two and stays better on the drug, allergies may be the cause. Some allergies are hard to diagnose, or hard to treat effectively, in which case the child might need to see the allergist.

Your pediatrician or family practitioner can usually diagnose allergies without an allergist’s help. If the child has lots of eye and nose itching and is always congested, if there is a family history of allergy, that may be enough. The doctor will often ask for the parent’s help with figuring out what is causing the allergic reaction- dust, dogs, seasonal pollens in the air, mold? What seems to make their child sneeze and twitch? Sometimes parents are asked to keep a journal of when their child has symptoms and where they are at the time. Your doctor can also order blood tests which can give clues to allergy being the problem and what is causing the allergy.

If your doctor has trouble figuring out if allergies are truly the cause of the child’s misery, or if standard treatments aren’t working, that is when the child is referred to an allergist. The allergist can perform more accurate tests to see if the child is allergic, and to what. Once the diagnosis is confirmed, the allergist then often goes back to the basics for treatment- avoiding the thing the kid is allergic to.

Avoidance is the mainstay of allergy treatment. If dust is the cause, and it often is, then the allergist can talk to the family about dust control in the bedroom and the rest of the house. If it is cockroaches, another common allergy trigger, they can address that. If medicines are needed, the allergist can help the family figure out what medicine or combination of medicines would be best. Finally, if a child has an allergy that is really hard to avoid and treat, the allergist can design a “immunotherapy” program to help the child’s body be less sensitive to the allergen. These are the”allergy shots.” Immunotherapy is safe and effective for the right patient, and can make a big difference in the quality of the kid’s life.

So if you think your child has allergies, talk to your doctor. Pay attention to what seems to make your child cough and sneeze and rub his nose and eyes. Itchy faces can be miserable, take it from my son.

Asthma: How Can We Breathe Easy?

Posted on March 7, 2013 by klfydoctor

When I was in college, I volunteered at a homeless shelter. Back then people were allowed to smoke indoors, and after a night shift I would leave with my hair stiff with cigarette smoke. Then I caught a cold, and a cough that did not go away. I hacked all day and woke up through the night coughing. After a month of misery, I went to the infirmary. The Physician Assistant there said I had a cold and gave me some cough drops.

Weeks later, still hacking, I went back. The PA did the same things, to no effect. Weeks after that I went back yet again, insisting on seeing the doctor. The doctor listened carefully to my story, said I had mild asthma from the combination of the cold and the cigarette smoke, and gave me an inhaler. Within days my cough was gone.

Many people find asthma confusing and complex. It is sometimes hard to diagnose, like my episode above. It can be triggered by many things and the medicines can be confusing- what do I give my kids when they are sick? How do we use an inhaler? What medicines should they take when they are well? How do I avoid asthma attacks?

Asthma, simply put, is wheezing that can be reversed by medicines. In asthma, the airways in your lungs are extra sensitive to irritants. The airways close up to keep out those irritants: cold viruses, pollen, cigarette smoke, extra cold air. When the airways narrow and close, the wheezing you hear and feel is your breath whistling through those skinnier passages.

To reverse airway narrowing, we use two classes of medicines. The first are called bronchodilators, that open up (“dilate”) your airways (“bronchioles”). These medicines are breathed in through inhalers and nebulizers. the second medicines are steroids, like prednisone, which take away the swelling in inflamed airways. Prednisone is a different steroid from the steroids athletes abuse. For the four-to-seven day courses we use for asthma, prednisone does not cause weight gain, hair growth, or rage attacks. For people with really bad asthma, there are medicines to take daily to make the airways less sensitive and help prevent attacks. These are called “controller” medicines.

More important than treating asthma is avoiding asthma and its attacks. Asthma is increasing in the population in the past 25 years, and many of the things that cause asthma are all around us. Pollutants like smoke, soot, and diesel exhaust eat at our lung tissue as we breathe. We live more and more indoors these days, and therefore have more exposure to indoor lung irritants like dust and mold. The more time we spend indoors too, the more time we are exposed to our fellow humans and the cough and congestion viruses they give us.

All those irritants assaulting the lining of our air passages add up. Some people have lungs that can take the abuse. Those with more sensitive lungs, like kids, get asthma. As we talked about above, when the air passages have had enough, they close up to keep out the bad stuff. Unfortunately, when they close up, they also keep out the air we need to live. What little air we can move in and out whistles through those narrowed air passages and we wheeze, and we have to pull and tug to get the air in and out.

So how do we and our kids avoid all those irritants? First, let’s not be so hard on the Environmental Protection Agency (the EPA). The EPA is not there to shut down factories, it is there to help those factories do less damage to our lungs from air pollution. Second, we need to avoid cigarette smoke. Smokers should never smoke indoors, at home with children, or at work or at bars with adults. Heck, smokers should see a doctor for help to quit! Finally, we and our kids need to spend more time outdoors, away from indoor dust and mold and sick people. Exercise is good for the lungs (and the rest of the body too) so outdoor activities are a double win.

So if you or your kids have a cough that won’t go away, or wheeze, see your doctor. You should talk about how to avoid asthma irritants, medicines to take for attacks, and if need be, medicines to prevent attacks. You and your kids should be allowed to breathe easy.

The Need For Speed

Posted on February 21, 2013 by klfydoctor

In the movie Top Gun, Tom Cruise, playing hot-shot fighter pilot “Maverick,” yells “I feel the need for speed!” He is of course talking about jets. In medicine, we are talking about stimulant use. Humans around the world commonly take the stimulant called caffeine, whether in coffee, tea, or diet coke. We drink caffeine to wake up in the morning and to pick us up in the groggy afternoon. We take it because it makes us feel good and by-and-large, it works pretty well.

Life gets pretty busy for kids when they become teenagers, and they start using caffeine too. They use it to stay up with school work or with friends, then drink it to wake up the next morning. And as we all know, many teenagers cannot get enough of a good thing, and start to overuse stimulants. Teenagers overuse stimulants in two ways: by drinking energy drinks, and by taking Attention Deficit-Hyperactivity Disorder medications that are not theirs.

Energy drinks like Red Bull, Monster Energy, and Rockstar became popular in the 1980s. They were invented to give more of what one could get from a cup of coffee- more sugar, more caffeine. They tasted terrible (still do), but marketing them as the drink for the really busy got people to try them. Since they worked, people got hooked.

Energy drinks work because they have a lot more caffeine and sugar than coffee or cola. They contain caffeine plus a substance called guarana, which is essentially a high-potency version of caffeine. Energy drinks can be so potent that besides use as a wake-up or study aid, some teenagers drink them to get a ”high.” When mixed with alcohol, the energy drink and the alcohol enhance each other’s effects, and the high is multiplied.

The potency of energy drinks makes them a problem for us in the Emergency business. We see many teenagers in the Emergency Department with complaints of chest pain, palpitations, dizziness, and anxiety. These conditions are often benign, but they are made worse, and happen more often, with the use of energy drinks. Take a teenager with anxiety and school pressure, amp him up on an energy drink, and the anxiety gets amped up too. When energy drinks are mixed with alcohol, alcohol effects are worse as well- more car accidents from drunk driving, more fights, more alcohol poisoning.

Another stimulant teenagers are using a lot are Attention Deficit Hyperactivity Disorder medications like Adderall, Concerta, and Vyvanse. Children and teens with ADHD are often helped by stimulants to keep awake the part of their brain that helps them stay focused and calm. The medicines are mostly derivatives of amphetamine, the drug known as “speed.” Many high school and college students without ADHD use these medications as a study aid. They buy them from kids with ADHD for a few dollars per pill (the price goes up at finals time!).

These stimulants can be effective study aids. The non-ADHD teen uses them to stay awake to study for a test or pull an all-nighter to write a paper. Two kinds of teens use these meds. One is the kid who failed to plan his school work and left a lot for the last minute. The other is the highly competitive kid in a highly competitive school environment, trying to stay ahead of his classmates.

Though ADHD medicines often work for these kids, they bring many problems. They are addictive. Typical teens will try a pill for a one-time study session. It works so well that they start using it for more tests, then to write papers, then to just get through their piles of homework. Eventually it is a steady cycle of blasting through work on an amphetamine high, followed by crashing and sleeping it off, often accompanied by weight loss and depression.

Also, it is illegal for kids to take these medications without a prescription. It is illegal for kids with ADHD to sell them. It is also just plain cheating to use stimulants for school work. Just like it is cheating for professional athletes to use these and other performance-enhancing drugs to get ahead in their sports, it is cheating for teens to use them to get better grades.

Finally, these drugs have the same side effects as energy drinks, only worse. Anxiety, tachycardia, hyperventilation, sleep deprivation, and post-high depression are all problems that bring teen users into the Emergency Department. Even worse, these medications bring risks like heart arrhythmias and sudden death to the user who has not had a proper medical screen by a doctor.

So help your teens to avoid wanting to use energy drinks or illegal stimulants to get school work done. Help them learn good time management, study habits, and sleep habits when they are younger. Learning those good habits is not only good for managing school work; they help when planning life. And if they feel like a pick-me-up, if they “feel the need for speed,” buy them a cup of coffee.

Stomach Ache- Is It Time For A Visit From The Surgeon?

Posted on February 5, 2013 by klfydoctor

I can still see my oldest daughter, 10 years-old then, with her forehead on the dinner table. She could not eat, her stomach hurt too bad. At that time she was having some school trouble, so my wife and I passed it off as anxiety or a virus, and excused her to go lie on the couch. Later that night when I got home from violin lessons, my wife and daughter were curled up together on my daughter’s bed. Now the pain was on her right lower side, and was getting worse. I had a feel of her abdomen, and we went to my Emergency Department. There were blood and urine tests and an IV, a visit from the surgeon, and the next morning my daughter had her appendix taken out.

Abdominal pain is a common reason for visits to the Emergency Department. Often parents are worried that the pain means something bad, like appendicitis, that needs surgery. When the pain is accompanied by vomiting and diarrhea, parents worry that the child might get dehydrated. The diarrhea and vomiting is messy too, and they want it to stop. Parents also come because the pain just plain hurts, and they don’t want to see their child suffer.

So when is stomach ache not an emergency? First, when it starts with diarrhea and vomiting, that is usually a “stomach virus,” an infection the child caught from someone else. The vomiting usually only lasts half a day, the diarrhea for 3 to 4 days, and it is unusual for a child to get so dehydrated that they need to come to the Emergency Department. The cramps are typically mild and easily treated with pepto-bismol, ibuprofen, or tylenol. When a child vomits, food and milk need to be withheld for 6 hours, and he or she given only clear liquids like gatorade, starting with small amounts to go easy on the stomach.

Abdominal pain that has been going on for weeks and months is also not an emergency. Pain going that long needs to be seen by the kid’s regular doctor, who can organize a methodic search for the cause, or refer the child to a specialist if the pain continues. By definition, pain that lasts weeks is not an emergency-the child would have already needed hospitalization or surgery in the first few days of pain if it were. Going to Emergency Departments for chronic pain means seeing a different doctor every time and having expensive, haphazard, thus and sometimes ineffective strategies for diagnosis and treatment. Chronic pain is often caused by constipation, or anxiety, or a combination of these and other factors.

What is an emergency? The most common emergency with abdominal pain in children is appendicitis. Appendicitis typically starts with pain, not vomiting and fever. The pain is steady and slowly worsens. It rarely comes and goes. Later in the course, after the pain has moved to the right lower side, comes the fever and vomiting. Diarrhea is unusual in appendicitis. Appendicitis needs surgery, so if the child has steadily worsening pain, call your doctor or bring him in to the Emergency Department.

Severe pain, where the kid is rolling about on the floor crying with pain, needs to come in. This is often because of cramping from constipation, but pain that bad needs to be looked at. Occasionally severe pain can be caused by something worse, like kidney stones in a teenager or a blockage in a toddler.

Other worrisome signs with abdominal pain are vomiting for more than 8 hours. Dehydration becomes a concern after that, and the parent should call the doctor to talk about it. A child who becomes progressively more tired and lethargic is concerning. This could mean dehydration or a worse infection than a stomach virus. Finally, any child with abdominal pain and shortness of breath needs to come right in. Again, this could mean a worsening infection or dehydration.

So next time your child starts with some vomiting, has diarrhea with some cramps, relax. It is probably a stomach virus, will run its course, and just needs some clear liquids and over-the-counter medicine like peptobismol or tylenol. If your kid has pain that steadily worsens or is severe, call your doctor. Your child too may need a visit from a surgeon.

Teachers! Don’t leave those kids alone! Keep them in school!

Posted on January 23, 2013 by klfydoctor

It is no secret that doctor’s offices and Emergency Departments are extremely busy these days. It is the “cold and flu” season, and RSV season, and that makes for a lot of sick kids. In other columns and blog entries, I have discussed which kids do not need to be brought to the Emergency Department, when they don’t have an urgent condition. It is even more disappointing when a parent brings a kid in who is not terribly sick, but needs a form filled out to return to school or daycare. The parent is not happy either- they often know their child is okay, but are missing work and pay, and can’t get into their doctor that day to get the child back into class.

The American Academy of Pediatrics has published guidelines about when kids can be kept in school and daycare. Rashes without fever, coughs and colds, and “pink eye” can be kept in school. However, a recent study in the AAP journal Pediatrics surveyed day care directors about knowledge of these guidelines. The study showed that the vast majority of directors would keep out kids who could have stayed. Teachers in public schools do not fare much better. I have seen too many kids in the Emergency Department with notes required for things like rashes and pink eye.

Here is a basic list of the conditions that DO NOT have to be kept out of school or daycare:

-Rashes, including scabies, ringworm, and poison ivy (NOT CONTAGIOUS!)

-Coughs and colds

-Fevers that have gone in 24 hours and the child is acting well

- Conjunctivitis, or “pink eye”

-Non bloody diarrhea that the child can control, or that is contained in the diaper

What should be kept out of school? Any condition with fever and the child acting sick, and vomiting. In the study in Pediatrics, vomiting was about the only guideline that daycare directors got right.

To be fair, the American Academy of Pediatrics has not done a great job of making these guidelines accessible to schools, day cares, daycare licensing agencies, and the public. They can only be found in two expensive books, one of which is a textbook for pediatricians. If you go to the AAP website, you can’t find these guidelines. A general internet search will bring up one AAP school guideline which is not very clear, and a lot of individual county and government guidelines which often conflict with the AAP guidelines. In Lafayette, day cares are bound by licensing requirements that also might keep more kids out than necessary. Therefore, school and daycare guidelines are often written with no expert input. Then teachers must follow these guidelines, because that is all they have to go on.

So, teachers, daycares, governments, and schools! Please revisit your policies on what kids to keep out of school, and when to take them back. At least keep the note requirements to a minimum! Doctor’s offices and Emergency Departments could use a break. Working parents could use a break. The kids DON’T need a break- keep them where they can continue to play and learn.

What the heck is Bronchiolitis? Is that like Bronchitis?

Posted on January 9, 2013 by klfydoctor

No one ever accused modern medicine of being good at naming things. There are so many jokes out there that whole web sites are devoted to making fun of medical terminology (Example: Definition of Barium: What doctors do after their patients die). Even Boudreaux and Thibideaux are in on the joke (Doctor: Boudreaux, you’re not sick, you’re just lazy. Boudreaux: Doc, I coulda tol’ you dat. But ah need you to give it a big medical name that I can go home and tell Marie!).

It really gets confusing when we name important and common things alike. Bronchiolitis is a very common and serious illness in infants, and we see it a lot in the winter. This winter has been particularly busy. Bronchiolitis starts out as a regular cold, with cough and runny nose. Then the baby starts having fevers and wheezing and trouble breathing that looks and sounds like asthma. Sometimes babies have to be in the hospital for oxygen and IV fluids, because they are too busy breathing hard to be able to drink their milk.

Bronchiolitis IS NOT bronchitis. When adult doctors use the term bronchitis, they are talking about an infection in the airways that is often treated with antibiotics. Kids don’t get bronchitis- rarely do they need an antibiotic for coughs and colds. Bronchiolitis is caused by viruses, and antibiotics don’t cure those. One of the more common viruses to cause bronchiolitis is the RSV virus, and often doctors and families use RSV and Bronchiolitis to mean the same thing. However, many viruses can cause bronchiolitis, not just RSV.

Unfortunately, there is not a lot of things that make bronchiolitis better. As above, antibiotics are useless. The breathing treatments we use for asthmatics do not help most babies with bronchiolitis. Steroids don’t help either. Doctors sometimes prescribe treatments or steroids for lack of anything better to do. The only thing really that can be done is “supportive care”. This means fluids and oxygen and monitoring in the hospital when needed.

How do you keep your baby from getting bronchiolitis? As usual, keep them clean. Wash your hands to make sure your cold virus does not get on baby and baby’s stuff. Visitors and family need to wash their hands too before picking up baby. People with colds need to keep their distance. Day Care and Mother’s Day Out workers need to be extra careful about this.

So when you hear your baby’s doctor talk about bronchiolitis, listen up. If the doctor talks about bronchitis, they must be making a joke. Paging Dr. Boudreaux.