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.

Who Let The Dogs Out?

In 2014 I reported on a 22 pound cat named Lux who attacked his family. The family’s seven-month old baby pulled Lux’s tail, so he clawed baby’s forehead. Dad kicked the cat, who went ballistic and trapped the parents in a bedroom, prompting them to call 911. Yet they decided to keep the cat, getting it “therapy.”  When therapy failed, Lux’s veterinarian diagnosed him with Feline Hyperesthesia Syndrome, which apparently means “cat goes nuts for no apparent reason.”  On medication and in an “experienced” cat-foster-home, he’s apparently doing somewhat better.

It’s been said that while dogs are man’s best friend, cats are, well, cats’ best friend. Dogs, as animals that live in packs, are natural fits in their “pack” families.  Cats, as solitary predators, are less so. What is the best pet “fit” for families?  A spate of animal bites recently in the Pediatric Emergency Department has made me think more about this.

Most cases recently have been dogs biting toddlers.  Many attacks are unwitnessed by the parents, as the dog and child are in another room when the confrontation occurs.  Often, pets and toddlers don’t mix.  Infants and toddlers don’t know how to behave with pets: they’ll pull tails, get between pets’ mouths and their food, and lean in to kiss pets on the nose, unmindful that they’re making them nervous. I waited until our youngest was 5 years-old before getting our first puppy, and trained both how to treat each other.

It’s also important to pick the right breed.  Guard dogs (Dobermans and Rottweilers), fighting breeds (pit bulls), and shepherds aren’t the safest with children. The first two can be aggressive, and shepherds often want to herd children, nipping at them like they were sheep or cows.  Yet while farm animals have tough hides that withstand dogs’ teeth, toddlers’ skin is much softer. Finally, while everyone wants to rescue a dog from a shelter, rescues’ temperaments are less knowable than those of dogs from breeders.  Finally, dogs neutered or spayed are less aggressive, and thus safer with kids.

Finally, don’t let that dog out!  Dogs wandering from unfenced yards is a recipe for trouble.  A big batch of bites we see is neighbors’ dogs straying into others’ yards, or children going into the dog’s “territory.”

Unlike dogs and cats, horses don’t usually bite kids.  One of few I’ve seen was the time a boy was feeding his horse sugar cubes, and his fingers got chomped. When children are bitten, we worry that the offending animal could have rabies.  If kids get rabies, they die. Always. Thus we call Animal Control to inspect the animal, and quarantine it for 10 days to see if it develops rabies.

Though I’d seen few horse bites before, I knew rabid horses are rare.  I called Animal Control about what to do, who called the Office of Public Health, who called their veterinarian consultant.  This advice came down: while probably safe, the horse could have been bitten and infected by rabid skunks or raccoons unnoticed.  Lacking a corral at their facility to quarantine the horse, Animal Control settled on visiting it at home every few days to assess it’s status.

Bites from dogs, cats, and other animals carry infection risks for kids.  First, tetanus is a concern, so it behooves parents to vaccinate their children, since tetanus is also quite deadly.  Second, animals carry bacteria in their mouths, so bites that break the skin require antibiotics. That goes for bites from horses, dogs, cats, turtles, and humans. Finally, we worry about rabies.

Sometimes when we tell parents we’re calling Animal Control, they get defensive.  They’re afraid their pet will be taken away, or killed.  However, the animal is simply watched for 10 days, either at home or at Animal Control’s facility.  If taken there, Rover returns home after 10 days. This protocol is for the child’s (and family’s!) safety.  Again, rabies kills 100% of it’s victims.  If we can’t watch the animal, like if it’s a stray or a wild animal that can’t be found, or parents hide their pet, then the child needs the rabies vaccine series.  This consists of 4 shots, on the day of the bite and days 3, 7, and 14 after that.  Also, the child needs Rabies Immunoglobin injected into the wound to prevent infection while waiting for the vaccine to trigger immunity. Getting shots into a wound and then 4 more in the arm is no fun for kids, and we usually convince families to give up Fido: he’ll come home soon enough.

Who Let The Seals Out?

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

The child wakes up in the middle of the night with a weird-sounding cough, struggling to breathe, a panicked look on her face. When she breathes in, she makes a honking sound. The parents jump in the car and race for the Emergency Department.  Upon arriving, the child is miraculously better.  She sits there cooing and gurgling, breathing just fine, looking between parents and doctor and nurse.  What’s all the fuss about, her expression says. “I swear she was in real trouble!” intones the mom. Rest assured mom, we believe you.  This is croup.

Croup is a condition brought on by regular winter cold viruses.  While most kids just have a cough and runny nose, a few get irritation in their airway below their vocal cords. The airway starts to swell closed, causing the characteristic “seal bark” cough. If you’ve never heard a seal bark at the aquarium, see it on Youtube. Instead of a dog’s “arf-arf” sound, seals make a much deeper “Orf-Orf” sound, as will your croup-afflicted child. When kids have bad attacks, they also have a sound when they breathe in called “stridor.”  Stridor is an inspiratory honking from even more narrowed airways.  When a child wakes up with this “Honk-Orf-Orf-Orf, Honk-Orf-Orf-Orf”, they’re working to get air through that narrowed passage.  They sound terrible and look panicked.

Daycare is a great thing.  At daycare, children get to socialize with other kids, receive important education, and parents can tend to their jobs and other responsibilities. Daycare plays a major role in many parents’ and children’s lives.  Daycares are also great places for kids to pass around cold viruses.

For the first 18 months of her life, our oldest daughter never got sick.  When she started daycare, she got her first runny nose. Then every other week she contracted yet another cold virus that her classmates passed around.  My youngest daughter got croup from these colds. Fortunately, we were able to settle her down at home and not need an ER visit. Remember how our girl above got better so fast?  There’s reasons for that we’ll go into below.

As we mentioned above, daycare can be a wonderful thing.  Kids get to play with other kids; and parents can go to work, earn money, and tend to other responsibilities.  Note how even during the worst of the pandemic this past spring, many daycares stayed open. They’re that important for families’ function.

Daycares are also great places for kids to get sick. Infants and toddlers are virus-breeding and virus-spreading factories. A child catches a cold virus, brews it in his body, and then begins sharing it with his environment: coughing, sneezing, and running mucus out his little nose. Put that kid in a room with several other active, exploring toddlers, and soon they’re inhaling virus-laden aerosol.  They also get virus-contaminated mucus smeared on them by their pestilent playmate, their hands go in their mouths, and bingo: several more virus-manufacturers-and-spreaders are recruited.

Like we said above, a few of those infected kids develop croup. Croup is a side-effect of cold viruses, wherein the afflicted child gets narrowing in her airway right below the vocal cords. Then she wakes up with that seal-bark cough and inspiratory honking called stridor. Often these kids struggle to breathe.

Fortunately, most kids get better within minutes of their attack. One reason for the noise is that they’re sucking in dry, night-time air, which is “sticky” in a narrowed airway.  Also, when they’re lying flat while sleeping, fluid in their body contributes to the swelling. When the child sits up, waking in her panic, the swelling drains away. Then when the parents drive to the Emergency Department, the moist outdoor air lubricates the kid’s airway, and upon arrival she looks fine.

Thus the basics of croup treatment.  When parents call the doctor for croup attacks, they’re advised to hold kids upright and take them outdoors, or into the bathroom with all the hot faucets on to steam it up.  If that doesn’t work, then get seen.  We often prescribe steroids to decrease the airway inflammation, and occasionally use a special breathing treatment called racemic epinephrine for bad cases.  Your usual home breathing treatment, albuterol, doesn’t help with croup, except for the mist coming out of the pipe. Easy enough to turn your little seals back into kids.

Screamin’ Down The Road- Part III

In previous installments of Traveling With Children, I’ve discussed avoiding disasters  like plane crashes or hotel fires.  Traveling With Children now has a new dimension: avoiding getting COVID on road trip potty stops.  Yesterday our cousins with three little girls sent us pictures of their driving supplies while they head out west.  They included a five-gallon bucket with a toilet seat, filled with kitty litter. The picture’s caption: “This helped us avoid at least 24 interactions in public spaces.”

When little kids use the potty, they touch everything: the toilet seat, the walls, you, their own mouths. Gas station bathrooms are nightmares keeping track of their hands and staying sanitary. Now add the risk of breathing in COVID-laden aerosol from fellow travelers. The Centers for Disease Control (CDC) recommends not traveling at all during the pandemic. Traveling means increased interactions with other people, at gas stations, restaurants, and the vacation destination itself.

However, many are craving their summer vacation and like our cousins above, heading out. The great outdoors is a popular destination this summer.  Open air seems to greatly decrease your risk of breathing in someone else’s Coronavirus, as opposed to being indoors and breathing other people’s recirculated air. Hiking is good exercise, and a welcome change of scenery from your home’s yard and four walls. And being outdoors lets you avoid crowds.

I find giving advice about vacationing is like giving advice to ATV riders.  People put kids on ATVs no matter what I say, so likewise here’s how to minimize your risk if you must go on vacation. First, don’t travel to COVID hot spots, like California or Florida, where your odds of catching it are increased. Second, minimize interactions enroute to your destination.  This means not eating inside restaurants. Using drive-thrus is safer, but three drive-thru visits per day still increases your interactions with potentially infectious strangers.  Best to pack your own food, which is also less expensive and can be healthier.

As far as that potty stop, good luck!  One friend mentions that she and her kids will go “over the side of the road,” but her kids are teenagers.  With three little girls, our cousins went with the home-made port-o-potty.  Maybe just stay home?

While many are hitting the road for summer vacation, those lucky enough to have boats are hitting the water. NPR recently reported on boaters in Washington State sneaking across Canada’s closed borders to visit. Locals at one coastal town complained about an American yacht with teens and adults “wandering the dock…no social distancing, no masks, and went through the store as if…shopping at Walmart.”  To avoid detection, US boaters switch off their transponders, which are required by international law to avoid collisions, particularly at night or in fog. With so many American boats “going dark” when they cross the border, the Canadians know they’re not all sinking.

For places that rely on tourist dollars, allowing vacationers in is a two-edged sword.  While their livelihoods depend on visitors’ lodging and eating, those visitors also bring disease. Canada decided that American dollars aren’t worth the risk of more Coronavirus.  Our National Park system decided the opposite.

The citizens of Jackson Hole, Wyoming, were expecting a quieter-than-usual summer, with the warnings against traveling. Jackson Hole is near Yellowstone and Grand Tetons National Parks, and has the region’s airport.  Instead, Jackson Hole is experiencing even more visitors than previous years, particularly at campgrounds and RV parks. People figure that camping and wilderness vacations are “safe-cations,” where they can breathe free of COVID-laden crowds. I’m sure the staff of the town’s only hospital, St. Johns Health, have eyes bugging out like deer in the headlights.

As we discussed above, the CDC recommends not traveling during the Pandemic, since this increases your odds of catching the virus.  Even the great outdoors’s wide-open spaces, with record visitors, is now less wide open.  If you must vacation, staying away from National Parks, sadly, is a smart move. Also stay away from any COVID hot spots like California or Florida.  Avoid crowds, where even outdoor air may not dilute all the aerosolized virus that’s exhaled.

Again like above, if you’re driving, minimize stops for gas, food, and the bathroom.  Sanitize your hands after using gas pumps, and wear those masks.  While flying is much safer than driving as far as avoiding crashes, personal interactions in the airport or airplane may increase your risk of catching Coronavirus. Maybe stay home, or at least stay south of Canada.

No Titanics Here

This week’s guest columnists are Drs. Dylan Poche and Brandon Saucier, Family Practice residents at the University Hospital and Clinics here in Lafayette.

As a kid, I spent summer weekends at the family fishing camp.  Lots of time we were tubing, being towed on an inner tube behind by our roaring boat, slaloming, occasionally bouncing off when we hit big waves.  One bad time I’ll never forget: another boat, driven by someone who’d been drinking, cut between our tube and boat.  Hitting the tow rope, they yanked my girfriend, who was on the tube, toward the stern of our boat.  She hit the propeller, sustaining deep lacerations.  Worse, she spent a long time in the hospital when they got infected.

Many South Louisiana families are now on the water tubing, fishing, boating, or zipping around on Jet-skis. Since this time is often for recreation, they couple it with another South Louisiana good time tradition- drinking. This leads to boat-driving like above: carelessness about where the boat’s going, how fast, and what it runs into. Impaired boaters are also more likely to drown if they fall overboard. They’re knocked out or pass out more easily, and are much less likely to be wearing lifejackets.

Boating isn’t like driving a car.  Boats don’t have the built-in safety features of cars, like seatbelts or enclosed cabins so passengers don’t fly out.  There’s also no brake pedal- stopping requires much more foresight. In cars the safe road is clearly marked with painted lines, warning signs, and guard rails to keep you on the straight and narrow.  Boat “roads” aren’t obvious- maybe a channel marker here and there, and you need a chart to know where the underwater hazards are, like sandbars and rocks. The rules of the road, particularly who has the right of way when boats approach, are more complicated. Many boaters skip a driving course,

Fun fact: the Louisiana Department of Wildlife and Fisheries requires everyone born after 1983 to complete an approved Boater Education Course, even to operate a Jet-ski!  This goes for kids and adults.  However, LDWF doesn’t have the personnel to enforce this rule like police ashore.  Ever see a Jet-skier get pulled over?

My father was strict about water safety, particularly enforcing wearing lifejackets in boats.  I wondered why he was like that, more than my friends’ parents, until one day he told me.  I had had an uncle who owned a racing boat.  He was a very experienced driver, and would always wear his lifejacket.  One day he was heading to a nearby camp, and didn’t wear it.  Going 30 miles per hour a freak accident happened- his steering cable broke and the boat jinked. He was thrown out, apparently knocked out by the impact on the water, and never came up.

According to the CDC, there’s over 3000 deaths each year due to accidental drowning.  About one in five of these victims are under age 14.  While many of these drown in pools, many also die in boating accidents.  Thus lifejackets should be worn by people of all ages, in all circumstances, near any kind of water.  Kids particularly should wear them, since they’re inherently less careful than adults about falling off docks, out of boats, or into pools.  Kids are also less capable swimmers, and thus more at risk when they tumble in.

As we mentioned above, adults are less attentive when drinking.  Alcohol and water seem to mix, at pool parties and on boats.  Imbibing adults are careless boat operators- driving recklessly and being more lax about kids wearing lifejackets. They run into things- docks, rocks, other boats; and everyone gets thrown in.  At pool parties drinkers are more distracted, and thus less observant of kids in the water.  Nighttime parties are the worst, where in the hubbub and dark a kid will fall in the water, no one sees it, until too late.

Often people don’t perceive the risk of being near water.  It’s a sunny day and everyone’s happy to be out. The water’s surface seems calm and, well, solid.  Being next to water is not like standing on a cliff.  Our brains understand the risk of falling off that cliff- you’ll die!  That same protective perception doesn’t seem to apply to water.  Thus people need to be conscious of the risk, for themselves and their kids.  At pool parties or in boats, have a designated sober adult to assure everyone’s safety.  And put those jackets on!