Choosing a Pain-Free Diet

I had my first “old coot” moment, when grampa yells at the TV when he sees something he doesn’t like.  For me, it was an ad for Miralax, a laxative.  It depicted a young cheerful woman in athetic clothes saying “I choose Miralax!” for her apparent sluggish bowel issues.  I shouted, “WHY NOT CHOOSE FRUITS AND VEGETABLES?”  Of course, she wasn’t listening.

Constipation can be quite painful for children.  We see them in the Pediatric Emergency Department with stories of doubling over, crying out with pain spasms.  They’re usually  better when they arrive, but it’s still disconcerting for parents.  Contipation actually is the most common diagnosis for abdominal pain visits to the Pediatric ED, ahead of stomach viruses and appendicitis.

Constipation is now a common problem in kids, given decreased fiber in their diets.  Fiber is plant carbohydrates that our digestive system can’t break down.  That fiber holds on to water and keeps poop soft and squishy as it passes through our guts.  When your body wants extra fluids, it tries to suck water out of your colon, drying out your stool.  Without enough fiber, your poo gets dried out, moves slower, gets harder, and harder to pass.  If lots of hard poo is moving too slow, painful cramps ensue.

Thus the fix to constipation: eat more fruits, vegetables, wheat breads, bran cereals, all having a high fiber content.  Miralax is simply an artificial fiber substitute- why not eat the healthier thing?  For kids, this means training them to like these foods.  The typical kid can take 10 tries of a food to learn to like it.  This takes persistence on the parent’s part, and is ruined if they get candy, cookies, chips, or fast food as an alternative.  Those foods are designed and manufactured to taste good on the first try, spoiling the child’s chances to learn to eat right.

Drinking more fluids and more physical activity also prevent constipation.  When kids sit around playing video games, their guts sit around too, not moving things through as much, and stool has more time to get dried out.  Active kids stimulate their intestines more, and have less constipation.

Once in residency I had a 10 year-old boy with constipation so severe he was admitted into the hospital.  He had terrible pain, and the parents thought he hadn’t stooled in weeks.  He also had anxiety issues so bad that he wouldn’t tolerate enemas or rectal exams, the quickest way to diagnosis and relieve constipation.  We thus decided on rectal exam under sedation, and do so in the xray suite so we could look at his insides, to rule out other causes for his pain and apparent blockage.

As soon as the sedation started, he relaxed his anal sphincter, and liquid stool poured out of him.  The diagnosis was instantly clear- he’d been purposefully holding in his poo, and it was liquid from all the laxatives he’d been given.  Unfortunately for the Radiology Department, he leaked so much that it ran all over the xray table, through every seam, dripping out the bottom.  They had to completely dismantle the table to clean it, and that room was out of commission for days.

Above we mentioned the diet reasons why kids get constipated- low fiber, inadequate fluid intake, and not enough activity.  But there’s sometimes psychological reasons as well.  Sometimes kids have a hard stool that hurts.  They decide, hey, I’m not doing THAT anymore!  Next time they get the urge, they withhold pooing until the urge passes.  After doing that enough, the urge gets too strong, and they have to go.  By that time the stool is so big and dried out that it’s another painful job, reinforcing their desire not to do it.  The constipation process becomes self-feeding.

Toddlers also can decide to withhold pooping during potty training.  Some kids just don’t like taking down their pants and sitting on that oddly-shaped thing we call a toilet.  It’s much easier to just go in their diaper.  Parents often try rewards, sometimes punishment, to encourage the kid to use the potty.  Willful toddlers may fight back the only way they can- with their anal sphincter.  Some psychologists say that any child can be potty-trained by age 2; others say wait until they show signs they’re ready, like watching their parents use it.  I think the latter, having seen many toddlers get constipated during potty training.

Under A Cajun Sun

Last Sunday, due to church in the morning, work in the evening, and grass long enough to hide large rodents, I mowed the lawn in the middle of the day.  I was ready- I did each part of the yard when shaded by trees, wore my sun helmet (a wide, airy hat like mail carriers wear), and took frequent cooling and hydrating breaks indoors.  Going in for one of those breaks, I took off my helmet, and yelped when I burned my hand on it’s top.  It was HOT!

Heat injuries in children are increasing.  As the planet warms, there’s lots more opportunities for kids and teens to get dangerously overheated.  Also, kids are getting more obese, and bigger bodies generate more heat and shed it less efficiently.  And while the invention of car seats has saved kids’ lives in car accidents, they also make kids less noticeable and more easily forgotten, to be left trapped in hot cars.

What happens when you’re in the heat?  First, you sweat, and water evaporating off your skin takes heat with it.  You also turn red as blood brings heat to your skin surface, to radiate it away.  However, these mechanisms don’t work so well on hot humid days.  If it’s too humid, sweat won’t evaporate, but just accumulate on your skin, keeping your heat with it.  And if it’s as hot out as it is inside your body, there’s nowhere for the excess heat to radiate out to.  Finally, it takes time to “acclimate” to heat, where your body learns to sweat and radiate more efficiently; the typical teenager needs 10-14 days of outdoor work to get used to it.

If you cannot shed heat well enough, your core temperature begins to rise, and organs begin to cook.  “Heat exhaustion” is when early signs of heat injury arise.  As your brain heats, you get headaches, become easily confused, and have nausea and vomiting.  You get dizzy and fatigued from dehydration.  Muscles begin to cramp.  Then comes “heat stroke,” where the victim begins to stagger when walking, is delirious, may have seizures, before lapsing into a coma.

I experienced heat exhaustion myself once on vacation. While in North Carolina, I went running with my marathon-competing brother Pat.  I was fit enough to keep up, but didn’t consider that I always exercise indoors.  I wasn’t acclimated to heat like Pat, who trains outdoors. Half way through, my bald head (say it isn’t so!) began to cook in the sun.  I started having a headache, worsening fatigue, muscle pain, and nausea.  We cut home and I spent several hours in the a/c pouring cold water on my head, walking around to evaporate sweat, and slugging down gallons of fluids.

As we mentioned above, two groups of kids get heat injury: exercising teens, and small kids in hot cars.  If children or adolescents show signs of heat exhaustion like I did, it’s time to treat.  Get the child out of the heat: indoors to a/c, or at least into shade.  Strip off hot clothes and equipment (i.e. football pads and helmets).  Cool skin with cold wet towels, or ice baths with a cold towel over the head.  Hydrate with cold fluids.  If kids show signs of heat stroke- staggering, confusion, vomiting- get them to the ER.

To prevent heat exhaustion in athletes, they need to acclimate.  This takes 10-14 days, and should be gradual and safe.  Work-outs should be early morning or late evening when it’s coolest.  Avoid hot equipment like in football, lacrosse, and baseball catching, for the first weeks of practice: shorts and t-shirts only, helmets and pads later.  Players need frequent hydration breaks in the shade, with coaches vigilant for signs of injury.

Car seats have saved thousands of lives.  However, now that kids aren’t sitting in laps, they’re easily forgotten.  Children are often quiet in car seats.  Then when arriving at the store or work, you forget to take them out.  It doesn’t take very long, or even a very hot day, for a trapped infant or toddler to die.  Even on mild spring days, the sun can heat car interiors dangerously, even with cracked windows.  So never leave kids in cars, no matter how quick you think you’ll be.  Set alarms or other reminders when buckling your child in, to remember to take them out after the drive.

Summer Terror

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

It started as a beautiful summer day- blue sky, hot grill, everyone visiting.  The kids were having a ball too, playing and swimming.  Then someone screamed- a toddler was at the bottom of the pool.  One party-goer jumped in to fetch the boy, another started CPR when he was lain on the concrete.  After some rescue breaths, the boy began to breathe, and was waking up when the ambulance arrived.  In the Emergency Department we admitted him for observation and he did fine, though the parents couldn’t quit crying.

“Submersion injury” comes in many severities.  Some kids fall in and are snatched out so quickly they barely know what happened.  Other kids are discovered too late and die.  In between are children who are resuscitated just in time, like our boy above, or survive but suffer some degree of brain injury.  How can these tragedies be avoided?

First, at pool parties you should designate an adult whose only job is to stay sober and monitor the kids.  It’s easy to become engrossed in conversation, help with the food, accept a cold beer, and lose track.  It doesn’t take long for toddlers to get out of sight either!  Losing track is even more problematic by lakes and rivers where the water is murky, and seeing lost children at the bottom and thus getting them out in time is pretty much impossible.  If they disappear, they’re gone.

The best way to avoid child drownings is not to have a pool.  Second best, the pool should be fenced on all 4 sides, meaning no patio door access.  The fence should be unclimbable, with a kid-proof lock.  If you’re by a large body of water, bring a playpen or other enclosure for the tots.  Knowing CPR is important to prevent drowning death after the patient has been submerged.  Most 12 year-olds are capable of learning and performing CPR.  Finally, although swimming lessons improve swimming ability, there’s no data that swimming lessons actually decrease the risk of drowning.  The American Academy of Pediatrics doesn’t recommend them for drowning prevention,

Kids can have wacky ideas about what’s hilarious, which parents DON’T AT ALL find amusing.  One day I thought it’d be funny to float face down in the pool and not respond when my mother called me.  She yelled and yelled, and when a family friend went to retrieve me. I picked my head up and smiled like nothing was wrong.  She was too freaked out to punish me, and only now as a parent do I realize how cruel that joke was.  I have since apologized.

Child drowning is often even more subtle than my ill-advised joke.  In particular, infants and toddlers, not knowing the danger when falling into a pool, sink to the bottom without making a sound.  They don’t thrash or scream.  Older kids too, when swimming and run out of gas, can slip under before they can call for help.  Therefore, as we said above, a sober adult dedicated to watching the kids helps prevent tragedy.  Also as we said above, the water in lakes, rivers, and oceans is murky, and hides drowning children.  You won’t see them after they sink, and thus they’ll be gone for good.

If a child is submerged, parents and bystanders need to be prepared to save a life.  One study showed that 14 out of 18 victims resuscitated by bystanders survived the event. This means knowing CPR.  It’s also clear that waiting for EMS to arrive without starting CPR seriously degrades the chance of survival.  If the child’s heart and breathing aren’t restarted by the time of arrival at the Emergency Department, the game is up.

So learn CPR.  Find a course near your at the American Heart Association website.  There’s almost weekly courses in the Lafayette area.  Every year around March the local AHA puts on the Be A Heart Starter event at the Cajundome, where over a thousand people learn CPR in one day, for free.  Children as young as 12 can learn the skills of CPR, using an AED (Automated External Defibrillator), and the Heimlich maneuver.

Drowning is preventable.  Through use of dedicated supervision, fences and other barriers, throwable floatation devices, and CPR, you may avoid losing a loved one this summer.

When Bears Attack!

As a Pediatric Emergency Physician, I’m calm in medical emergencies.  But good at one kind of emergency doesn’t translate to all emergencies.  One summer my family was hiking in Grand Tetons National Park.  The path ran along a lake, and nearby boaters began to shout, “There’s a bear coming towards you!”  We should have turned back, but someone nearby said, “My husband knows bears, he encounters them all the time.”  Since most bear encounters are fine, there were 10 of us in this group (bears are intimidated by numbers), and we DID want to see a wild bear, we strode on. I also had a can of Bear Repellant spray on my hip.

Soon enough, a brown bear came loping down the trail.  “Okay,” said our ‘bear guide,’ “everyone in the water.”  We stepped aside into the shallows of the lake, me ending up between the bear and everyone else, struggling to get the can off my belt.  Finally, it jerked free, I accidentally hit the trigger, and a 20 foot spray shot out towards Yogi.  He ambled on, unmindful of us.  “You weren’t supposed to spray unless he came at us,” chimed my daughter.  “I didn’t mean to,” I mumbled, embarrassed that I wasn’t more cool facing wild beasts.

Emergency situations are scary.  By definition, they’re life-threatening; we naturally get shaky when in danger.  Also, emergencies are rare, so we don’t get any practice knowing what to do. They can require unfamiliar skills, like CPR, or getting bear spray off your belt with trembling hands.

Everyone should have some idea how to handle common emergencies, particularly for their kids.  The three leading causes of death in kids are car crashes, firearm injuries, and drowning.  The best emergency preparedness is avoiding the injury in the first place: seatbelts and car seats, no cell phones while driving, swimming lessons, have a sober kid-watcher at pool parties, and locking up guns with ammunition locked up separately.  But if something bad does happen, having taken CPR and a first aid course really helps.  If kids are around grandparents or other elderly relatives, teach them how to dial 911, and be able to tell the dispatcher their address, and who they need (Fire, Police, or Ambulance).

On September 11, 2001, John Pelletier was the manager of Corporation Service Company’s office in the World Trade Center.  At 8:46 am he heard a rumble and saw flames from the tower next door.  Though the PA announced that their building was fine, he thought otherwise and ordered his office evacuated.  His 100-plus employees were on their way down the stairwell when the second plane struck his building.  If they’d stayed, they would have been trapped above the impact site, and perished.

Survivors of that day recall co-workers waiting for Emergency personnel to get them. In mass casualty situations, like hotel fires and airplane crashes, it takes time for Police and Fire to get to the scene and rescue people, and whoever waits for them may be too late.  For those who can run- run!

Above we discussed people’s unreadiness to respond to emergencies, because they happen so seldom.  No one gets to practice what to do.  So when you’re on a plane, do the practice. Read the safety pamphlet, watch the demo, identify your nearest exit, and rehearse in your mind: unbuckle, move to the exit, open the door.  When staying in hotels, find your nearest exit, go out it and down the stairs.  It’s good exercise, it’s fun to explore, and it may save your family’s lives.  Rehearsing prepares you to evacuate when necessary; those who wait do so at their peril.

We also already discussed being ready for personal emergencies.  Again, for kids this means preparing to avoid, or deal with, their most common threats- car crashes, firearms injuries, and drowning.  Buckle them  into their car seats or seatbelts.  Many times I see kids hurt in crashes who didn’t buckle up because they were “just going down the block.”  If the car is moving only 15 miles per hour and crashes, the child’s impact will be equal to a 15 foot high fall.

Firearm injuries often happen when exploring kids shoot themselves or playmates accidentally.  Lock up guns unloaded, with ammuniton locked up separately.  To prevent drowning, get kids swimming lessons, and swim where there’s life guards.  Finally, make sure kids know how to dial 911, tell the dispatcher who they need (Police, Fire, Ambulance), and their address.

Itchy And Scratchy

This week’s guest columnists are Drs. James Hyatt and Amir Farizani, Family Practice residents at the University Hospital and Clinics here in Lafayette.

Friday night in the Pediatric Emergency Department, a 16 year-old checks in with mom.  While mom looks concerned the boy, wearing headphones, is obviously annoyed to be here.  Not his first choice for a Friday night destination!  They tell me he was on the porch swing last night with his girlfriend when itchy bumps appeared on the back of his neck and arms.  He wasn’t concerned, but when his mom noticed them tonight she hustled him into the car to come in.

After examining him, I realized that though the boy only had mosquito bites, mom had worse worries.  Was this a severe allergic reaction?  Would he start wheezing, his throat close up, and could he die?  After reassuring her this wasn’t anaphylaxis (“I told you it was just mosquitoes!” huffs the boy), they head home.

Child and adolescent rashes make up 12 million office visits per year.  The vast majority are annoying but benign: insect bites, eczema flares, poison ivy, viruses, or hives.  So when do you worry?  First, it’s rare for something to be bad without other signs and symptoms.  If your child has a rash without fever, fatigue, shortness of breath, or vomiting, these rashes aren’t emergencies.  If your child does have a fever accompanying the rash, that’s a little more concerning, but even most of these are okay.

What many parents worry about is anaphylaxis.  This is a life-threatening allergic reaction caused by whole-body sensitivity to an allergen.  Allergens are small molecules in the environment- pollen, ant venom, poison ivy- that trigger our immune system.  Usually the reaction is localized to one organ, like the skin (making hives) or the nose (making it itchy and runny).  When an allergen irritates more vital organs- airways, lungs, or the cardiovascular system, that’s anapylaxis.

Fortunately (as far as diagnosis), anaphylaxis is easy to spot.  There’s immediate lip and eyelid swelling, watering eyes, shortness of breath, wheezing, drooling, and fatigue. Time to call 911.

Like our boy above, it seems most benign rashes come in at the most unlikely time- weekend nights.  This next girl, 8 years-old, came in Sunday night after a weekend at the beach.  When she was in the bath, mom saw a strangely shaped rash on her arm.  It looked so freaky that mom snatched her out of the tub, threw on some clothes and came in.

The rash sure was odd, with paisley shapes and curly-cue streaks, like someone had  splashed liquid sunburn on her.  One question solved the mystery: were there limes at the beach?  “Why yes,” replied mom, “we were having margaritas, and she had a non-alcoholic one.”  In fact, she squeezed her own limes.

DIagnosis: Phytophotodermatitis.  Cuter names for this are Margarita Burn, or Lime Disease (instead of tick-borne Lyme Disease, get it?).  When certain plant substances drop on your skin, like lime juice, and are then in sunlight, they cause irritation.  Skin turns red, burns, and can even blister.  After the initial inflammation, the rash becomes hyperpigmented, like a tan, and can last for weeks.  Besides lime, many other plants can cause this reaction, merely by brushing their leaves.  Wild parslies, mulberry bushes, and hogweeds are some of the culprits, and the sun-activated streaks they leave on skin are often mistaken for poison ivy.

Like we mentioned above, many parents lose nights of sleep thinking about worst-case scenarios.  It’s only natural to worry about kids, but late-night internet searches don’t help.  Most helpful for parents is knowledge about common rashes, and what are the “red flag” symptoms.

Most pediatric rashes are caused by benign infections like viruses, and minor allergic reactions like hives, eczema, and heat rash.  While these rashes can cover the whole body and look freaky, if your child is otherwise acting well, he is well.  For example, two  common viral rashes are Roseola and Hand-Foot-Mouth disease.  While covered with spots, most of these kids are smiling, drinking, and calm.  They might have fever initially, but they’re not showing bad signs.

Bad signs are shortness of breath, worsening fatigue, pain, headache, and vomiting.  Rashes accompanied by these need to be seen.  But if your child is otherwise well, don’t panic over funky rashes!  Instead ask, Where were the limes?    

Camp Mt. Allamuchy

One of my favorite summer camps as a kid was violin camp.  My teacher had a bunch of us work on Corelli concertos every day for two weeks, with a concert for our parents at the end.  Corelli’s music is complex and entertaining, yet reasonably easy to play for school kids. I enjoyed it, but my best friend from that camp, Jonathan Dinklage, had such a ball that he wanted to jam even during breaks, grinning away with his violin tucked under his chin.  Something apparently clicked, and Jonathan went on to play professionally in hit Broadway plays, with rock bands, and his own groups. Jonathan’s even more famous brother Peter, (star of Game of Thrones), was probably doing theater camp in another part of the building.

While I still languish at the back of the ULL symphony viola section (my career aspirations lay elsewhere), summer camps and activities are important for child development and health.  Not every kid will find his life’s passion like Jonathan, but they can still have fun and make summer time fly by.

Leave kids alone and bored long enough, and of course they’ll gravitate to video games.  A summer of sitting at consoles, with no school schedule or work to distract them, does these kids a world of hurt.  They don’t get up and move around, causing soreness, poor muscle tone, and constipation and ensuing abdominal pain.  They don’t interact with their peers face-to-face, leading to isolation, loneliness, and depression.  They can develop addictive behavior, wherein they’ll scream, get aggressive, and lie to avoid being torn away from their electronic cocaine.

Get to work on that summer schedule now!  A great place to find opportunities is the 2019 Ultimate Guide to Summer Camps In and Around Lafayette.  This website has listings for regular day camps, and camps for music, cooking, swimming, theater, science, karate, dancing, cheering, painting, sewing, and soccer.  The University of Louisiana at Lafayette Programs for Children and Families has academic options in science and engineering.  The ULL sports programs have camps for kids too. Individual businesses, like sewing schools and swimming pools, also have their own summer programs.

As a teenager my wife worked at a summer camp in North Carolina. It was frequented by kids of wealthy New Yorkers, and many moms decked out in high heels and designer sun glasses whined about about how they couldn’t take their little darlings anymore after the long school year. Then they breathed perfumed sighs of relief, depositing their kids for the whole summer and heading to Europe.

While most of us can’t afford that kind of summer, there’s plenty of local sleep-away camps that fit most budgets.  While parents like a week away from their children, it’s the kids who really benefit. They get to try out a slice of life away from home, have some freedom, get outdoor exercise, and make new friends. 

As we mentioned above, spending summers home playing video games isn’t a healthy option.  Those kids get weak, develop back aches, and have abdominal pain from slouching around and getting constipated.  They complain of headaches from staring at screens all day (and night).  They can develop addictive symptoms, screaming and lying when parents try to limit their gaming. These are preventable ailments, easily avoided by real-world physical and intellectual activity.

My favorite summer camp was Boy Scout camp (Mt. Allamuchy).  During my first year at camp, at age 11, I was wracked with homesickness, but every year after I had a blast.  I learned to cook, canoe, lifeguard, sail, build a tower out of tree limbs, and hung out with my friends around campfires.  Overcoming homesickness was a growth experience, and I only half-joke that my leadership skills were learned with the mistakes made as a patrol leader.

Another good option is Camp Hardtner, near Pineville.  It’s a church-based camp, and provides scholarships for kids whose families have financial need.  Hardtner boasts 4 lakes, along with the traditional cabins, craft shacks, pool, and dining hall.  Another great thing about Hardtner is that there’s no phones or other electronics allowed.

So parents and grandparents, make those summer camp plans for your kids now.  Ask them what they’d like to do, either at sleep-away or day camps.  It’s good for them, and fun, and while you may not get to Europe while they’re gone, maybe Grand Isle instead?

It’s Always Sunny in Acadiana

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

One spring day, a teenager decided to get a head start on his summer tan.  Like any teen, he didn’t heed his parents’ advice to wear sunscreen. It was a pretty cloudy day at the beach, so to increase his chances of tanning, he applied tanning oil. It had an SPF of 4, so you’d think he was okay between the SPF and the clouds, right?  Wrong!

When he got home and looked in the mirror, he was shocked to see he was red as a lobster!  It really hurt to get a shirt on to go out that night with friends.  Then when he got into the car, he scraped the top of his head on the door sill- YOW!  While his friends killed themselves laughing, he realized he had burned his scalp too.

Sunburns seem to be a rite of passage for kids and teens at the beginning of the summer.  We sometimes see kids in the Pediatric Emergency Department for these burns- they whine and hurt and can’t sleep.  Though teenagers often laugh at their discomfort and cherry red skin, our Dermatologist colleagues shake their heads- they’re contemplating their future skin cancer patients.

How did our teenager burn on a cloudy day?  Sunlight is composed of several wavelengths of radiation, including infrared heat, visible light, and ultraviolet rays.  While clouds stop some sunlight, they don’t stop it completely.  After all, you still have plenty of visible light to see on an overcast day.  Likewise for ultraviolet wavelengths, the ones that burn and lead to cancer. There’s two types of ultraviolet, UVA and UVB.  UVB is the spectrum that causes sunburns. UVA rays are the sun’s “silent killer,” because though you don’t feel them, they penetrate skin and damage skin cells’ DNA, a potential cancer trigger. Like visible light, they get through clouds just fine- burning and injury may take longer, but it happens. This is especially true here in the South, where we’re closer to the sun than the northern parts of the globe.

Dr. Hamilton once took his new 6 week-old daughter to the beach.  His wife loves the beach, and couldn’t wait to get out of the house after recovering from delivery.  They used all the precautions- floppy hat, big baby skirts, even a beach tent with an SPF rating. But that first day when they got home, baby’ face and arms were sunburned.  They learned that sunlight reflected off sand and water, up under tents and hats, can burn just the same!

Babies under 6 months old should be kept out of direct sunlight, in shade.  As Dr. Hamilton discovered, avoid reflected sunlight!  Infants that age are too young for sunscreen, but over 6 months, slather it on liberally.  Babies of any age shouldn’t be in the sun between 10 am and 2 pm, the brightest part of the day, where anyone is most likely to burn.

All kids, when wearing sunscreen, should have it applied 15 minutes before going outdoors, since it takes time to absorb into the skin.  Use SPF 30 or higher-less isn’t enough.  Cover all surfaces- ears and tops of feet and hands.  If your kid isn’t wearing a hat, get that scalp.  You don’t want your kid to be that teenager from above, who burned his scalp sunbathing.  If your children are at the beach or pool all day, re-apply every 2 hours, and after kids get out of the water.  Don’t forget lips- use at least SPF 15 lip balm if you don’t like the taste of regular screen.

This past Mardi Gras, the Scott parade was on a sunny day.  Since it was February, many families didn’t think to use sunscreen.  That night we saw so many sunburned kids in the Pediatric ER that our nurse dubbed it “The Scott Mardi Gras Glow.”  If your kid gets sunburned, you don’t have to bring them in.  Do what we recommended: keep skin moisturized, particularly with an aloe-containing lotion.  Burned skin dries out, and then itches and burns more.  Use ibuprofen or tylenol for pain at bedtime.  Cool baths with moisturizing soap help, but don’t use washcloths, which scrape sensitive skin.  When they get out of the bath, pat dry with towels, don’t scrub dry.  Then slap on that moisturizer!

 

Miniature Monster Movies

I loved japanese monster movies as a kid, watching titanic lizards and insects stomp scale models of Tokyo.  Doctors are biology nerds at heart, and find depictions of biology-gone-haywire entertaining.  So you’ll understand my thrill at an American Academy of Pediatrics conference where we learned why there’s few Lyme disease cases in Louisiana.

Lyme disease is transmitted by deer ticks.  Lyme bacteria is carried in deer and mice,  tick feeds on those, and then when biting humans, regurgitate the bacteria into the human.  Infection starts with a target-shaped rash at the bite site: a central red spot surrounded by a red ring.  If untreated Lyme can infect joints and even the brain.  So why don’t we see Lyme in the South?  It turns out that while ticks in the North feed on mice and deer, ticks in the South feed on…..LIZARDS!  COOL!  Talk about monster movies in miniature! 

While lizards have proteins in their blood that kill Lyme, humans have to worry about Lyme and other tick-borne infections.  Rocky Mountain Spotted Fever, Erlichiosis, and Tularemia are just a few of the tick-borne infections.  Now that it’s a warm and lovely spring and we want to be outdoors with blooming flowers and trees, ticks are blooming too.   

Ticks live in bushes, dead leaves, and tall grass, so hiking, hunting, camping, and gardening are perfect activities for ticks to hitch a ride as we brush past. To prevent this, wear clothing treated with 0.5% permethrin, or spray clothes yourself.  Ticks climb upwards, under pant cuffs, so tuck those cuffs into socks or boots to keep them off your skin.  You can put certain sprays on your skin, but some you can’t put on kids under 3 years-old, and none on babies under 2 months.

Soon after being outside, shower to not only wash off sweat and dirt, but wash off ticks. While doing so, inspect for ticks that have already started to burrow into skin.  Ticks love to hide- in hair, behind knees and ears, in armpits and belly buttons, under waist bands, and way up between legs.  Check those places carefully.

Let’s continue our theme of minature monster movies, starring ticks and lizards.  When we discussed ticks feeding on lizards and humans, what exactly does that mean?  Well, horror-movie fans, it means they suck your blood!  How they do that has been unknown, until 5 years ago when german scientists caught the act on film.  Go to Smithsonian.com to watch that mini-monster movie.

Ticks have two specialized harpoons on their heads called chelicerae (pronounced Kale-y-Siri).  These harpoons are covered with barbs like fish hooks, so as they plunge into your skin, the barbs lock in.  After about 30 thrusts of these weapons, the tick’s deep enough to deploy another barbed spear called the hypostome. This thrusts down between the chelicerae to open a big enough path for blood to flow up to it’s mouth.

About this time we discover the tick on our kid, head buried, body sticking out.  After experiencing a profound case of the creeps, it’s time to act. If the tick can’t be brushed off, it means those barbed spears are stuck in.  Your grandparents’ methods of removing ticks won’t work.  Smearing them with butter to suffocate them so they’ll run away- myth. Touching them with a hot match-head- kills them, but they don’t release.  Painting them with toxins like nail polish or gasoline- same result.  They die, but die before they can extricate themselves.

Tweezers are the best way to remove ticks.  Grasp the tick by its head, up against the skin, and pull gently but firmly.  If the tick breaks and the head’s still embedded, you can pick it out with a sewing needle and tweezers, like a splinter. The good news is that you don’t have to turn your kid into hamburger to extract every last fleck of tick parts. The chelicerae and hypostome don’t carry disease, and the skin will extrude those with time.

More good news. If you catch the tick before it’s engorged, it won’t have transmitted disease. Ticks only regurgitate infections after a blood meal.  They need to get full of blood before refluxing blood and infection from the rear of their bodies down into you. So if the tick isn’t swollen, it’s cool as far as worrying about Lyme disease or Rocky Mountain Spotted Fever.  The monster loses!

The GERD, The Bad, and The Ugly

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

My dad enjoys telling about the time he ate my vomit. Stay with me!  When I was a few months old I loved being tossed up in the air.  One unlucky day while playing our favorite game, I was mid-air over dad when my latest feed flowed out and into his laughing mouth.  He still caught me, or so he claims.

While perhaps not suffering this same fate, many parents have spitty babies.  When they spit up a lot, it’s called Gastro-Esophageal Reflux, or GER.  When tots have complications of GER, like problems gaining weight or throat irritation, that’s called Gastro-Esophageal Reflux Disease, or GERD.

GER is no big deal, medically.  It’s normal behavior in babies because, first, newborns’ stomachs are tiny.  At 2 days old, it’s the size of a cherry; at one month, that of an egg.  Not until one year of age is it as big as a small grapefruit.  Second, the muscle that seals the top of the stomach, the Lower Esophageal Sphincter (LES), is still weak.  Like it takes months for babies to be able to sit unsupported, the LES needs time to develop too.  Thirdly, well-meaning parents fill their newborn’s tummy with 3 to 4 ounces of milk at a time, so it’s no wonder that what doesn’t fit comes back up.

When is GER a problem, or GERD?  Fortunately, the vast majority of reflux babies are just spitty kids who still gain weight, mature normally, and soak lots of bibs.  It’s GERD when babies don’t hold down enough milk to grow.  These babies need to be on high calorie formulas or other regimens to put on weight.  Some get irritation in their throat, nose, or airways from stomach-acid irritation.  Those tots can have chronic congestion, coughing, fussiness, and sometimes wheeze like asthmatics.

It’s great that babies who spit up do fine, but are parents expected to just suck it up while their child’s LES gets into shape?  And what about vomiting?  When is spitting up not just spitting up, but true vomiting?

James Herriot, the best-selling British veterinarian, writes of mis-diagnosing a vomiting puppy.  It first grew normally, but then began spitting up and losing weight.  He tried everything- antacids, de-worming, small frequent meals, and still puppy wasted away.  Then one day while examining the dog yet again, it vomited clear across the room.  “Does he always do it like that?” Herriot asked.  “Aye, he mostly does, sends it flying out, like.” replied the owner.  Herriot realized his mistake, not asking the details which supplied the diagnosis: Pyloric Stenosis.

The occasional baby gets Pyloric Stenosis too, and this story illustrates the difference between vomiting and simple spitting up, or Gastro Esophageal Reflux (GER) that we discussed above.  The American Academy of Pediatrics defines reflux as “the effortless passage of gastric contents,” while vomiting is “the forceful expulsion of gastric contents.”

As mentioned above, rarely does GER affect growth (called GER Disease (GERD) when it does).  But vomiting in babies is more serious.  Babies can get dehydrated, or have surgical emergencies, with vomiting.  Most babies who vomit have a simple stomach virus and get better.  The occasional baby has Pyloric Stenosis, wherein the muscle at the bottom of the stomach (the Pyloric Sphincter) grows much faster than the rest of baby, gradually cutting off the stomach outlet.  These babies begin to vomit more, and more forcefully, until they vomit like the dog in the story, called “projectile vomiting.”  These babies (and puppies) need a simple surgery to fix the sphincter.

There’s other surgical problems heralded by vomiting.  If baby vomits dark green, or vomits with a swollen abdomen, those are signs of a potential intestinal blockage needing emergency surgery.  Also, babies who vomit and have bloody poops need to be seen immediately.

But if your baby’s simply urping milk, smiling away, then relax.  There’s things to make that better.  Breastfeeding results in less reflux than bottle feeding, giving baby the right amount of milk to grow, be healthy, and spit up less.  Feeding baby less formula but more often, thickening formula with rice cereal, and holding baby upright for 30 minutes after feeding may help too.  But no worries!  If your baby is fat and happy, leaky’s okay! 

Industrial Nightmare

It’s the stuff of nightmares: your child is wandering around a busy factory floor.  She walks past red hot surfaces and open flames that threaten to burn her, or catch the place on fire.  There’s cauldrons of boiling liquid, machines full of whirring blades.  Crowds of workers bustle about, threatening to bump her into anyone of these dangers.  Some of these people do sinister things- encourage your child to play with the knives lying about, or pick up broken glass.  Is that candy down there too?  No!  It’s poison in disguise, don’t eat it!

Wake up, and welcome to your kitchen.  The red hot surfaces and open flames are your stove, topped by pots of boiling liquids. Teaching kids food prep explains the knife handling, and who do we expect to clean up after they break a glass?  Whirring blades: blenders and sno-cone makers.  It’s a high-traffic area too, with parents cooking and kids going in and out to get something to eat.  Someone’s bound to bump somebody into something bad.  Poison disguised as candy?  Look under your sink at those dish washing detergent pods.  Why do they have to make them look so tasty?

It’s surprising there’s not more kids in the Emergency Department with kitchen injuries.  The most common injury we do see is scald burns from liquids in the microwave.  It happens like this: the child heats up some noodles, goes to take out the bowl, and gets bumped by that big clumsy microwave door.  They often get burned on some of the most sensitive places- faces and hands- as well as on chests and bellies. The second most common kitchen injury is knife cuts.  Kids are often supervised when this happens, but aren’t quite respecting the sharpness of the knife. The third most common injury is toddlers eating rat poisons and detergents from under the sink.   

Why don’t we see more injuries?  First, parents are generally pretty good about watching their children in this potentially dangerous environment.  The second reason is that these days kids and parents are spending less time in the kitchen. While this may be better for injury prevention, it’s not so good for overall family health.

Though my kids are ages 25, 23, and 21 years, they still get dragged into our traditional  Christmas cookie making.  While I prefer traditional decorating, like icing the Christmas trees green and the stockings red, the kids think it’s hilarious to make gIngerbread men with five eyes and bullet holes, sheep with missing limbs, trees iced to look tie-dyed, whole trays of cookies decorated like some LSD-fueled acid trip. My wife and I have apparently raised some sick puppies.

But we did something right getting our kids into the kitchen: they all can cook for themselves, and know healthy eating.  There’s many dangers in the kitchen enumerated above: hot stoves and liquids, sharp knives, lots of traffic, broken glass, poisons under the sink.  Though these come with the territory, the kitchen’s also a great place to learn important life skills.

People aren’t feeding themselves enough anymore, relying on packaged, pre-prepared food, or fast food, rather than on home-cooked meals from natural ingredients. For the world to feed itself in a healthy and sustainable way, the next generation must learn how to cook. Kids should how to use knives without cutting themselves.  They need to learn to make meals with fruits, vegetables, good starches and proteins.  They should know how to handle raw meat using non-wooden cutting boards, washing their hands and tools afterward, and disposing of the wrappings and skins safely.  They need to learn how to use the stove, oven, and microwave without setting themselves or the rest of the house on fire.

Besides knowing how to make good food, the kitchen is also a place for healthy interactions. It’s where the family cooks together, learns together, eats together.  Cooking is a creative art, and exercising creativity grows healthy kid brains.  Children develop pride in their new-found abilities, and of course, everyone likes to eat.  Families talk better while eating a meal together, rather than separately in front of TVs, games, or computers.

So make your next meal at home and get those kids into the kitchen with you, to learn what you know.  And I guess it’s okay to let them screw around with the Christmas cookies.