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.

Island of Misfit Toys

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

I have fond memories of Sunday dinner at my grandfather’s.  We followed the same routine: mom brought the potato salad, grandmother made fried chicken, grandfather made the coffee.  And we’d play games: dad liked horseshoes, my brother… lawn darts.  Remember lawn darts?  They were comically-enlarged versions of traditional darts with a weighted end, to be tossed in the air at a target on the grass.  You may not remember them because of the Consumer Product Safety Commission, a government agency that banned them after several children were injured, some critically.

Many toys have been removed from the market over the years.  Some people think “they’re taking childhoods away from us!” Perhaps, but lawn darts had a proven record of hazards, and some toys prior to the Safety Commission’s founding were just flat-out ridiculous.  Look up the Gilbert Atomic Energy Lab, a toy marketed in 1950 by Alfred Gilbert (inventor of the more popular, and safe, Erector Set).  This set contained actual uranium ore which, besides producing cool effects, brought low levels of radiation into the household, and could cause radiation burns if handled improperly.  One play suggestion: secret the ore somewhere in the house, and play hide-and-seek with the included geiger counter.

Another obvious benefit of this agency was the removal from the market of Aqua Dots, an arts-and-crafts toy with beads manufactured in China.  After several toddlers were hospitalized with comas after ingesting the beads, they found that their chemical coating contained GHB. Popularly known as the “date rape” drug, GHB is particularly toxic to children.

A more routine responsibility of the agency is assigning age ranges for toys.  There’s a common misconception that the age suggestions are based on intellect or maturity level.  Thus parents buy the toy or game for their child who’s younger than the age range, thinking that their kid is advanced enough to enjoy it.  However, the age range is actually for safety’s sake, particulary for kids under age 3.  It’s decided by rigorous testing to assess the choking risk of small parts.

I recall when my brothers and I got our go-kart.  Back then, a go-kart was a glorified piece of sheet metal with wheels bolted on each corner, one of which attached to a small motor.  I vaguely remember a steering mechanism, but we ran into trees and dirt piles so much I can’t be certain.  It’s easy to remember the safety features though, because there were none.  Of course our parents didn’t make us wear helmets either.  I carry a reminder of that go-kart on my right elbow, a shiny white scar from when I jumped off while riding on the back, one thing mom did specifically warn us not to do.

Things have changed since then.  Go-karts and other motorized toys have become more complex.  While there’s been some focus on safety, they’ve also gotten more powerful, with new and different dangers.  With advancement in battery technology, there’s even electric dirt bikes for kids, though their size and speed don’t necessarily correlate with age-appropriateness.

Like we discussed above, the Consumer Product Safety Commission sets age levels for toys and games.  Though they base these assessments on proven algorithms, the science is still evolving concerning motorized riding toys.  For example, many of these are intended for use on dirt roads and isolated driveways.  They are unsafe on paved streets, particularly top-heavy and overpowered ATVs.  Another consideration is use of these toys by children with Attention Deficit Hyperactivity Disorder.  These kids have  decreased attentiveness and a penchant for risk-taking, so it’s important to keep in mind your child’s potential for accidents.  And bad injuries happen with these toys to any child, ADHD or not.

Parents can limit the use of these devices, ensure safety measures, and purchase them with their child’s capabilities in mind.  Helmets, elbow, knee, and wrist pads, and boots are helpful.  Designate safe areas for play, keeping kids off roads where they’re hard for cars to see and avoid.  Set use hours with the best visibility, for kids to see hazards and the hazards (cars) to see them.  Be there when your kids are riding or using potentially dangerous items.  We see castastrophes all the time in the Pediatric ER; don’t let your child be one of them.


Don’t Choke: Learn CPR!

This week’s guest columnist is Dr. Kevin Morris, a family practice resident at the University Hospital and Clinics here in Lafayette.

My wife and I sit down to enjoy dinner with our boys- the three year-old in a booster and the 8 month-old in a high chair.  We are chatting and relaxed when the baby quits making sounds.  He had inhaled to cough and sucked in a piece of teething biscuit, completely blocking his airway!  I pulled him out of his high chair and used three quick back blows taught in basic rescue classes.  The piece popped out and tragedy was averted.

Most people understand the danger of non-food items causing choking, like coins or rocks, but any object in the mouth is a hazard.  This is especially true for infants and children, who explore with their mouths and aren’t careful about chewing. The National Safety Council Injury Facts 2016 reports that choking is the fourth leading cause of unintentional death.

What to do?  First and foremost every adult, parents or not, should take a Basic First Aid/CPR course.  In these you’re taught important life-saving maneuvers, including the Heimlich maneuver.  There are different techniques to use depending on the child’s age, and you practice hands-on.  Call the American Red Cross, American Heart Association, or your local Fire/EMS for a class, or navigate their websites.

The most obvious way to avoid a choking episode is to make sure there aren’t small, non-food items within the child’s reach.  This includes marbles, rocks, small toys like lego pieces, button batteries, etc.  ”Within reach” is a big place for a toddler- they explore by crawling and walking wherever they can.  Since their mouths are one of the most sensitive parts of their bodies, they lick and taste new things they find, and pop them inside for a really good going-over.

Thus to keep children safe from choking, parents, grandparents, and other sitters need to be diligent.  Caregivers should periodically get on their hands and knees and explore the house and yard like a toddler would- finding and cleaning up all small things that the child might ingest.  You can look on-line for all sorts of other ways to “toddler-proof” their world.

Keeping non-food items out of your child’s mouth is one thing; but food is also a choking hazard.  My boy, who choked on the teething biscuit as a baby, had a second episode when he was 5 years.  When we were leaving a restaurant he grabbed a peppermint from the bowl on the counter. Once in the car I was backing out of the parking space, looked over my shoulder, and saw a scared look on my son’s face.  His hands flew to his throat, the classic sign of choking.  Since he was older, the back blows I used when he was a baby were no longer appropriate.  I jumped out, grabbed him from his seat, and administered the Heimlich maneuver. After five abdominal thrusts the peppermint was expelled and my son was breathing again.

Like we said above, prevention is the best medicine for choking.  The American Academy of Pediatrics recommends avoiding these foods for young children: hard candies like that peppermint, un-cut hot dogs, nuts, peanut butter chunks, popcorn, seeds, whole grapes.  You get the idea: any firm object large enough to block your child’s airway.

Grapes are good for kids, they just need to be cut into halves or quarters.  Hot dogs need to be sliced.  Children don’t always chew food thoroughly, and aren’t yet able to reliably keep food from falling to the back of their throats.

Another important rule is never let toddlers and small children walk and eat.  It’s hard for a kid to do both when they’re still new to those activities.  When kids walk, they breathe harder, chew less, and thus increase choking risk.  And when they’re walking, they can walk out of your sight and choke to death without you even knowing it!

Therefore, all kids from infancy to elementary school should sit while eating, where they can be monitored by adults.  And as I have repeated, we highly recommend that every parent, caregiver, and babysitter take a BLS/First Aid course to have the skills to save a choking child.  Like I did twice with my son, you may save a life very important to you!

Feeding New Babies New Foods

This week’s guest columnist is Dr. Nichole Miller, a family practice resident at the University Health Center here in Lafayette.  Dr. Miller has a four-month old baby, and know of what she speaks:

Brandon’s mom was excited, her baby is 6 months-old, sits up without much assistance, and is now interested in food.  Great!  What a big step in little guy’s development.  But now: “Which foods should I start with?  Is he really ready to eat foods?  What if he has food allergies?  Sheesh, why is it so complicated?”

Every parent’s journey includes the exciting time of feeding foods for the first time.  This new adventure comes with those questions.  According to the American Academy of Pediatrics (AAP), babies are ready for solids when they can hold their heads up, sit with minimal support, and open their mouths to food.  Easy enough, right?  But again, what foods to start?  Start with simple puree foods, like baby cereals.  Vegetables should come before fruits.  No highly allergic foods, like foods containing peanuts or egg.

Give one new food at a time and wait three days before introducing another new food.  This helps identify any food allergies your child may have- if baby starts with a bad rash, vomiting, or diarrhea after eating that new food, stop serving it.  If you give new foods too close together, you can’t know which one caused the rash.

Let’s fast-forward: Brandon is now one year and his mom is at the next hurdle, the picky eater stage.  Every parent worries about picky eaters.  The AAP reminds parents that toddlers sometimes just aren’t hungry.  Brandon may eat all his breakfast and not touch lunch or dinner.  Instead of fighting about food, offer a variety of foods and let your toddler choose.  Whatever he doesn’t eat, offer it at the next meal.  Remember the four main food groups: meat, dairy, fruits and vegetables, and breads and cereals.  Offer items from each group.  Avoid highly processed foods, which means foods which are highly packaged and have ingredients you can’t pronounce.

That covers the “do’s” of feeding toddlers food, let’s talk about the “don’ts.”  Say Brandon still won’t eat any foods, only drinks milk.  Milk is good for a kid, right?  So mom feeds him all the milk he wants- four 8-ounce bottles per day.  Since he won’t eat meals, she lets him snack all day.  This is common with new parents and toddlers, and reveals three don’ts.  First, no bottles after one year- kids should drink from sippy cups.  Second, toddlers shouldn’t drink more than three 4-ounce cups of milk per day- more than that kills their appetite for foods, and filling up on milk robs a kid of important food nutrients.  Finally, snacking also kills appetites for meals, and snack-grazing behavior contributes to obesity.

However, Brandons’ parents read our blog and he is eating a variety of foods and is doing great.  Now Brandon’s dad offers him grapes.  He eats one and begins to choke.  Mom panics, pounds him on the back, and he coughs up a barely-chewed grape.  Many small firm foods are choking hazards for toddlers because they don’t know how to grind their food while chewing.  The AAP recommends the following foods be avoided: un-cut hot dogs, hard candies, nuts, peanut butter chunks, popcorn, seeds, whole grapes, and the like.  Parents should take a CPR class to learn choking management like the Heimlich maneuver.

Another food concern is eating things that aren’t food.  Say Brandon is now 7 years-old and in T-ball.  He just finished a game and is enjoying some sunflower seeds like real baseball players.  However, unlike the guys on TV, he is swallowing the shells with the seeds instead of spitting them out.  The next day, Brandon has terrible pain when pooping.  The pain gets so bad he’s brought to the Emergency Department.  On x-ray, we see the shells stacking up and forming an impaction in Brandon’s rectum.  Also, the shells’ sharp edges hurt like broken glass.  Brandon has to go the Operating Room to get the horrible impaction out.

Parents, never let your kids eat sunflower seed shells- just the seeds please!  Leave the shell eating-and-spitting to the pros, who get paid to do that on TV.

Throw Me Something Mister- I’ll Try Not To Swallow It!

This week’s guest columnist is Dr. Libby Going, a Family Medicine resident at the University Health Center here in Lafayette.

Mardi Gras is here!  That means celebrating with floats and parades, king cakes…..and beads.  Edible treats quickly come to mind when we thing about Carnival season, but occasionally kids try things that are not edible.

Part of baby development is learning about objects by putting them into the mouth.  The mouth is one of the most sensitive parts for babies, so they use it to explore their world as much as they can.  This means every parent has had to grab something inedible out of baby’s hand or mouth.  ”Don’t eat that!” or “That’s not food!” are common phrases for parents with small children.

Many iconic Mardi Gras items have great appeal to a baby or toddler who already wants to put things in his mouth.  Sparkly, smooth, multi-colored beads, small plastic babies (looks just like me!) hidden in king cakes, and shiny gold doubloons- what more could a little one want?!?

So how do we keep this natural behavior for kids from becoming a 911 call or Emergency Department visit?  First, many bakeries now help out by not putting the baby into the king cake before purchase.  Parents can decide to place the inedible object into the cake or not.  Please decide not!  Let’s face it- toddlers will at the very least lick it, and maybe eat it. An idea for the older child who “just has to have the baby” is to put the baby on top of her piece and then take it back soon after.

Coins (or gold doubloons at this time of year) and button batteries are also favorites for trying in the mouth.  Thus you must be vigilant about not letting those in baby’s reach. Beads are also a serious choking hazard, so don’t be careless about leaving those around either.  But babies will be babies and sometimes just get ahold of these things, so it is important for parents to take a CPR class.  There you can learn the Heimlich maneuver, which works great for choking and can be life saving.

Even when Mardi Gras is over, kids will still put interesting things in their mouths and maybe swallow them.  If they do swallow something, and maybe gag and choke, this is one of the worst experiences in parenting!  This fear brings a lot of kids and their folks into the Emergency Department, even when the kid looks fine and swallowed something seemingly innocent.

When a child has swallowed what we call a “foreign body,” he may have increased fussiness, only want to drink liquids, vomit, complain of throat or chest or abdominal pain, or have a different sounding cough or gagging noise.  With any of these signs, your child needs to be evaluated.  Button or disc batteries are particularly dangerous because even if your child seems fine after they swallow one, batteries can cause serious internal burns. We often use xrays to show the culprit and where in the body it is.  Even if the parent doesn’t know exactly what was swallowed, the object’s shape on xray can tell us what it is.

Most foreign bodies pass harmlessly through the gastrointestinal tract and appear at the opposite end.  Sometimes a couple of xrays can be used to monitor the journey of that very interesting object.  However, some objects may require removal, usually by endoscopy.  This is a flexible fiberoptic tube with tiny tools and a light at the end, through which the doctor can see the thing and grab and retrieve it.  Some things that need to be removed include batteries and objects that are stuck and not moving through.

One important note to remember is never give your child something to drink or a snack once you decide to bring him in.  Children need to have empty stomachs for surgery, to have anesthesia safely.  Also, trying to feed a child with a blocked esophagus can cause vomiting and further choking hazards.

Mardi Gras can be a great time for the whole family, toddlers included, but some precautions must be taken to ensure that the fun does not end in the Emergency Department.  Laissez les bon temps rouler!

He Put What In His Mouth??

The mom came in with the ambulance crew, sobbing “She is so fast!”  Her 2 year-old daughter was skipping past dad as he watched TV.  She grabbed a piece of his popcorn and before anyone could react, tossed it in her mouth.  She suddenly stopped skipping, a look of surprise on her face, and began gagging and coughing before settling down to a steady wheeze.  The parents called 911, and she was brought in still struggling to breath. The x-ray showed the popcorn in her windpipe, just below her vocal cords.

It would take a surgery to reach down that far and get it out, so I made the calls and waited for the crew.  Meanwhile we stood by watching her struggle, not wanting to agitate her more, for fear that if she got more worked up, she could suck the popcorn further down and completely block her airway.  After an eternity of watching her breathe, watching her get more and more tired from the effort, the OR stretcher showed up.  Everything in surgery was ready, and off she went.  It took the surgeon a good hour to fish out the piece, but in the end the girl did well.

Toddlers are choking episodes waiting to happen.  First, they like to explore the world, and they explore it most with their mouths.  Their mouths are the most sensitive things they have, so everything gets licked and tasted.  If the object of curiosity fits, they pop it in for a really good going-over.  Second, toddlers have zero good-judgement.  They know nothing about what is safe to put in their mouths.  Dimes, electrical cords, bees, whatever they can put in, they will.

Finally, as we often say in this column, toddlers can not be watched every second of the day.  And they are doing potentially dangerous things all the time.  I myself have come home to the babysitter sobbing, “She is so fast!” when my toddler daughter, without warning, ran over and kicked my infant son.

There are some good rules for preventing choking episodes like happened with the girl above.  The first rule is not feeding your toddler unsafe foods.  Such foods are small, hard to chew, and too yummy for toddlers to pass up.  These are foods like candy, gum, nuts and seeds, hot dogs, hard meats, and small firm fruits and vegetables like raisins.

Toddlers and infants haven’t got many teeth to properly chew up these foods to make them safe to swallow.  Toddlers also, like we said before, have lousy judgement about what to eat.  Who cares if that hard candy is a choking hazard and bad for their teeth?  If it tastes good and is in your purse, they will fight you for it just the same.

Another good rule for toddler and infant eating is sitting down.  Small children should only be allowed to eat when they are sitting and being supervised.  No walking, playing, running, or lying down while eating.  Kids breathe harder and eat more carelessly when they are moving.  Just like the old joke about some adults being unable to walk and chew gum at the same time, toddlers can NOT safely walk and eat and breathe.  Not only are they safer sitting still when they are eating, but you can watch that only safe things are going in.

All homes with infants and toddlers should be swept for choking hazards.  Get down on your hands and knees and crawl around everywhere at your child’s eye level.  Pick up small objects that your child could inhale- coins, marbles, deflated balloons, small toy parts.  Particularly dangerous are button batteries and magnets- both can cause deadly internal injuries if swallowed.

Finally, all parents should take a CPR class to learn the Heimlich maneuver.  If our girl with the popcorn in her windpipe had suddenly stopped breathing, that would have been our best life-saving intervention.  The Heimlich is easy to learn, easy to do, and works great.

So be careful about what foods you let your toddler eat.  Get down on your hands and knees and clean house.  And sit your kids down anytime they eat- that way you can know What He Put In His Mouth.