School Blues

On my first day of medical school, the dean gave a little speech about how it’s stressful, and that the school had a counseling center for students when their anxiety got overwhelming. Though the course work is intense, the dean said, most visits to the center “are about a girl.”  Everybody laughed- relationship trouble worse than medical school?  I laughed too, until 2 years later, when I found out my girlfriend at the time was seeing someone else; two weeks before a major exam that if you didn’t pass, you got held back a whole year.  Turns out the counseling center was pretty cool.

We see lots of anxiety, and anxiety-related symptoms, in the Pediatric Emergency Department.  Sometimes the kids come right out and say, “I’ve got anxiety,” and describe their depression, negative thoughts they can’t control, their feelings of impending doom.  Often though, they come in with symptoms that freak everyone out: trembling, shortness of breath, complaints of chest and throat tightness, even seizure-like activity.  Everyone is concerned that the teen is having an asthma attack or severe allergic reaction, when these symptoms are actually how he’s experiencing a panic attack.

We usually see these kids coming from school.  The child starts having these worrisome symptoms, a school nurse isn’t available to calm everyone down, and the ambulance is called.  By the time the stretcher wheels through our door, the kid’s back to normal, and it’s time for us to determine if this was a real allergic or asthmatic episode, or was it anxiety-related behavior.

Schools are a stressful place for children.  For most of their day, kids are immersed in multiple, continuing, unrelenting social interactions.  Often those interactions are good: laughing with friends, learning cool things with a favorite teacher, horsing around at PE or recess.  Sometimes they’re not so good.  Bullying is still mostly a school phenomenon, when a strong-willed kid and her group gang up on someone vulnerable.  Maybe the child’s having trouble with academic achievement, maybe add an unpleasant teacher, or a break-up..  All kids struggle with their sense of self-worth; put them in this pressure-cooker environment, and sometimes bad things happen in their heads.  It’s a wonder ambulances don’t get called more often.

My son’s college transcript showed that he failed Business Law, a bad start for a kid thinking of going into…business law.  After emailing his professor, he stumbled through the day in a haze of misery.  When he found himself enjoying something- a joke or nice weather, the happiness was quickly extinguished by the thought, “I’ve failed.”

Later that afternoon his professor replied- it was a mistake. My son’s final exam grade hadn’t been entered into the system, triggering the fail.  It would be fixed, and he breathed an enormous sigh of relief.  But it still took some time to shake that dread that had haunted him.  Anxiety can be sticky.

We’re born with a need to be anxious.  It’s an ancient motivator from evolution, keeping us from getting eaten.  Worried about that sabre-toothed tiger eyeing you? Good, run away!  Even animals as primitive as lizards have anxiety.  Just approach one, watch it twitch and scuttle about, before tearing off.

Anxiety has been rising in past decades. Most families worry about money. Despite corporate economic gains, people’s buying power has declined, as their wages remain stagnant against rising costs.  There’s also growing distrust in institutions meant to protect us, like law, medicine, and government.  Finally, there’s the 24/7 news cycle, the channels and websites finding more bad news (crime, war, injustice, political bickering) to keep us glued to them and their advertisers.

Children get anxiety too.  Not only do they get it at school, as we described above, but it’s fed by their parents’ anxieties too.  When parents hear that the world is spiraling to destruction, kids hear that too.  Sometimes they get symptoms like we discussed above- palpitations, trembling, tight chests- and come to the Emergency Department.

When kids’ anxieties interfere with their lives, counseling and sometimes medication  help.  However, prevention is always better.  The world’s actually a safe for you and your kids. I’ve visited countries that, in news stories, are constantly violent.  Yet I see people instead living in peace. New York City used to be portrayed that way, but really wasn’t more dangerous than Disneyworld.  And institutions like government, medicine, and law, still work quite well.  Teach your kids that the world’s okay.  And maybe turn off the cable news.

Milking For All It’s Worth

This week’s guest columnists are Drs. Meghan Gaddis and Camtu Nguyen, Family Practice residents at the University Hospital and Clinics here in Lafayette.

Nothing’s worse than a crying, inconsolable baby.  We face them from time to time in the Pediatric Emergency Department, and this one evening mom was equally frazzled: hair in a messy bun, bloodshot, teary eyes from nights not sleeping, clothes stained with various colors and textures.  “My baby hasn’t breastfed or taken a bottle since yesterday!  I don’t know what to do!”

Baby was 6 days old, and seemed a poor breast-feeder due to trouble latching on.  This first-time mom maybe wasn’t producing much milk with the latching difficulty, and stressing out certainly wasn’t helping her supply.  To make breast milk, breasts need stimulation from baby, and a calm mom. She was also using a breast pump to stimulate supply, but this wasn’t going well either.  She was dead set on NOT giving baby formula, because of course, “breast is best.”

However, baby looked pretty darn healthy.  Sure he was fussy, but calmed down with swaddling and a pacifier.  He looked rounded-out and well fed.  He wasn’t dehydrated, with moist eyes and mouth, and acting vigorous, and making wet diapers.

Many first-time mothers aren’t aware of the timeline of milk production.  The first milk produced immediately after birth is called colostrum.  Colostrum is thicker than later breast milk, and has a higher protein content. This “liquid gold” only comes out in teaspoonfuls at a time, but that’s all baby needs.  It provides enough calories, encourages baby to practice sucking, swallowing, and breathing, before regular breast milk comes in in quantity.  And believe it or not, newborns’ stomachs are only about the size of a cherry, so a few teaspoonfuls will fill her up just fine!

In three to five days, breast milk really comes in.  Mom’s breasts begin to feel heavy and full, and baby begins gulping and swallowing with more vigor.  Urine and poop production also ramp up with this increased intake.  Poop goes from the tarry green, sticky “meconium,” to a loose yellow stool that looks like it has oatmeal flakes, or “seeds” in it.  Isn’t this an enjoyable talk with your morning coffee?

Breast-feeding has always had a bit of a stigma.  From ancient Egypt to medieval times, nobility considered itself above breast feeding.  Queens and princesses often employed wet nurses, mothers who recently weaned their own babies, to feed their little heirs.  When 20th century technology brought ordinary people things that only royalty used to have- one’s own in-house music, indoor plumbing, ready-made meals- it also brought formula.  Now, no one had to breast-feed.

Bottle feeding is easier for moms and babies, in the beginning.  As we mentioned above, latching and sucking takes some training. While bottle feeding, like many other technologies, has the front-end convenience of ease, it begats more problems than it solves.  Bottle-fed babies more easily become obese children and adults, with higher risk of diabetes.  They have more colic (nightime cramping and fussiness) in the first few months. They’re often more constipated and spit up more.  Finally, bottle-fed babies get more stomach viruses, colds, and ear infections than their breast-fed cohort.  Then these moms come to the Pediatric Emergency Department or their doctor’s offices with their vomiting, constipated, infected, squawling progeny.

Breast feeding has many advantages for moms, as well as for babies.  Making milk burns calories, and thus moms lose weight faster.  Suckling stimulates the release of oxytocin, a hormone that shrinks the uterus to pre-pregnancy size, and reduces bleeding.  Finally, breast feeding parents have less junk to haul around.  Traveling with babies has become a modern-day caravan, with car seats, portable cribs, and diaper bags bulging with spare clothes, diapers, wipes, ointments, etc.  Add to that an assortment of bottles and nipples, formula cans, and measuring cups.  And where can I get some sterile water, please?

Back to our mom from above, who was worried her newborn wasn’t getting enough breast milk and dehydrating.  How can you tell if baby is getting adequate fluids?  First, if your baby is crying, the fact that the little booger is hooping and hollering means she has enough fluids to be active.  If she’s making tears, that’s another good sign.  The best way to tell if baby is hydrated is if he’s making wet diapers.  At least one or two wet diapers per day means baby’s getting enough milk, for all it’s worth!

How EDs Work

It was morning in Honduras on my most recent medical mission.  I padded in my pajamas to the room where the coffee was supposed to be, but alas it wasn’t out yet.  I went back to my room, got dressed, back to the coffee table- still no joe. Somewhat miffed, I went to brush my teeth.  Finally on that third trip back, now really irritable, there was finally coffee!  Later that morning, I stood in the clinic doorway and greeted a family that was all smiles, though covered with dust from their three-mile walk from the open-air hut they called a home.  Makes my irritation over coffee pretty lame.

Anger over having to wait is a pervasive emotion in the Emergency Department too.  Families are already stressed about their sick child.  Then they have to wait for the doctor- sometimes an hour or two, sometimes more.  They really get steamed when  another kid passes them in the waiting room, being ushered back ahead of them.  What the hell’s going on??

Getting passed up touches on an under-current of frustration in our society.  While America is supposed to be class-less, everyone equally important, we see that’s not the case.  In court, the rich can afford better lawyers, and beat raps that would have us behind bars for years.  In the airport, there’s first class lounges and airplane seats, and there’s the rest of us in crowds and cramped seats, only a tiny bag of pretzels for our trouble.

But the ER is a true meritocracy. We treat emergencies first- kids who have real trouble breathing, compromised airways, or shock from dehydration or blood loss.  If we don’t see them first, they can get dangerously more ill, and even die. The front of the ER is called “triage,” a military term for sorting casualties to maximize lives saved- the most critical go first, the mildly injured wait, and the dead are dead.

You’ll sometimes see an apparently well child go ahead of you.  A kicker in Pediatric Emergency Medicine is that often the first signs of distress are subtle- mild trouble breathing, hidden signs of shock, before the quick and inevitable “crash.”  The child jumping to the head of the line may look okay from afar, but really isn’t.

Once a mom complained to me that at a previous Emergency Department visit, she waited for hours with her child.  When finally brought back, they passed the nurse’s station where the nurses and doctors were laughing and leisurely eating pizza, like they were at a Superbowl party. They didn’t seem to be busy with many other patients either.  Since hearing of this apparent outrage, I furtively eat my meals in our back conference room.

In defense of that ER crew, they may have just finished resuscitating a major trauma, having spent hours putting in tubes and lines, taking the patient to CT and back, giving blood and meds, and calling in surgeons.  Finally they get to eat a meal, and while they’re at their jobs, what’s wrong with some camaraderie after a stressful event?

As I mentioned above, I just returned from my annual medical mission to Honduras. In the mountains, when a mom’s child gets sick, she has nowhere to go- no ERs, no walk-in clinics, no medical care at all.  Once a year we show up at a local school house, and people walk miles to see us.  They wait hours in line in the hot sun. To make time go by, we have a station where the kids get crayons and paper and make pictures.  They pass around their creations and chatter with everyone around, having a better time than any tablet could provide.

To survive your visit to an ER, some patience and perspective is in order.  If a child is truly sick, they’ll be seen quickly.  If you’re not rushed right back, count your blessings- the triage crew has assessed your child as not being gravely ill.  If you get passed up by another, know that that kid is worrying us, but we haven’t forgotten you- the computer tracker assures that. Better still, if your child doesn’t have an emergency, like only having a fever, cough, or rash, see your doctor the next day.  If they have ear pain or a sore throat, give them ibuprofen or acetaminophen (Tylenol). And be thankful that, unlike coffee growers in the mountains of Honduras, you’ve got somewhere to go.

Keep The Change

This week’s guest columnist is Dr. Hanh-My Tracy Tran, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

It’s shameful getting sent to the principal’s office, so I recall the time it happened to me.  My fourth-grade teacher was worried that I was ill, and then grew more concerned when she noticed red marks and bruises on my neck, back, and shoulders.  When she asked me about them, I said that’s how my mom treats me when I’m sick.  Even more freaked out, she sent me to the principal’s.

My response raised fears of abuse, but to me, a Vietnamese, the practice of “coining” is normal. Known as cao gio (pronounced gow yaw), coining is a common traditional technique in Southeast Asia.  It’s used to treat flu, colds, muscle pain, and fatigue.  The literal translation is “catching the wind.”  It’s believed that we get sick because of being  too much in windy weather, causing an imbalance in the immune system.  To restore balance, ”bad wind” is released from the body by coining.  Objects with smooth edges like coins or spoons are dipped in heated oil and rubbed in a specific pattern on the back, chest, shoulders, and neck.  This leaves red lines that last for 3 to 5 days.

When children come to the Emergency Department, doctor’s offices, or schools with these marks, things can become hectic.  Doctors, teachers, and other parents who aren’t familiar with coining worry about abuse, and think about reporting it to police and the Department of Family and Children’s Services.  All the more reason for doctors to listen to patients and their parents without prejudice.  Physicians must be willing to be open-minded about different practices.  For parents, it can be uncomfortable to discuss alternative medicine with doctors, fearing judgement.

It’s important to discuss alternative practices with doctors, because some can help, but some can be harmful.  Doctors are becoming more aware of these practices, and science is helping to figure out which are actually good, and which might be dangerous.  The National Institutes of Health now has a Center for Complementary and Integrative Medicine (NIH-NCCIH) to study these issues.  Stay tuned!

In these high-tech days with tele-medicine, you can meet your doctor or specialist over the computer. They can see you, discuss your problems, look at labs and xrays together, and have a nurse practitioner do a proxy physical exam .  I know a woman with a low-tech equivalent: she calls up her traiteur, and gets her healing over the phone!

Alternative medicine is ancient.  Wherever there’s people with limited access to health care, lack of understanding of disease, or few resources, they turn to what’s at hand.  In medieval Europe, they used what herbs grew in the forest or garden.  In Asia, they used coining like we discussed above, and other methods like cupping, acupuncture, massages, and their own herbs.

Many of these therapies survive today.  Olympic athletes use high-tech training tools like high-speed filming of their techniques and oxygen/substrate burn measures, but then show up with odd red circles all over them.  In the 2016 Olympics in Rio De Janeiro, Michael Phelps and others used cupping, a centuries-old technique where a cup is heated and applied to the skin.  When the air cools inside the cup, it sucks onto the skin, leaving distinct round bruises. It’s believed that cupping helps muscles recover from fatigue.

Science is just starting to evaluate these practices, to see which really help, and which might be harmful.  For example, St. John’s Wort is a plant that’s been used for centuries for depression, and is available as a dietary supplement.  However, it can interfere with some life-sustaining medications, like prescribed antidepressants, heart medications, chemotherapy, and a host of others.  To get the facts on St. John’s Wort and other dietary supplements, go to the NIH-NCCIH (mentioned above) website for their “Using Dietary Supplements Wisely” fact sheet.  This is especially important when considering supplements for kids, as their ability to handle these can be different than adults.

When you take your child to the doctor, be sure to mention all alternative practices you use.  Some are helpful, some aren’t, and it’s important to know so we can make sure  standard medicine doesn’t interfere with the alternative stuff.  And so when we see odd circles or coining streaks, we don’t panic either!

Hot Dog

My feisty little dog Milou hates squirrels. They’re harmless, but you wouldn’t know it the way he barks and barks when they’re running around the yard.  When we let him out a high speed chase ensues, him nipping just behind the trespasser’s tail, before the enemy slithers through the fence and is gone.  Milou continues to bark, his shrill yapping annoying everyone, particularly my back-fence neighbor, who blows an air-horn when he’s had too much.

Like Milou and squirrels, parents and grandparents are irrational regarding fevers. Their fear stems from what fevers used to mean in children, generations ago.  Before 1990, fevers could mean life-threatening illnesses like meningitis and blood infections.  Before 1950, it could mean polio or measles.  Ancient memories probably haunt dogs too, their DNA wired to attack intruders into territory and food supply meant for the pack.

Like squirrels, fevers themselves are harmless, and actually good!  They’re part of the body’s immune response to invading infections.  The brain senses evidence of infection and sets the body’s thermostat to make fever.  Just like cooking food kills germs in it, fever makes it harder for germs to grow in the body, giving the immune system a chance to overtake the infection and destroy it.  Myth buster: fevers don’t hurt the brain, and seizures that accompany fever in infants and toddlers are rare and benign.  Finally, vaccines have eliminated the vast majority of serious infections that fevers once heralded.  These days, fevers usually mean mild illnesses like cold viruses and ear infections.

More important than the fever is how your child is ACTING with the fever.  Kids in terrible pain, who work hard to breathe or drink poorly, or are lethargic; those are the ones we worry about. But if your child is drinking well, breathing comfortably, and of course tired from the fever but wakes up to act reasonably alert, then no emergency!

For feverish kids who feel rotten, give them anti-fever medicine, like acetaminophen (Tylenol), or ibuprofen (Motrin, Advil).  Sometimes fevers make kids breathe fast, have fast heart beats, and act tired.  If these improve after medicine, that tells us things are okay.

There’s a term for irrational fear of fevers, like my dog’s irrational hatred of squirrels- “fever phobia.”  This term describes that fear, and the lengths parents go to combat it.  Some examples of parents talking fevers: “It shot all the way up to 100!”  “His fever was 102, so he had to come to the ER.”  “I took her temperature every hour.”  “He was shivering, I was afraid he might catch a seizure.”

These attestations reveal misconceptions about fever.  Fever is defined as temperature greater than 100.4 Farenheit, but temperature height rarely correlates with severity of illness.  In other words, higher fevers don’t mean your kid’s more sick. Some children in the hospital with pneumonia have temps of 101, some at home with ear infections are 103.

Fevers don’t cause brain damage, and won’t rise to life-threatening levels if untreated.  But given these fears, parents go to extremes. They take their kids’ temps hourly, wake them up at night to give them medicine, bathe them with rubbing alcohol, and visit the Emergency Department, as if their babies will burst into flames like overheated race car engines.

Fevers are actually good.  As we said above, it’s part of the body’s defense mechanisms against infection.  There’s a faction in pediatrics that wonders if we should even give anti-fever medicine, that maybe without them kids would recover faster.  No one has studied that yet, and certainly giving ibuprofen or acetaminophen (Tylenol)  helps your child feel better.

Feverish kids feel bad- they have headaches, they don’t drink well, they breathe fast and their hearts go fast, and they sleep so hard they can be difficult to arouse.  Anti-fever medicine makes these better.  Kids drink better, act more appropriately, and generally scare parents less.  But give enough- as much as the box says!  While fearing fevers, many also fear overdosing their children, and don’t use adequate doses to alleviate symptoms or fever.  Then when the fever persists, they panic more. And no alcohol baths- these CAN poison children through skin absorption.

With medicine, remember you’re treating to help your child feel better, not necessarily eliminating fever.  If you can’t get the fever down, don’t panic.  As long as your kid’s breathing comfortably, drinking adequately, and arousable, that’s okay.

Cook Drops The Ball

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

Watching the instant replay, I saw exactly when Jared Cook lost consciousness.  In yesterday’s Saints game against the 49ers, he made a great catch, and hung onto the ball through his fall.  But as he lands he’s hit in the helmet.  His hands go slack, and the ball rolls away. To return to play, Cook will undergo daily neurological evaluations while his brain heals. Then he must stay well under increasingly challenging conditions- during exercise, then drills, then scrimmaging.

Concussion is defined as a brain blow followed by loss of consciousness, headache, nausea, trouble with balance or coordination, memory loss, disorientation, and slowed thinking.  Bright lights and loud sounds can make it worse.  Irritability, depression, anxiety, and mood swings are also part of the picture.  Concussion isn’t brain bleeding or skull fractures.  It doesn’t show up on scans- it’s simply defined by the symptoms.

It’s important to immediately remove an athlete with suspected concussion from the game. Continued blows can worsen the injury; prolonging recovery, worsening pain, and even risking brain swelling and death.  It’s sometimes a while before concussions are obvious to coaches, or the player himself.  Thus with any suspected injury, the player needs a sideline evaluation with one of several tools approved by the league- NFL, NCAA, LHSAA.  Don’t wait until the player is staggering about, slurring his words, and vomiting.

If a player is suspected to have concussion, that’s it for the game.  He needs a more thorough evaluation by his doctor, plenty of rest, pain medicines, and time.  The doctor determines fitness to return to play.  Sometimes the simplest things can bring headaches back- trying to read, math homework, exercise.  It can take weeks for an athlete to be ready to play again.

These rules go for all sports with head injury risks- soccer, cheerleading (lots of throwing and falls off pyramids!), basketball, baseball and softball.  No one’s invented an attractive cheerleading helmet yet, any takers?

Kids are constantly bonking their heads, like when my son was learning to walk.  He would take steps along the couch, holding on for support.  Then he’d toddle away, swaying back and forth.  Once he tipped forward and smacked his forehead on the floor.  My wife squeaked, snatched him up, and looked to me for help.  I froze, mouth gaping. Oh, right, I’m a doctor!  Then I remembered my time in the Pediatric Emergency Department.

In the ER we have guidelines about which head injuries are fine, and which need CT scans for brain bleeding.  There’s separate guidelines for kids under 2 years, and those over 2.  My son was in the under 2 category, so these told me he was okay: he wasn’t knocked out, crying immediately after flopping down. Then later he acted fine. This wasn’t a severe injury mechanism, for his age meaning falls greater than 3 feet; he’s under 2 feet tall.  He had no scalp swelling or other signs of a skull fracture.  Thus I knew he didn’t need an ER visit.  Myth buster- no need to wake him up every hour at night to check on him either.

The criteria are a little different for kids over 2.  Notice I didn’t worry about vomiting in my son.  Toddlers vomit easily, especially when they’re upset.  Vomiting has no correlation with bleeding at that age.  However, over age 2, vomiting is on the worry list.  Other signs are being knocked out and/or having a really bad headache.  Indications of skull fracture are “raccoon sign” (black eyes without a blow to the face) or “battle sign” (bruising behind the ears).  If the child is acting dazed and confused (worse than usual, for your teenagers!), that’s concerning.  Finally, if there’s a severe mechanism of injury, like falls greater than 5 feet, blows by a high-impact object like a thrown baseball, or getting hit by a car while walking or riding a bike without a helmet, get checked!

We don’t CT scan every kid who comes into the ER with a smacked noggin.  CT scans carry a small risk of causing cancer by their radiation dose.  We see all severities of injuries, and with experience and these guidelines can make the scan-or-not call with a cool head. If your kid needs it, he’ll get it.  If not, whew!

Hush Little Baby

It wasn’t the greatest vacation for our kids.  We were at an all-inclusive resort, and put our pre-school kids in the tots’ activity program.  To sell it to them, we called it “Special School,” as in “Yay, you get to go to Special School!”  But after a few days of missing us, they began to tear up in the morning. “We don’t want to go to special school!” they’d wail.  Compounding that misery, our 2 year-old son stopped sleeping through the night, waking to cry at 3 am.

It was a bad time for the tough-love approach to get him back to sleep.  Known as “cry it out,” the strategy is to let your child cry in the middle of the night, after one or two trials of comforting them, so they learn to fall back asleep themselves.  Usually the kid cries the first night for about 45 minutes before falling asleep. The next night, 20 minutes, the next 5 minutes.  By the fourth or fifth night, they’re sleeping all night again.  Unfortunately for this vacation, he couldn’t forget us, being able to see us from his portable crib.  And with the thin walls of the hotel, he kept other guests up as well.

There’s a tension as you raise children, between meeting their desires, versus meeting yours and your other kids’ needs.  For example, they want cookies and candy, you want them to have good teeth and ache-free tummies. This applies to toddlers who in the middle of the night, or at bedtime, decide they’re lonely and want to sleep with you.  You need your sleep, they want comfort.

There’s two schools of thought on this issue.  One is the “family bed,” where children don’t sleep in a separate bed: everyone piles into one big bed.  This is okay if your child doesn’t toss, turn, and kick to keep you awake, or if you can afford a big enough bed to keep away.  If you don’t mind the lack of privacy or sleep interruptions, then no problem.  If, however, you want your kids to sleep in their own bed, in their own room, then you will eventually resort to some form of “cry it out.”

The ”cry it out” strategy for children waking in the middle of the night seems harsh to some.  My mom, one of the most loving people I’ve known, said “two closed doors between you and baby is about right.”  And crying-it-out works for toddlers who will stay in their beds.  However, my oldest would come out of her room and stare at us if we left her in her bed.  Thus, I installed a hook-and-eye lock on her bedroom door.

After two attempts to comfort her when she’d wake up in the middle of the night and not go back to sleep, I’d lock the door.  The first night she cried for 45 minutes, then fell asleep at the door. The next night she cried for 30 minutes, then slept next to her bed. The third night she cried for 10 minutes, and slept in her bed.  After that, she slept all night.

This sounds cold-hearted but in some ways, so is not letting kids have snacks anytime they want, or time-outs for discipline (we had to buckle that oldest child in her time-out chair, lest she wander around).  The advocates of the “family bed” strategy hold that kids should sleep with parents.  Of the cry-it-out strategy, one family bed advocate writes that parents think that the kid has “learned to sleep alone.  What the child has really learned is that their cries were not answered, their needs not met.”  Cry-it-out advocates argue that their kids have no emotional scars, while the family bed kids tend to be brats.

There’s more than one way to raise children.  If there was one right way, there’d be one book, one website, on how it’s done.  Since there’s hundreds of ways, there’s hundreds of books.  It comes down to what you can stand.  If you don’t mind the loss of privacy with kids in your bed, if you don’t mind restless sleepers, the family bed’s for you.  If you want your children to sleep in their own beds, then you’ll use some version of cry-it-out.

Everyone agrees on this: bedtime should be quiet, wind-down time.  No TV, phones, or video games within 2 hours of bedtime.  Then: bath, book, bed, prayers.  Lights out.

All I Want For Christmas…

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

My 1 year-old daughter was climbing everything in sight, including standing and balancing on her bouncer seat.  Quite a trick, until one day it flipped and she flopped, just avoiding a face plant.  I thought about maybe storing the bouncer in the attic but, duh, decided against it.  One Friday night she climbed on again, balancing and babbling away, and flipped again, only this time landing face first.  After consoling her, we went to wipe up the blood that had poured from her upper lip, and found a tiny white chip on the floor.  Looking in her mouth, an upper front tooth had that chip missing.

Toddlers are hurting their mouths all the time as they learn to stand, walk, and run away when you need them to stand still the most!  They trip and hit their mouths on floors, furniture, toys, etc.  Fortunately, their mouths seem designed to take the punishment.  The mucosa, what we call that shiny wet skin inside your mouth, heals remarkably.  Deep or long cuts that many parents, and walk-in clinic providers, think need stitches usually heal well without.

Also, toddlers’ teeth are their primary, or baby, teeth.  These are pretty much disposable.  If they get chipped or knocked out, it’s no big deal- there’s permanent teeth waiting to replace them.  Occasionally your dentist might want to put a knocked-out baby tooth back, to hold it’s space for the next tooth to come in straight.  If the tooth is knocked out, put it in some cold milk or saliva.  Then call your dentist about what to do next.  Don’t put a baby tooth back in yourself- jamming it in may damage the permanent tooth underneath.

When we got to the dentist with our daughter and tooth chip, alas, the piece was too small to glue back.  It would likely break back off next time she bit something hard.  Her beautiful smile has not been the same, but the adorable snaggle tooth smile has grown on me.  And one day, it will fall out and be replaced by the new model.

I was sharing this story with one of my mentors, and he had one to top mine.  One day his seven year-old daughter was at a birthday party with a fun jump.  She was jumping around, smiling away, when she hopped face first into the netting.  Her two upper front teeth were snagged in the net, and just like that they were yanked out and gone!

Like we said above, if your child loses a baby tooth, it’s no tragedy.  There’s spare parts, the permanent teeth, waiting underneath.  Sometimes the dentist will want to put a baby tooth back, to hold it’s space open so the permanent tooth comes in straight.  Otherwise, the other teeth may crowd that space, and the next tooth be guided in crooked.  Often though, it can be left out.

However, like my mentor’s daughter, permanent teeth are a different matter.  To save them, they need to be re-implanted right away.  Find those teeth!  When you do, wash them off with clean water, without soap.  It’s going to hurt briefly, but then push them back in the socket.  Don’t put them in backwards!  Then have your child hold the teeth in place with a clean cloth, and get to the dentist.  Like we said above, don’t put baby teeth back in yourself- this may damage the permanent tooth underneath.

If this makes you squeamish (there is usually a lot of blood when a tooth gets knocked out), or you’re not sure if the tooth that’s out is a baby or permanent, call your dentist.  While waiting for a call back, put the teeth in cold milk or saliva after washing them off.

Sometimes teeth aren’t knocked out when injured, just crooked.  This often can wait to see your dentist the next day, but call your dentist to check.  A tooth may need to be straightened right away if its an upper tooth that’s pushed back so it’s tip ends up behind the lower teeth, instead of in front.  In other words, your child’s tooth suddenly is an under-bite, rather than an over-bite.  If you can’t push it back in place easily, your dentist may have to do the job.

Safe To Sleep

The parents put their 4 month-old on their bed, for just a few minutes, to tend to the toddler.  She was in the middle of the mattress, with rolled up blankets around, to prevent her from scooting over and rolling off. Minutes later, they returned to find baby pale and limp.  She had rolled on her side up against the blankets, face in, smothered by the thick bedding.  The parents gave rescue breaths, called 911, and baby was recovering by the time they got to the ER.  But what if it had been only a few more minutes before she was rescued…

October was Safe-To-Sleep month, a national campaign to remind new parents about safe sleep positioning for newborns.  In the last 50 years, we’ve discovered that a lot of “crib deaths” happened because babies smothered, either because they had been placed face down on thick bedclothes, or rolled over by sleeping parents.  In 1994 the American Academy of Pediatrics had their first “Back To Sleep” campaign, encouraging parents to put babies to sleep on their backs, on thin mattresses, in their own cribs.  Crib deaths rates plummeted.

Since then we’ve found other factors also contribute to unsafe sleeping.  When my kids were infants, we but them on their backs, but on sheepskin, with bumper pads in their cribs so they didn’t hit the hard bedrails.  Our kids survived, but those things are also smothering risks.  Pillows, plush toys, thick and loose sleeper suits, are all hazards.

One risk for crib death that’s been known for centuries is co-sleeping, or sleeping in the same bed or couch with baby.  Even medieval societies recognized this smothering risk. Germany had a law in the year 1291 forbidding women from taking children under 3 years-old into bed.  In 1862, the English Women’s Journal warned, “Nor must we forget a frequent and lamentable cause of death that in which the infant is ‘overlaid’ in it’s slumbers by a careless, perhaps drunken nurse or mother.”  You don’t have to be careless or drunken, to commit this grievous error.  Babies are exhausting, up all hours with dirty diapers, feeding, and consoling.  Falling asleep with baby still in parents’ bed, instead of moving him to his own bassinette, is a real possibility.

Safe-To-Sleep month, October, coincides with Halloween.  In this spirit, doctors and nurses at Montreal Children’s Hospital invented a training tool called the Crib of Horrors.  They place a CPR baby mannequin in a crib with numerous safety hazards.  Then they hold a contest wherein staff from different units (Emergency Department, ICU, clinics, etc) name as many violations as they can find.

The Crib of Horrors includes several things we discussed above: piles of blankets near baby’s head that he could smother in, and loose pajamas that could cover his face.  There’s also more hospital-specific hazards, like coils of oxygen tubing that could strangle a rolling baby.

This exercise illustrates mistakes parents sometimes make when putting infants to bed.  Though it looks cozy, a crib with heavy blankets, stuffed animals, pillows, and bumper pads is unsafe.  And like oxygen tubing, strings that hold pacifiers, or necklaces, are strangling risks. Babies should sleep on their backs, face up, in a thin one-piece sleeper, on a thin mattress with a fitted sheet. Pacifiers have recently been shown to be protective against crib death, but no strings attached!

When babies get colds, they become noisy breathers, rattling at night, occasionally gagging and vomiting mucus.  Parents worry that baby might choke to death on secretions.  To watch babies more closely, they violate the cardinal rule about not bringing baby into bed with them.  Unfortunately, “watching baby” becomes “sleeping with baby.”  After all, infants are exhausting.

Like we mentioned above, the smothering hazard of “co-sleeping” with baby has been recognized for centuries.  We recommend “co-rooming,” where baby sleeps in a crib next to parents’ bed.  Thus baby is watched without being in the adult’s bed where  mattresses, bedding, and the adults themselves become suffocation risks.

One of my less happy duties is attending the Child Death Review panels at the regional Health Department, where we examine all Acadiana’s child deaths and discuss prevention strategies.  It’s heart-breaking to see a crib death wherein the parents just wouldn’t put their baby to sleep in her own bassinette, continuing to keep her in their bed with them, until tragedy struck.  Preventable deaths- don’t let them happen to you!

When Seizures Attack!

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

I saw my first seizure while at a family reunion.  I was eating with teenage cousins when one of them suddenly stopped eating and said “I feel kinda weird.”  Then her eyes rolled up to the back of her head, her arms began jerking, and she slid out her chair onto the floor. After a few seconds of shocked silence, we all began shouting at once, moving furniture away from her, and fumbling with phones to call 911.  Her body stopped shaking after a few minutes, and then a few minutes after that she opened her eyes.  “What’s going on?” she slurred, her head rolling around to see us all standing over her, “Whatchya all looking at?”

I didn’t know much about seizures then, but that was before medical school.  When the brain functions normally, it’s cells communicate with each other using tiny electrical impulses.  Our brain coordinate and controls these impulses to do things like think, talk, and walk.  During a seizure the impulses go haywire, firing randomly and excessively.  The patient goes unconscious, and muscles sometimes twitch from faulty nerve signals coming from the brain.

Seizures are scary, especially for parents of a seizing child.  The good news is that the vast majority of seizures are benign.  Patients typically recover from a seizure pretty quickly.  Kids breathe adequately during a seizure, though this can be hard to perceive with all the shaking and foaming at the mouth.  Kids don’t swallow their tongues- that’s a myth.  The only real danger from seizures is if the child’s alone in a bathtub or pool, or a teenager seizes while driving.

Epilepsy is a diagnosis where a child has regular seizures.  One common type is the Absence seizures, typically in elementary school-age kids.  These are super-brief seizures, just a few seconds, where the child appears to be just staring and day-dreaming, but is actually unconscious.  Then they come to before they have time to lose muscle control and fall out of their chairs.  Other kids have full-blown “tonic-clonic” seizures, like my cousin above.  Fortunately, anti-seizure medication controls most epilepsy.

Fast forward 10 years from that exciting family reunion.  I was on my first shift in the Pediatric Emergency Department at Lafayette General.  The paramedics brought in a teenager who had a seizure at school.  The vice-principal who came with her reported that she had suddenly closed her eyes tightly, and her arms began shaking.  The girl (we’ll call her Tina) remembered shaking, and classmates talking to her.  However, despite her best efforts, she couldn’t open her eyes or get words out.  The episode lasted about 2 minutes, and she felt fine immediately after.

This wasn’t Tina’s first seizure.  She had already seen a neurologist.  Her MRI showed normal brain structure, and her EEG showed normal brain electrical activity.  The neurologist diagnosed Psychogenic Non-Epileptic Seizure, or PNES.  Unlike epileptic seizures, with their haywire brain electricity we discussed above, these manifest from extreme psychological stress.  Patients often aren’t unconscious because their brain cells aren’t misfiring.  If they do go unconscious, it’s from passing out, not brain malfunction.

PNES starts with post-traumatic stress and developmental issues.  Post-traumatic stress stems from disturbing things like bad car accidents or abuse incidents.  These kids also have poor coping and communication skills. When faced with difficult memories or tense situations, their brains go into a kind of protective mode, walling off the unpleasant circumstances and directing the emotional intensity to physical symptoms like trembling and fainting.

PNES can be difficult to treat.  It requires combinations of therapy and medications like anti-depressants or mood-stabilizers. It also requires lots of patience from parents, therapists, and schools.  After all, these are teenagers!  With thorny problems!

A final word about the most common seizure in the Pediatric ER- febrile seizures.  These are brief seizures in infants and toddlers with fevers.  Like epileptic seizures, these are scary for parents, but benign for the kids.  Most toddlers have only one in their lives, and outgrow them by age 6.  Like epileptic seizures, kids breathe adequately during the seizure and their brains aren’t injured, and aren’t being “cooked” by the fever. The majority of fevers are from viral infections that pass in a few days on their own.