Skin and Bones

Dealing with ailing bodies and human foibles all day long, it’s no wonder doctors have a sick sense of humor, me included.  When people show me their kids’ rashes in public, I play it straight and happily consult.  However, occasionally adults will haul up their shirts at parties to show me the latest blemish on their bellies or backs and ask, “Hey Doc, what the heck is this?” I nod confidently: “It’s definitely cancer,” I say. Then I give them a wry smile that says, hey, only kidding!

Given the warm winter we’ve had, the early spring, and the early school closings, I predict a rough summer for rashes.  Children meet the outside world with their skin.  When falling off bikes or monkey bars, not “sticking the landing” as they say in gymnastics, they get scrapes and cuts and bruises.  When they plow through vegetation exploring or searching for stray balls, their skin gets irritated by thorns or poison ivy. Mosquitoes enjoy a blood meal from our children, and later, when the bite itches, they tear at themselves with ragged, dirty fingernails.  Sun cooks hot, exposed skin too.

We’re all learning new habits from Coronavirus concerns, like washing our hands more often and extra carefully, wiping down potentially contaminated surfaces, and trying not to touch our faces.  It’s also a good time to improve skin-care habits for children.  That’s the best prevention for skin injuries and infections that we’ll see in the Emergency Department in the coming months.  Paradoxically, skin is hardest to hurt when it’s soft and pliable.  It bounces back, and heals better.  Hard dry skin cracks under pressure and itches worse when insulted.

Kids should use moisturizing soap. Buy brands like Dove and Caress, which are easy on skin, rather than harsh drying soaps like Ivory, Zest, Dial, or Irish Spring.  Washclothes and vigorous toweling also can irritate, so kids should use only their hands and the soap, and pat dry with towels. Advanced Parenting involves using white lotion to moisturize kids’ skin, putting on sunscreen, and applying bug spray.  When a kid gets a cut or scrape, “rub dirt on it” is just a joke!  Wash broken skin with soap and water, and dress it with neosporin and bandages.  Please keep those grubby ragged fingernails clean and short.

In 2008, New York City mom Lenore Skenazy was shopping with her 9 year-old son.  They had ridden the subway, and that day he begged Ms. Skenazy to let him ride home by himself.  Having taught him how to read subway maps and distinguish between uptown and downtown trains, she decided to let him go.  He got home safely and was ecstatic with his feat.  But when Ms. Skenazy wrote about his adventure in a newspaper column, she set off a storm of controversy.

Some called her the “world’s worst mom.” Child Protection paid her a visit.  Others praised her for giving her child freedoms not allowed by “helicopter parents,” so-called because they hover over their kids’ every move. Ms. Skenazy then briefly had a reality TV series where she coached such parents on letting their kids ride bikes or slice vegetables.  The show’s title: World’s Worst Mom.

Fortunately, we in Acadiana needn’t worry about children navigating crowded cities. But they will be having adventures on bikes and trampolines, or dirt bikes and ATVs.  Most emergencies we’re seeing now are injuries from these. If your child falls off a bike or monkeybars, check the head first.  Head injuries are the most common serious injury in pediatrics.  If the kid has been knocked out or is acting confused, get them into us right away.  Please put helmets on bike-riders before this happens!

If the head checks out okay, limbs are next.  Broken bones are obvious: the child cries and points to the dinged wing.  Sometimes it’s bent in an unnatural way.  The best care for an injured arm or leg is to immobilize it. Preventing the hurt part from moving is the best pain control.  Tape it to a rolled up newspaper or magazine, or a handy board. Give your child some pain medicine, like ibuprofen or tylenol.  DON’T give your child anything to eat or drink.  They’ll need an empty stomach if anesthesia is necessary.

If your child crashes a motorized bike or ATV, you’ll feel like the World’s Worst Mom- these vehicles’ power and speed are too dangerous for little bodies.  Bikes are good enough, and better exercise for their skin and bones.

Happiness In The Age of COVID

The Advocate newspaper carries a column on parenting by child psychologist John Rosemond. I’ll herald the latest installment to my wife: “Hey Honey, cranky ol’ Dr. Rosemond is at it again!”  He’s old-school, wherein children-should-be-seen-and-not-heard, hard-work-is-its-own-reward, etc.  While not exactly advocating that kids work 14 hour-shifts in textile mills, he likes to cast doubt on such “modern” diagnoses as ADHD.

He sometimes makes good points. His column “Why Some People Believe That They Are Entitled,” speaks to the erosion of happiness in the age of COVID.  Entitlement is the idea that you deserve happiness, wealth, and success, whether you’ve earned it or not.  According to Rosemond, recent generations have raised kids to think like European Royalty, that they’re more special than everyone else, and thus Entitled.  Even cheating to get what you want is okay, since you’re above the rules meant for commoners.

Many argue that instilling a sense of Entitlement, and generally spoiling children, has led to the rise in depression and suicidality in kids and teens.  When kids don’t get their way in the real world, in school, with other kids or adults, they’re profoundly disappointed, their world-revolves-around-me view shattered.  Now with social distancing, travelling restricted to grocery shopping, and economic free-fall, few adults are getting their way anymore either.

With loss of work and freedom, people are bored, depressed about a life without purpose, and full of anxiety that they or their loved ones will get seriously ill. Many raised in the land of plenty are, like spoiled toddlers, now profoundly disappointed with life.  However, many others, in the search for meaning in this new age, have taken action. They’ve started life-affirming tasks- learning new skills like a new language or cooking; spending more time with their kids (and parents!), making masks and delivering food to health care workers and shut-ins, donating blood.

John Rosemond is right, at least about this aspect of parenting. Kids should learn that being useful, being moral, and working hard, are more important than striving to be happy and successful.  Then strangely enough, the pursuit of character begats happiness anyway.. Especially in the Age of COVID.

Another pillar of happiness is being connected with others.  While we just discussed that hard work and a meaningful life lead to happiness, social interaction helps too.  Before the invention of telephones in 1876, people communicated from afar by written letter. Also in those days, early death was a constant.  About one quarter of infants died before their first birthday, and almost half of children died before puberty.  The average adult was lucky to live past 40.  Thus letters between distant family members often started with “I hope this letter finds you well,” followed by a summary of the health of those at home.

That was the snail pace of life, death, and communication in the Age of Enlightenment. Thanks to the internet, with email, twitter, instagram, and facebook, the above sentiments are transmitted instantly.  I’ve gotten scads of electronic messages from near and far asking me if I’m okay on the “front lines” in the Emergency Department. At home we’ve been spending lots of facetime with my daughter in Seattle and my son in New Orleans, COVID hot spots.

Though it’s a good time for the internet, with it keeping us connected and informed, the net’s also a two-edged sword in these respects. Hateful and divisive posts on facebook or twitter come at us instantly as well. Nothing gets people fired up, and not in a good way, like a skewed political post claiming the other side is criminal or incompetent.

Misinformation spreads quickly too, For example, there’s many posts about how influenza, the plain old flu, has caused many more deaths than COVID, and yet we never tanked the economy by closing schools and businesses during flu season. What they don’t mention is that COVID threatens to cause even more deaths than influenza, since it’s more deadly to individual patients, may be even more contagious, and has no vaccine or anti-viral medication to check its spread. The only way to stop it and save lives- closures and social distancing.

So for information on keeping you and your kids safe, and your futures, please use expert sources without political or social agendas: the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP.org). These places will give you the straight scoop as it becomes known, without an extra helping of anger to dampen your happiness.

School’s Out For….Spring?

This week’s guest columnists are Drs. Mark Carreras and Jacob Sellers, Family Practice residents at the University Hospital and Clinics here in Lafayette.

When I was a kid, the last day of class would end with a final bell, and we’d blast Alice Cooper’s “School’s Out For Summer.”  We were free, thrilled we’d “survived” another year, as if we’d reached high ground just ahead of a tsunami. With schools closed probably for the rest of the year, many kids celebrated pretty early.

For parents this is NOT a fun, exciting time (their lyrics: “Well I tried to make it Sunday, but I got so damn depressed”).  School’s definitely not out yet for summer, and while parents are used to kids’ summers off, this is very different.  There’s no more family vacation, with many household budgets taking a hit and vacation spots closed. Working parents must find babysitting and activities for their kids way before they were ready.  And there’s school work still to be done. At home.

Unless you’re a professional educator, schooling and teaching are tough. Who remembers what they learned in history, much less technical subjects like trigonometry?  While schools are transitioning to on-line teaching and assignments, parents must do their share to keep their kids from falling behind.  More on this below.

Doctoring must be done at home too. Offices and clinics have shortened hours, and visits are more time-consuming.  Many practices have parents wait in their cars, and staff call them when it’s their turn to come in.  Emergency Departments are COVID war zones, with really sick and contagious patients; not places you want to be with your child.

This blog’s a place to go for advice if your kid is sick.  If you’re reading this in the Advocate, note the blog address below.  Stock up on ibuprofen, tylenol, and benadryl. Make sure asthma medicine is refilled, as COVID can make trouble for wheezers. And don’t panic. Many kids are still getting cold and fever viruses, and parents worry it’s COVID.  Rest assured that in most kids, COVID is benign, and soon gotten over.  Only go to the ER if kids are short of breath, too sleepy to drink enough, or vomiting continually.

As a new parent, one of the most shocking realizations for me has been the power of the screen.  My 2 year-old is typically unreserved, energetic, and sociable. All at once.  He’ll hold a conversation with you while leaping from couch to chair.  However, a flip of the television switch turns him into an expressionless, drooling zombie.  I wouldn’t be surprised if he started moaning “..brains….brains….”

Limiting screen time may be the biggest challenge for parents during this extended school break, or school-at-home-for-the-rest-of-the-year.  But this battle is worth fighting, as increased screen time is linked with worse childhood obesity, depression, poor diet and constipation, and worse sleep.  In other words, an overall tanking of quality of life.  As Dean Wormer said in the movie Animal House, “Fat, drunk, and stupid is no way to go through life, son.”

One recipe for success during this COVID outbreak is maintaining a routine.  Filling kids’ days, making them adhere to school work and stay off the computer/phone/tablet/TV sounds tortuous.  However, mapping out a daily schedule can actually save time and make things easier.  Start with wake-up time, three meals, snacks, and bedtime. Then insert school work, indoor play time, outdoor playtime, chores, and family activity. There can be some fluidity in that schedule, but keep in mind that kids are happier and better behaved when kept to a routine. The wake-up, mealtimes, and lights-out should be reasonably enforced.

One daily activity that can’t be discounted is reading.  Study after study shows that reading with children improves brain development, social-emotional skills, language, and of course literacy.  Your schedule should absolutely include reading to your child, or them reading independently.  When they read on their own, make time to discuss with them what they’ve read.  One of the best opportunities to read to your child is bed-time. This should ALWAYS be part of the nightly ritual.

How you manage this challenging time will make a difference about how your children grow up.  Do you want them to be successful and happy?  Kids thrive on structure and reading.  Reinforcing these makes the difference between your kid being strong and independent, or being a screen-addicted zombie, depending on others for…..their brains!

Don’t Touch Your Face?

When we visited my 89 year-old mother-in-law last week, we met on the patio. Staying on the swings far from her chair, we couldn’t pass her the COVID virus if we were carriers.  My wife brought her own bottle of wine.  Later Nana went into the kitchen to refill her glass, and through the window we saw her pick up my wife’s bottle, examining the label, while we both slapped our foreheads: “Nana, go wash your hands!”

Staying safe from the COVID-19 virus, aka Coronavirus, is like playing “invisible force field,” where any surface (counters, door knobs, wine bottles) is potentially contaminated, and you need to wash your hands before you touch your face or food.  That’s how COVID, or any cold/flu virus, gets into your system.  You inhale it when someone coughs or sneezes near you, or you put it in your mouth, nose, or eyes with your fingers.

The good news is that so far, COVID doesn’t seem bad for children.  They get a cough, runny nose, and maybe fever, but many fewer kids are hospitalized for breathing trouble than adults. Like any other cold and fever virus, kids get by with ibuprofen or Tylenol for fever and pain, and plenty of fluids.

The bad news, and the main reason why schools and daycares close, is that kids spread infection around.  They cough and sneeze without covering their mouths, letting fly with virus-laden droplets.  They wipe their nose and mouths with their hands, and smear infectious drool onto every thing they touch.  Kids shed virus into the environment worse than adults, because they’re, well, gross.  So we close schools so kids don’t pass the virus from family to family, sending it into households with vulnerable family members- the elderly, cancer patients, or those with certain medical conditions.

Some kids get seriously sick from COVID.  The Chinese experienced some pediatric hospitalizations, with some critically ill. Kids with asthma might get it worse, or kids with heart conditions, or infants.  If your child has a potentially dangerous condition, be extra vigilant about who they contact, where they go, and what they touch.  And don’t touch your face!  More on that below.

Three weeks ago my wife and I were on vacation.  We weren’t in China or Italy; we were in the snowy woods of Quebec, away from crowds, cross-country skiing.  However, we flew home through Newark airport, part of New York City’s transportation network, with lots of international travelers milling about.  In the Customs line a kid next to us kept sneezing without covering his mouth, his parents oblivious. Great.

We haven’t gotten sick, so the little turkey apparently hasn’t given us COVID, but it’s  now revealing itself in Acadiana.  As you keep hearing, the best defense against catching the virus is good hygiene. Cough and sneeze into your elbow to avoid spreading the virus.  Don’t get close to anyone since they might be shedding it.  Wash hands frequently, in case you’ve inadvertently touched a contaminated surface. And don’t touch your face?

As we mentioned above, the virus gets into you through your mouth, eyes, and nose.  You can pick up the virus from a doorknob, a handshake, a handrail, and then when you touch your face, you pass it into those portals.  It’s remarkable how many times people touch their faces- on average several times per hour.  After all, faces are sensitive, and need scratching.  Noses need picking, thumbs need licking..

Telling people to stop touching their faces is like telling them to lose weight or stop smoking.  Eating badly, smoking, and rubbing your nose are all near-impossible habits to break.  Hence the draconian steps of closing schools, restaurants, and anywhere else people mingle. The virus spreads too easily, and people pick it up too easily as well.  And try teaching kids not to touch their faces!

That’s also why we’re advised to wash hands so much.  When we do touch our faces, we’re safer with clean hands.  Frequent hand-washing is easy for me, washing them over forty times per day at work anyway, before and after touching each patient.  But not everyone has that habit.

The CDC has warned that wearing a face mask doesn’t really stop the spread of infectious droplets. But maybe wearing the mask will keep you from getting your fingers into your mouth, nose, or eyes.  Maybe people should wear mittens instead.  And definitely, for the next few months, stay away from Nana.

Elbow Woes

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

I was two years-old.  “Pick me up! Pick me up!” I yell to my sister. She grabs my hands, begins whirling me around, and up into the sky I go.  “Faster! Faster!”  Suddenly a pain in my left elbow.  I begin to shriek as my sister lets me down, a puzzled look on her face, what did she do?  Now Mom’s worried, she doesn’t know what happened either.  On my first trip to the Emergency Department, the staff’s all smiles, no big deal, just a dislocation.  1…2..3.. back in place.  Soon I’m running around again, but no more flying in the sky.

“Nursemaid’s Elbow” is an occasional event in toddlers, where a bone in the elbow gets dislocated. The forearm has two side-by-side bones, the radius and the ulna.  Their ends near the elbow are held together by a rubber-band called the annular ligament. In some kids that ligament is weak, and the radial end can be pulled out of that loop by traction. Traction like being whirled around like me above, or having the hand jerked to hurry a slow toddler along.  Sometimes it happens when a parent is trying to get a shirt off, tugging away at that long sleeve, and pop!

When children dislocate their radius, they cry at first, but then settle down.  It looks benign- no swelling like with a broken bone, and kids often start playing again.  Except that they’ve stopped using that elbow, letting it hang by their side, and do everything with the other arm.  When parents bring them in, no x-rays necessary.  If the story’s right (“Pulled on the wrist, eh?”), it’s a simple maneuver to put it in place. The elbow clicks like you’ve cracked a knuckle, a brief squawk from the child, and in a few minutes she’ll give you a high-five. Fixed!

To avoid this injury, of course, no tugging on hands and wrists. Pick up infants and toddlers under their armpits.  But kids like being swung around, and they also can dislocate when wrestling or falling just so. When they pop that elbow, bring ‘em in. The good news: kids prone to Nursemaid’s Elbows develop stronger annular ligaments and stop dislocating by age 5.

Fast forward from 2 year-old Tasia above, to 1994. I’m on the playground at Boudreaux Elementary in Gretna, climbing the ladder to the monkey bars. Grab one bar, swing to  the next, and the next, and….I’m falling through the air and land on my right arm.  I’m crying, my elbow hurts so much. I went to my teacher, who wasn’t worried because there wasn’t any swelling, and by the end of the day I was using it again.  No Emergency Department visit this time, but I’ve never been on monkey bars since. Just looking at them makes me break out in a sweat.

Sometimes though, kids end this scenario with a swollen elbow that just won’t stop hurting. Besides being vulnerable to dislocations as we discussed above, kids’ elbows are susceptible to fractures.  The bone at the elbow end of the humerus (the upper arm bone) is thin.  When kids land on their elbow, or impact on their outstretched hand, that bone end can crack.  In fact, 70% of these fractures occur when the child falls and puts his hand out to brace himself. The force is transmitted through the forearm and snaps that vulnerable spot.

These injuries are more obviously bad than the Nursemaid’s elbow from above. The elbow is swollen and sometimes blue from internal bruising, and it really hurts.  These need to be seen in the ER for x-rays, pain medicine, and treatment.  Sometimes all that’s needed is a cast to hold the broken elbow still and protect it while it heals, usually 4-6 weeks. In some unlucky kids, however, the end of the humerus is cracked all the way through and shifted. These need surgery to pin that thin bone end back in place.

Finally, let’s briefly talk about the word “fracture.”  Occasionally, a parent will be discussing their kid’s bone injury, and ask “is it broken or is it fractured?”  This question puzzles us, since a fractured bone IS broken. It’s like asking “is the sky blue, or is it azure?”  Fracture is just a fancy word for broken, and either way, it needs treatment, usually a cast, but sometimes surgery.  Hopefully when your kid hurts their elbow, it will just be sprained like mine was, and get better in a matter of hours.  But if it’s swollen and really painful, come on in!

 

 

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.