A Tale of Two Teenagers

Hard to believe, Amy loves the Army.  She’s in boot camp, enjoying lots of exercise, full days, new jargon to learn, and she even likes the lectures on Army protocol. It’s stressful to be sure; it’s supposed to be tough.  Some girls are fainting, some are washing out because they can’t hack it, some stay up too late and lose sleep. Amy has her eyes on the prize- graduating and moving up.  When she gets anxious, she swallows it and moves on. Uncharacteristic for her, she’s eating well and going to bed early.  Her parents are proud, not only for her accomplishment but for how far Amy has come.  Her life wasn’t always this way.

From an early age, Amy was having a rough go.  She had trouble paying attention in first grade, though she was highly intelligent.  She angered some teachers with her pointed, seemingly rude commentaries, though other teachers “got” her. She was tried on ADHD medications, which helped for a time, but then began causing side effects where Amy acted confused and panicky.  By high school, it was clear Amy was depressed.  She was sullen, didn’t get along with most of her classmates, and scraped out poor grades. Despite grasping the material, she just didn’t care enough to get papers in on time or study for tests.

Amy had no obvious reason for depression.  She had two loving, educated parents and two happy siblings.  At the first sign of trouble with attention or mood, she got the best doctors and therapists.  As Amy got older and was able to verbalize what was going on inside, it seemed her depression was “chemical:”  she was just born that way, with no external reasons like bullying or her looks.

Anti-depressant medication helped, as did continued counseling.  Her parents cheered her on through thick and thin, and as she got older Amy’s life began looking up.  College was much better than high school as far as academics and having friends. She had positive dreams for her future.  Joining the Army wasn’t her parents first choice; heck, even with a bachelor’s degree she enlisted rather than take on the responsibility of being an officer. But now they were singing a different tune.

Sharon has it much worse than Amy.  I saw Sharon in the Emergency Department last month.  She came by ambulance after being beaten by a gang of boys.  They ran up behind her, knocked her down, and kicked her repeatedly in the head and chest. There had apparently been some bad blood between Sharon’s friends and other factions in the neighborhood.

From our computer record I saw that Sharon had had a tough life already, though only 15 years-old. She had been seen by us twice for sexual assaults, another time for being beaten up, and once to be admitted to a psychiatric hospital for suicidal thoughts. She came from a rough house in a rough neighborhood.  Her mom obviously had mental illness of her own, from the pressured speech of hyperactivity or drug use, to her peculiar tattoos.  Mom yelled a lot, at Sharon and us, though this seemed to be not from anger but how she usually spoke.

Certainly Sharon’s depression has not gotten the attention that Amy’s did.  Though she had been in hospital for depression, Sharon isn’t on anti-depressants and isn’t in counseling.  Chaos rules her home life: her father’s gone, and she bounces between mom’s and the homes of several other families. Her school and neighborhood aren’t safe.

Despite all this, I have some hope for Sharon.  Kids can be resilient, and Sharon still had an occasional smile and some spunk, despite what just happened.  Mom also did seem to care about her, as did an aunt with her who seemed more emotionally stable.  They agreed that counseling was a good idea, and to see her doctor about a psychiatric referral.

Some kids like Amy are born with depression.  Some like Sharon, besides having inborn depression, also have life stresses that contribute.  Both kids need attention- counseling and maybe medicine to get them through bad patches. If your kid seems depressed, telling them to buck up and act happier isn’t enough.  You should ask about suicidal thoughts, why he is depressed, and see his doctor.  Depression is rough, so better that your kid gets the attention that Amy got, rather than Sharon’s. 

The Mumps Is Not A Muppet

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

This winter we’ve seen nearby outbreaks of Mumps in Arkansas and Texas.  Last week a mother brought her 3 year-old daughter into the Emergency Department worried about just that.  The girl had fever and headache and mom had just heard the news.  Instead the girl turned out to have influenza virus, which causes many of the same symptoms.  But this raised the question: what exactly is the Mumps?

Though it sounds like a muppet character, the mumps is an illness caused by a highly contagious virus.  The classic sign of mumps is swollen parotid glands, which are glands at the back of your cheeks.  When they swell you look like a chipmunk. Mumps usually starts with fever, headache, and maybe vomiting.  Symptoms also include cough, runny nose, poor appetite, muscle aches, and generally feeling run down.  Sure sounds like the flu- no wonder that mom was worried!

The biggest concern about mumps is that in rare cases it can cause encephalitis, or brain infection and swelling.  In teenagers and adults, it can also cause exquisitely painful swelling of testicles or ovaries.  Before the mumps vaccine was invented in 1967, people were understandably scared of this disease. Now with the MMR (Measles/Mumps/Rubella) vaccine, mumps has mostly passed into history books, except for the occasional case.

If there is a nearby outbreak, what do you do?  First, speak to your doctor.  If your child has concerning symptoms, she can order the mumps blood test.  A big clue to whether your child has the mumps is exposure- was your child around someone with mumps? Figuring this out can be tricky, because it can be weeks after exposure before you begin to have symptoms.  Who remembers where they were two weeks ago- it’s tough enough remembering what you had for lunch yesterday!  So usually when it comes to the individual kid, we count on the classic chipmunk-cheeks to make the diagnosis.

How do you get the mumps anyway? Transmission is by respiratory droplets, which means an infected kid coughs and sneezes, or wipes his slimy hands, on his playmates.  The new victims stick those virus-laden droplets on their fingers, into their noses and mouths.

So to prevent mumps, kids should do the things to prevent catching other infectious diseases, like colds and stomach viruses: they should wash their hands.  Frequent hand-washing should be taught and encouraged at home and school.  Hand sanitizer dispensers are readily available in public places, and are a reasonable substitute.  I teach kids to wash hands to the Happy Birthday song- if you wash all surfaces of your hands using the amount of time it takes to sing the song, you’ve done a great job of disinfecting.

Also use disinfectant wipes to clean household and school surfaces.  Those respiratory droplets and their viruses can linger on tables and doorknobs, and contaminate unsuspecting hands that touch them later.  Teach your kids to cough and sneeze into the crook of their elbows- this keeps grubby hands from infecting surfaces too.

If your child gets the mumps, the only treatment is for symptoms- there’s no medicine to make it go away quicker.  Use acetaminophen (Tylenol) or ibuprofen for pain and fever.  The chipmunk cheeks or swollen testicles of mumps can really hurt, so don’t skimp on those medicines!  Ice packs can also soothe these sensitive parts.  Most kids and adults get over mumps in about 2 weeks.  Occasionally children need hospitalization for pain control or IV fluids.  If they get encephalitis, they’ll need intensive care to control brain swelling.

Vaccination is great protection against mumps.  Kids get their first MMR shot at 12 months-old, and the second before kindergarten.  This vaccine is very safe, much safer than the car ride to the doctor’s to get it!  Some get a mild fever a week after vaccination, but serious complications are quite rare.  Like any vaccine, your child is incredibly more likely to catch and be harmed by mumps, than be harmed by the vaccine.

So all concerned moms and dads out there, if your child has flu-like symptoms (cough, fever, headache, fatigue) with swollen cheeks, it might be the mumps!  See your doctor for testing.  But with vaccination, odds are you won’t ever be in this worrisome place.

2016- The Worst of Times?

My son came home from college, shaking his head. His fellow millennials were lamenting that 2016 was the worst year ever: “David Bowie and Prince died!” My son’s response: “Worst year ever?  What about 1939?”  Nazis starting World War II was a lot worse than some celebrities passing away.

As a pediatrician, I saw many good things about 2016. While preparing for my yearly mission trip to Honduras, I’m reminded of positives for even the most impoverished U.S. citizens- clean water, with no risk of cholera.  And while some American kids go hungry, there isn’t the abject starvation of the third world.

Though we worry about the environmental impact of coal, oil production, and car exhaust, we enjoy pretty clean air compared to the third world.  Their vehicles and factories have unregulated emissions, families cook inside over open fires, and farms often practice slash-and-burn techniques.

In fact, Americans suffer from too many good things.  Too much food and too much sitting around looking at screens leads to obesity.  2016 has highlighted another rising glut- too much information.  The recent presidential race has revealed growing anxiety about which information is real, which is made up.  Is this candidate telling the truth?  Where are they getting their facts?  What are the facts, and where to find them?

There was a recent political cartoon depicting two people looking at cellphones, wondering if the news they were reading was real or fake, and how they could find out. Standing behind them was a newspaper stand.  A subtext of the joke is that many no longer trust information from traditional sources, like newspaper and TV media, government, or science.  Too many conspiracy theories, too many scandals, have undermined faith in these traditional institutions.

As a doctor, my decision-making relies on good data.  It’s a professional duty to find facts for the good of the patient. Newspaper and TV media and government scientists are the same.  The vast majority of journalists and scientists are professionals, diligent about getting facts right.  You can trust them for the best information, better than random websites. When looking for medical information, like about vaccines, go to the Centers for Disease Control or the American Academy of Pediatrics, rather than some un-credentialed crank.

Besides cataloging the year’s best and worst, a favorite new year pastime is making New Year’s Resolutions.  I’m not big on resolutions myself. Doctors have to continually make new good habits and throw out old ones, as medical knowledge evolves. Nothing’s special about New Year’s when it comes to medical innovation.

I don’t encourage New Year’s resolutions in others either, as humorist Dave Barry wrote, “so that you can become a better you- a more-attractive you, an organized you, a you that is…well, less like you.”  This column is always about making good habits all year, throughout your childrens’ growing-up, so they are safer and happier.

Good habits aren’t actually hard to make when there’s quick results. New Year’s resolutions, the good habits that we continually fail to make, are the ones that require persistence to get to the pay-off.  Losing weight or exercising are commonly failed resolutions because it’s months before you look or feel better, while you suffer through cravings and pain.  Quick pay-off habits, like always putting your car keys in your left pocket so you never lose them, are easy to develop.

Here’s an easy habit to keep your kids happy, healthy, and safe: get them a doctor and dentist.  Many kids I see in the Emergency Department don’t have these. Some kids don’t get sick much, so their parents stopped taking them for yearly check-ups. When the kids do get sick, they get taken to a walk-in clinic or ER.

However, doctor and dentist practices help you keep good habits.  At yearly check-ups, they discuss how to keep your kids well, appropriate to their age and development.  If your kid’s a toddler, they discuss tooth-brushing and toddler-proofing the house.  For teenagers, it’s about acne, wearing seat belts, and not getting pregnant.

My dentist’s office books my next appointment before I leave.  Six months later I get two phone calls to remind me when to come. That’s a slick outfit- they keep their patients coming in, and my my teeth stay clean.  Get your kids a dentist and doctor with such a well-run office.  They’ll do your New Year’s resolution work for you. 

Forever Seared Into My Memory

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

Forever seared into my memory is the image of my friend, running down the dock at summer camp, his body engulfed in flames.  Behind him trailed burning footprints, lighting his path in the night.  All boys are fascinated by fire, and at age 14 we discovered that aerosol bug spray was flammable, and would briefly burn on your skin without causing injury.  This led to the scene of my friend, doused in flaming insect repellent, running down the dock to jump in the lake.  Luckily he survived the ordeal unharmed, minus some hairs on his head and eyebrows.

Many children, though not as foolish as we were, are not as lucky either.  According to National Institutes of Health (NIH) statistics, a quarter of all burns treated in the U.S. involve kids under age 16.  While teenage foolishness may be unavoidable, burns are largely preventable.  The incidence of burns, and most importantly severe burns, has decreased in recent decades.  This is due to improved building codes, education in schools about fire escape planning, and smoke detectors.  Yet burns do still occur, and fortunately most of these are minor.

As a medical student I spent time on a burn ward, and saw many different types and severities of burns.  One thing that stood out for me was the disproportionate number of young children admitted for burns.  According to the NIH, most pediatric burns happen to kids under age 5.  Most of these are scald injuries, and occur in the kitchen.  And given that we adults are in charge of the kitchen, these are avoidable.

Preventing burns includes common sense things like keeping small children out of the kitchen while cooking.  Don’t carry children and hot food at the same time.  Advice that might seem less obvious: turn the pot handles on the stove inward, so they don’t stick out where kids can grab them.  Make sure appliance cords don’t hang over counters either, for the same reason- curious children grab stuff, and if that stuff is hot toasters or pots full of boiling soup, disaster can ensue.

Several times in the past in this blog, Dr. Hamilton has mentioned that most of the burns he sees are when little kids take hot bowls of noodles out of microwaves.  Someone else happens along, bumps that big, in-the-way microwave door, and the bowl spills on the child.  In my time as a medical student on the burn ward, I also saw a lot of kids burned when they pulled on a tablecloth that had a container of hot liquid on top.

As we mentioned above, kitchen burns can be prevented with a little extra care.  Small children should be kept out of the kitchen while hot food is being prepared, and should never operate microwave ovens without an adult hovering.  Pot handles and electric cords should be out of reach.

After age 5, burns happen more with open flames.  This includes campfires and bonfires, and fireworks.  Open fires should be contained within fire pits, with no flammables (extra wood, long dry grasses) close by.  Kids shouldn’t wear loose flowing clothing near fire, or clothes that easily catch fire with a spark (synthetics).  And though it seems obvious (to the sober), don’t throw lighter fluid or gasoline on open flames.  We see too many kids who get engulfed when those fluids become an exploding cloud.

Though we do our best to prevent children from harming themselves, burns happen. Fortunately the vast majority do not require seeing a doctor.  Small burns can be managed at home by remembering the 5 C’s.  Clothing- immediately remove any clothing involved, so that the hot liquid or flaming clothes don’t continue to burn. Cooling- cool water stops the burning process, and feels good too!  Cleaning- soap and water is sufficient, to minimize infection if the skin barrier is compromised.  Cover- put on antibiotic ointment generously and cover with gauze.  This also soothes, and prevents infection. Comfort- pain relief with Tylenol or ibuprofen.

When should kids see a doctor for burns?  Burns that blister, or are larger than the area of the patient’s hand, or involve faces or joints, should get seen.  Kids should have up-to-date tetanus vaccines, since burns increase the risk of tetanus infection. 

‘Twas The Night Before Christmas- AAUGH!

According to the American Academy of Pediatrics, Christmas is only slightly safer for kids than riding bikes no hands, eyes closed, on the roof.  The AAP website has a three page list on avoiding flaming disaster in the living room.  To be fair, their are some extra hazards in the season.  However, my experience in Pediatric Emergency is less about Ralphie shooting out his eye with a Red Rider B.B. Gun, and more about toddlers chewing Christmas tree light bulbs.

Toddlers love putting brightly colored, shiny objects in their mouths.  Decorative light bulbs have thin glass, easily cracked when bitten. Fortunately, the curious kids get only a few minor cuts in their mouths and quickly heal. Occasionally we see more traumatic ingestions when toddlers get a tiny bit of Christmas lodged in their airway or esophagus and need surgery for removal.

No matter how well your house is toddler-proofed, with cabinets locked and choking hazards swept away, Christmas undoes all that.  It’s impossible to police boxes of decorations, toys with tiny pieces, things hanging off Christmas tree branches. Thus one more holiday stress: having to watch your cruising babies extra carefully with all that stuff around.  Best advice: keep decoration ambitions small and manageable.

The next realistic Christmas safety worry is kids and dogs.  Kids and dogs interact more during the holidays, either with new dogs as presents, or visiting friends and relatives with dogs.  Trouble starts when kids want to meet the pooch, poochie gets nervous about approaching strangers, and bites them in the face. Best advice: don’t get a new dog until your children are 5 years-old, when they can learn to treat animals safely. Closely supervise interactions between your child and others’ pets.

Fires are another seasonal worry.  The Christmas tree tradition started in Germany, with candles on them for illumination.  My dad lived there in the 1950s and told of proud Germans who eschewed electric bulbs for old-fashioned candles, and the busy Fire Brigades racing from one tragic house fire to another.  Even with electric bulbs, trees fires are possible. Trees dry out easily, are covered with flammable ornaments, kindled with paper wrapped gifts, and stand next to overloaded power sockets.  Keep tree water filled, and unplug lights overnight.

Besides physical risks for kids at Christmas, the season is emotionally stressful. Parents get overwhelmed, and kids too.  We’re looking for Peace On Earth and Good Will among men, yet find ourselves cutting each other off for parking spaces at the mall.

One source of stress is that during Christmas we are supposed to be happy, and are disappointed when the season isn’t any happier than usual.  The disappointment is even more acute when we become less happy due to seasonal hassles.

The list of things that drag on us at Christmas continues: overeating, driving through traffic to shop in mad crowds, dragging decorations out, extra cooking.  And while visiting family is usually a good time, you also visit some you don’t like (you moved so far away for a reason).

Kids get stressed too. They overeat, and eat too many things that cause stomach-aches. They stay up too late, and are exhausted the next day.  They get sick- it’s the cold and flu season after all.  And parents aren’t paying them enough attention because we’re too busy on a regular day, and adding a Christmas list makes that worse.

Besides the safety cautions from above, you need a strategy to minimize holiday hassles for you and your kids.  Most importantly, keep it small.  When it comes to decorations and shopping, small and tasteful beats big and garish.  Make small amounts of special Christmas food and involve the kids when you do, so cooking becomes more of a positive for you both.

Second most important: keep the kids’ routine.  Make bedtimes and meal times pretty normal.  If things get chaotic, kids get more stressed.  Again, make sure your kids are mostly eating a regular healhy diet.  And like we say in almost every column in this series, everyone’s should wash hands- that’s the best prevention for illness.

Humorist Dave Barry wrote: “No matter how hectic it gets, you need to remember what the holidays are all about…exactly how much can you charge on your credit cards before going to jail?”  Don’t be that Christmas parent; keeping it simpler equals Peace On Earth.

You Don’t Want The Flu!

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

Flu season is here.  If you’ve never had the flu, you’re fortunate.  Dr. Hamilton tells the story of when he had it.  Besides the cough, headache, and body aches, he was under the covers shivering violently from fever despite having taken both ibuprofen and Tylenol.  He was shaking so badly he swore he had something worse than influenza, though tests showed that’s all it was.  Since then Dr. Hamilton gets the shot every year.

The “flu” we’re talking about is the Influenza virus.  It affects all ages, little ones too.  It usually attacks the upper airways, causing cough, runny nose, and sore throat.  It can also affect the GI tract, with vomiting and diarrhea.  What’s universal is a whole week of misery, with headache and fever and hit-by-a-truck fatigue.  It’s particularly rough on babies, and children with asthma, who are at risk for complications like pneumonia and dehydration.

While most viruses have no treatment and must run their course, influenza is one of the few with a medicine that can help- Tamiflu.  Tamiflu may shorten the time kids are sick, and make them less contagious.  It should be started within 48 hours of onset of illness or it won’t help at all, and it only shaves a few days off the week of misery.

Thus the best treatment will always be prevention.  Influenza is highly contagious, easily passed between kids by coughing and sneezing on each other, and touching each other with infected hands; in other words flu is passed when kids “slime” one another.  Kids should therefore be taught to cough and sneeze into their hands or elbow crook, and wash their hands often.

The other extremely effective weapon against influenza is vaccination.  To illustrate the vaccine’s effectiveness, a 2014 study showed 74% decreased pediatric intensive care admissions in vaccinated kids; meaning 74% fewer kids got influenza’s life-threatening complications.  And a flu vaccine not only protects the kid who gets it, but all the other kids around him whom he WON’T infect.

I know one old Cajun who just won’t get the influenza vaccine.  He agrees it’s a good idea and used to get the vaccine every year.  However, he got sick every year right after the shot.  In fact, it seemed he was getting the flu itself- long lasting cough, fever, aches, fatigue, upset stomach.  “Ain’t goin’ do it,” he exclaims, “had enough gittin’ sick from dat shot!”

Like we mentioned above, influenza virus is highly contagious, and highly miserable.  It comes around in wintertime, makes you and your kids feel rotten for a whole week, and spreads easily.  Besides hand washing and avoidance, vaccination is the best way to prevent getting it.

Why do you need a shot every year?  Don’t you stay immune?  Unfortunately, every year the influenza virus changes chemically- it evolves to fool your immune system and sneak by.  So every few years scientists have to make predictions about how the virus might change, and tweak the vaccine’s design. Then you need the new shot to cover the new strain.

What about that old Cajun who believes he gets the flu from the shot?  I’ve encountered other families who refused the vaccine because of this concern.  However, it’s impossible to get influenza from the vaccine.  This is because the virus in the vaccine is either “inactivated,” meaning it’s ability to reproduce in your body has been removed, or the vaccine is “recombinant,” meaning that only pieces of the virus are in the vaccine.

So saying you can get the flu from the vaccine is like saying you are going to drive your car to the store, even though the engine has been removed (“inactivated”), or the only parts of your car available are the steering wheel and a fender (“recombinant”). Either way, you’re not getting to the store.

People who seem to get influenza from the vaccine are actually catching the flu (or other illnesses) around the time they’re getting vaccinated, but before the vaccine can “take.”  If you’re in the office waiting for your shot, and the kid next to you already has it and coughs on you, too late!  You’re going to get sick before your immune system has a chance to build immunity to the virus.  Bad luck! 

Why Is Your Pediatrician So Grumpy?

I was worried I had a brain tumor.  That afternoon at work, I began having double vision. I could correct it by tilting my head, but as the day went on I was talking with parents with my head cocked over more and more.  My Fourth Cranial Nerve was malfunctioning, a nerve that controls eye movement, and it was weakening by the hour. I needed an MRI and couldn’t get one where I worked at the time.

The next morning I called my internist to get seen, but the receptionist said, “Go see an eye doctor.”  ”You don’t understand,” I explained, “It’s a cranial nerve, not my eye, and I need to get seen.” She still stalled me until I pulled the “doctor” card, insisting I speak to my colleague.  She put me on hold, then came back on: “He said ‘go see an eye doctor.’” I hung up, not believing my ears.

Coincidentally I had a check-up scheduled that day with Dr. David Fisher, my optometrist. Fortunately, David knew exactly what was wrong. My vision was already recovering, and he explained that that nerve goes funky occasionally, especially in plumbers who bang their heads on the underside of sinks.  No worries about brain tumors, whew!  Then I found a new internist.

Why do doctors, supposedly caring professionals, sometimes act insensitive or downright grumpy?  It starts when applying to medical school.  You need good grades in a tough science curriculum to get in, and nerds don’t always learn people skills, being too busy learning study skills.  Then in medical school you are surrounded by other “medical nerds,” and don’t learn how to relate to non-scientists.

Then comes residency.  My father was a seminary professor, and once gave a workshop for hospital chaplains.  He told me of a priest who had observed that the hours are so long and punishing, the apprentice doctors in residency get the humanity “ironed out of them.” After graduating, some regain their hearts, some don’t.

All doctors get grumpy.  For me one time, it was a mom who kept interrupting. Her child had a headache, and I was explaining that I didn’t think she had a brain tumor, but needed a CT scan to be sure. But every sentence I started, before I could get to the CT part, mom cut me off with “that’s all stupid, I want a CT.” I finally snapped and shouted, “Shut up, quit interrupting, and I’ll tell you what you want to hear!”

Everyone, especially doctors, gets grumpy in “people” professions.  While most patients are nice and polite, some aren’t.  And doctors don’t always start life warm and fuzzy. As we discussed above, medical schools select for academic performers rather than kindly grannies with a twinkle in their eyes.  Then comes the rigors of residency, where long hours and crushing responsibilities turn the nicest guys into ogres.

After residency, the hours and the responsibilities don’t quit.  Fatigue is an occupational hazard, and one continues to have to make potentially life-and-death decisions all day. Doctors dread the patient coming back to the hospital, maybe dying, after making a judgement call that turned out wrong.  Dr. Richard Selzer explained this internal struggle best:

“Yet he may continue to pretend, at least, that there is nothing to fear, that death will not come, so long as people depend on his authority.  Later, after his patients have left, he may closet himself in his darkened office, sweating and afraid.”

So doctors sometimes get snappish, and may seem uncaring about your child’s suffering. Yet worry for patients caused the stress in your doctor in the first place.  So if your kid’s doctor seems grumpy, give him or her a break, a second chance to recover. If he continues to seem uncaring, get a new one.      

Mammal Bites

This week’s guest columnists are Drs. Marc Fernandez and April Weliever, Family Practice residents at the University Hospital and Clinics here in Lafayette.

We see it all the time in the Emergency Department: the family cat bit the toddler, “a wild raccoon bit our girl,” “the neighbor’s dog bit our boy,” the neighbor’s boy bit our boy!”  Dog and cat bites are the most common bites, usually from the family or neighbor’s pet. Sometimes kids will chomp other kids hard enough to warrant a visit to the ER.

Our country sees between 2 and 5 million ER visits per year for bites, costing the medical system about $1 billion dollars per year.  That’s a lot of meat-eaters!  And those are the ones that come for care- there’s many more that don’t come in, getting taken care of at home.  Most ER visits are for dog bites, followed by cat bites, then bites by rodents and other smaller, wild animals, and least of all, human bites.

What bites need the doctor?  The most obvious bites to bring in are those that break the skin-these all need assessment, because they’re at risk for infection.  Some bites that don’t break the skin may also need to be seen: crush injury that might damage bone, nerve, or tendon, or cause significant pain.  When bringing a child for care, there are other considerations: was it a pet or a wild animal?  Is the animal vaccinated?  Is the child vaccinated?

Before coming to the ER it’s good to clean the wound. Most bites kids get are on the arms, legs, hands, or face.  Running the wound under tap water is a great way to get some of the infection-causing bacteria out.  Gently scrub a wound that can’t be run under water (like on faces).  At the hospital we can numb wounds that need more extensive cleaning.

The next consideration is x-rays.  Most bites and scratches don’t need these.  However, sometimes an animal tooth can break off in a deep wound.  X-rays can find if there’s a bit of tooth that needs to be removed.

The most common story involves the neighbor’s dog.  The child goes out to play, walks by the neighbor’s property, and the dog runs out and bites.  These kids usually get it in the back of the leg, while running away from the dog.  The next most common story is the toddler or pre-school kid playing with the family pet.  She puts her face too close to the pet, the pet gets nervous, and snaps at the child.

We talked above about which of those bites needs medical attention- broken skin or crush injuries.  Which bites needs stitches?  We usually close open wounds with stitches, but not always with animal bites. Animal bites are at high risk for infection, and the last thing you want is to sew those nasty bugs into your child’s skin.  For this reason we don’t stitch most bites- except face wounds that need them for cosmetic reasons, to minimize disfiguring scars.

All animal bites that break the skin get antibiotics.  This is especially true for deep wounds or puncture bites that might drive bacteria in to where they can’t be easily washed out. Also, the places kids get bitten (arms and legs) have poorer blood supplies to clean up infection.  And when kids get bitten on the face, wound infections can increase scarring, so those get antibiotics too.

Vaccine considerations are very important.  Animal bites are at risk for two deadly infections: rabies and tetanus.  If your child gets tetanus, he or she will get very sick, and have a high risk of dying.  If your child gets rabies, he or she WILL die.  Thus we always ensure that bitten kids are up-to-date on tetanus vaccination.  We also need to know the biting animal is rabies-free. Animal Control is called to find the offending animal, check its vaccine status, and quarantine it.  If the animal remains rabies-free after 10 days, it goes home.  If the animal can’t be found, the child needs rabies vaccination. 

By far the best way to treat mammal bites is prevention.  Children should be taught to stay away from wild animals, and give neighbor’s dogs a wide berth.  Toddlers should never play with family pets- neither toddlers nor animals have the skills to avoid confrontation. “Confrontation” meaning: one animal bites the other.

 

Cozy Does Not Equal Safe

She thought she was doing the right thing.  She was leaving baby for two minutes to get her toddler dressed.  She put the 4 month-old in the middle of the bed and rolled up blankets around the edges in case baby scooted over, so baby wouldn’t fall off.

Minutes later she came back, finding baby against one of the blanket rolls face- in, pale and limp.  She screamed for her husband to call 911, snatched up baby, and began rescue breaths.  When the paramedics arrived, the infant was breathing. When they got to me in the Emergency Department, baby was still groggy but awake, and we all heaved a sigh of relief.  And shuttered to think, what if mom had been another few minutes…..

October is SIDS Awareness Month.  SIDS is Sudden Infant Death Syndrome, sometimes called crib death, wherein babies are put down to sleep and found dead.  In the last 50 years it was surmised that many of these deaths were from smothering, babies often being found face down in thick bedclothes.  Two decades ago the American Academy of Pediatrics began it’s Back-To-Sleep campaign, encouraging parents to put their babies to sleep on their backs.  The SIDS death rate plummeted.

Since then we’ve found other factors in crib deaths.  When my kids were infants, my pediatric-nurse wife and I put them to bed on their backs, but on sheepskin, with bumper pads in their cribs.  We also placed stuffed animals with them.  My kids survived, but those things are now on the danger list too. Sheepskins, bumper pads, quilts, plush toys, and pillows are all smothering risks.

One risk for SIDS that has 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 its slumbers by a careless, perhaps drunken nurse or mother.” 

SIDS Awareness Month in October coincides with another fall tradition, Halloween.  In this spirit, doctors at Montreal Children’s Hospital invented a training tool they called the Crib Of Horrors.  They placed a CPR baby mannequin in a crib with numerous safety hazards, and held a contest wherein staff from different units (Emergency Department, ICU, clinics, etc) would name as many violations as they could find.  The winner was the team that found the most hazards.

They included several things we discussed above: piles of blankets near baby’s head that he could smother in, loose pajamas that could cover baby’s face, and other articles in the crib that could suffocate.  There were also more hospital-specific violations, like coils of oxygen tubing that could strangle a rolling baby.

The Crib Of Horrors illustrates mistakes that parents often make when putting infants to bed.  Though it looks cozy, a crib with heavy blankets or quilts, stuffed animals, pillows, and bumper pads is unsafe.  And like the oxygen tubing, strings that hold pacifiers, or necklaces, are strangling risks.

Babies should sleep in 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 SIDS, so they’re okay.  But no strings attached.

When babies get colds, they become noisy breathers, rattling and snorting at night, occasionally gagging and vomiting mucus.  Parents become worried that baby may choke to death on secretions (which actually is NOT a SIDS risk).  To watch baby more closely, they violate the cardinal rule about not bringing baby into bed with them.  Unfortunately, “watching baby” often becomes “sleeping with baby.”

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

Cozy does not equal safe when it comes to sleeping babies.  Keep infants on their backs, even if they have colds- babies are designed to handle congestion and reflexively keep their airways clear lying face-up.  Be sure your infant’s bed doesn’t become a Crib Of Horrors. 

Febrile Seizure- Stay Calm?

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

It was mango season on Saba island, Netherlands Antilles.  My wife and I were on the beach eating some, and we decided to give our 8 month-old daughter a taste.  She liked it, but then paradise turned scary- she became lethargic, turned blue around the lips, was twitching, and seemed to stop breathing.  We called 911 and the island police rushed her to the local ER.  By the time we arrived, she was awake, pink, and breathing fine.  And now had a 103 degree fever. This was our first “febrile seizure,” and it had nothing to do with the mango.  Our daughter had an ear infection, which caused the fever, which led to the seizure.

What is a febrile seizure?  Simply, it’s when a child has a seizure with a fever. The child suddenly goes unconscious, has rhythmic twitching of the face, arms or legs, and is unarousable.  The child’s breaths are so shallow that it’s hard to tell if they are breathing.  After a few minutes of seizing, the child relaxes and breathes normally, and though sleepy and confused-acting, can be aroused.  After 10 to 20 more minutes he becomes more awake.

Febrile seizures only happen to about 4% of kids, but they sure are memorable when they do!  It’s frightening to watch, but doesn’t cause lasting harm.  Intelligence and other aspects of brain development aren’t affected- these kids grow up fine.  And kids do breathe adequately during seizures, although it’s tough to tell.

More good news: most kids who have febrile seizures never have another.  About one third of these kids have more than one, but they all outgrow them by 6 years of age.

Febrile seizures happen between ages 6 months to 5 years.  How high the fever goes, or how fast it goes up, has nothing to do with having a seizure.  Thus if your child has a fever of 104, that does not mean they’re going to seize.  Some kids seem to get them, most don’t.  In fact, seizures usually happen before the onset of fever, so if your child is already hot, it’s less likely that they’ll have one.

During my second year of medical school, it happened again.  My daughter was 16 months at the time.  She was playing with the neighbor’s kids when she suddenly stopped, fell straight back on the floor, and began shaking.  The other mothers freaked out, but my wife assured them that it was “only a seizure.”  She sure got some strange looks!  Then the fever started, and it turned out to be another ear infection.

As we discussed above, febrile seizures are scary to watch, but are actually no reason to panic.  They don’t hurt child’s brain, kids breathe adequately during the seizure, and go on to grow up fine.  Easy to say, but what do I do if my child has one?

First, stay calm.  Roll the child onto his side, so if he won’t choke if vomiting. Don’t put things in the mouth.  Some people worry kids will “swallow their tongue” or bite their tongue, and think sticking something in will help- wrong!  Kids don’t choke during seizures, and shoving things in can hurt their teeth and mouth. Don’t try to stop the jerking either- you can’t, and again may hurt the child by trying.

Watch the time.  Seizures lasting past 5 minutes may require treatment. If the seizure is going that long, call 911.  Paramedics carry medication that can stop seizures.

Once the seizure is over, the child should see a doctor, to determine the source of the fever. Fevers are usually caused by viruses that go away by themselves, but sometimes kids have bacterial causes like ear infections, and need antibiotics.  Blood tests are mostly unnecessary after febrile seizures.

Can you prevent febrile seizures?  Regular dosing with acetaminophen (Tylenol) or ibuprofen don’t prevent them. Giving anti-seizure medication, like for kids with epilepsy, may help.  However, in most cases this is not recommended. Potential side effects of daily anti-seizure medications usually outweigh the benefits. Remember- febrile seizures are not harmful. The only danger is leaving kids in the bathtub unattended and they seize and drown.  But you shouldn’t leave kids alone in the tub anyway, seizures or not.

Febrile seizures are scary for parents.  Follow the plan above, recognize the signs and symptoms, and stay calm!