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Daily Dose

Ear Infections

1:30 to read

Musings from the very busy pediatric office:  with all of the advances in technology over the last 30 years why is it that examining a child’s ears and visualizing their eardrum continues to be challenging?  I started thinking about this while examining a very unhappy, strong and febrile toddler….probably the 20th patient of the day. 

 

During the “sick season” many of the patients who come to my office are young children whose parents are worried that they may have an ear infection.  This concern is one of the most frequent reasons for pediatric office visits. While I realize that many of my colleagues are in the operating room operating on brains or doing open heart surgery (truly saving lives) the one advantage that they have is that their patient is under anesthesia while they are doing complicated procedures. Which only means that they are not trying to wrestle, cajole, or coax a child into letting them look into their ear canal, and then only to find that you can’t see a thing as the canal is full of wax (cerumen).  

 

At times examining ears can be fairly simple and straight forward, but some days it seems that it may be easier to attempt to fly than to look at a 16 month old child’s ears. Today was one of those days. It seemed that every child I saw had a temperature over 102 degrees, and they all had “waxy” ears. While there are several ways to remove wax from the ear canal, none of them is easily done in a toddler, especially when the wax is hard and difficult to remove. Having 3 children myself and one who had recurrent ear infections and tympanostomy tubes, I know what it is like to have to hold your child on the pediatrician’s exam table while they irrigate or “dig” wax out of the ears.  Not fun….!!!  But, at the same time I realize that this is the only means to see if the ear is infected and if there is the need for an antibiotic. 

 

With the advent of the HIB and Pneumococcal vaccines the incidence of ear infections has dropped significantly, as these bacteria were common causes of otitis. But, ear infections are still the #1 reason that a child receives an antibiotic, especially in the first 2 years of life.  Therefore, a good ear exam is one of the most important things your pediatrician does, as I know you don’t want your child to receive an unnecessary antibiotic!

 

Please know that pediatricians do not enjoy making a child uncomfortable, but somehow that ear drum needs to be seen…especially in a sick child.   

 

So…why has some brilliant medical device inventor not found a way to wave a magic wand over a child’s ear to “tell me” if their ear is infected?  To date, I have not seen any “new” ways to accurately examine an ear other than with the otoscope…and a clean ear canal…which means unhappy children (and parents ) while I try to clean their ears.  

 

Remember, don’t use q-tips in your child’s ears and if your pediatrician has to struggle a bit to clean out  your child’s ears, it is only because they are doing a good job!!  I am waiting for the “easy” button.

   

Daily Dose

Pink Eye

1:30 to read

This is another time of the year that I see a lot “pink eye”.  Any time the eye is pink..you have “pink eye”, which mothers seem to be quite confused by!!   They often comment…”this is pink eye?” , to which I respond, “well, the child’s eye (conjunctiva) is pink (red), so yes…this is pink eye”.  The term is just a description of the eye….but then you need to determine why the eye is “pink”.

 

Conjunctivitis is one of the most common causes of a pink eye….and there are many different types of conjunctivitis.  As with any condition the history is really important in helping to determine why a child’s eye is inflamed.  Several of the most common causes of the “pink eye” are bacterial, viral and allergic conjunctivitis.

 

Bacterial conjunctivitis often shows up in younger children and they have lots of matting of the eye lids and lashes and a mucopurulent discharge (gooey eyes). Some moms say that the “goo of gunk” comes as quickly as they can wipe it.  The child often has a lot of tearing and will rub the eyes as they feel that something is in their eye and it is irritated.  Bacterial conjunctivitis will typically resolve in 8 -10 days on its own, but antibiotic eye drops are used to shorten the course  of the pink eye and also reduce the contagiousness.  It seems as if every child in a day care class room will get conjunctivitis as they constantly rub their eyes and touch toys!!  Hand washing helps….but you can’t wash a child’s hands every time they touch their eyes.

 

Viral conjunctivitis usually occurs in combination of with systemic viral illness. Sore throat, fever and bright red eye are often seen in older children and teens and is due to adenovirus.  While the eye is red, the discharge is typically watery and matting is much less common. These patients are contagious for up to 12 days so it is important to practice good eye/hand hygiene, especially in the household. Artificial tears may help the feeling of eye irritation, but antibacterial eye drops rarely help except in cases of a secondary infection.  I get many phone calls from parents saying, “we tried prescription eye drops and they are not working”. I make sure to tell my older patients to take out their contacts and wear glasses for 7-10 days.

 

At this time of year I am also seeing a lot of seasonal allergic conjunctivitis.  These children have intensely itchy and watery eyes, as well as swelling of the eyelids and area surrounding the eyes. They look like they have been crying for days as they are so swollen and miserable. Many also have a very watery nasal discharge. They do not have fever. Using over the counter medications for allergy control, such as nasal steroids and anti-histamines will help some of the allergic symptoms. There are also over the counter eye drops (Zaditor, Patanol) that help when used daily.  During the worst of the season I make sure that the child has daily hair wash and eyelash and eyebrow wash with dilute soapy water to make sure the pollen is removed after they have been playing outside. It is nearly impossible to keep a child indoors for the 6 or more weeks of allergy season!

 

Daily Dose

How to Treat Stool Holding

Stool holding part 2: how to treat this common ailment.On Friday, we discussed stool holding and encopresis: what it is and why kids have trouble going to the bathroom.   Now it’s time to discuss treatment.

The medicinal component of treatment begins with  cleaning out the rectum. This is typically done by using enemas (Fleets) to get rid of the large amount of old stool that has distended the rectum.  Mineral oil given orally may also help the stool to be evacuated (it is tasteless but a child can see the oil, so get a soft drink or juice and put a top on it and mix in the mineral oil and serve with a straw), you can also mix into oatmeal. I typically use an enema to start and then keep up daily mineral oil for awhile until the stools are routinely soft and not painful.  Enemas are not well liked by anyone.  A daily laxative is also important. Milk of Magnesia and Miralax are my favorites.  The dose may be titrated but you want to ensure that your child is having a stool every day. The laxatives are not habit forming, but are serving a purpose to help the colon begin to work correctly again. Once your child is having regular bowel movements without pain, or avoidance you can slowly wean the laxative too, but do this over several months. Dietary therapy is also important to help soften stools and decrease the transit time of stool in the colon. Healthy eating habits which incorporate high fiber foods are helpful. The formula for fiber intake is the child’s age in years + 6 = number of grams of fiber /day. You would be surprised at fiber content of foods and they are all listed on the food packages. Benefiber is also a good source of fiber and can be used daily.  I like  to use Metamucil cookies too and if necessary put a little icing on top.  Adding more fluid to a child’s diet is equally important , and a “prune juice cocktail” made with prune juice and seven up or ginger ale is a great way to get in some more fluid with additional laxative benefit. (you taste it not bad at all!) Lastly, behavior modification.  Begin by establishing a regular toileting schedule. This is typically after each meal (to take advantage of the gastro-colic reflex which occurs after eating and causes intestines to contract) and at bedtime.  I sometimes use a timer as a game to try and have the child “beat the clock” in pushing out their poop, and then they receive a “prize” (Dollar store is adequate, does not need to be expensive etc.). A child needs lots of positive reinforcement with charts, stickers to show their progress and even larger reward (maybe trip to bookstore, or ice cream store etc) for a week of good work. Remember, this is not an overnight resolution but typically takes weeks to months of work, so be creative as to positive reinforcement. If your child does not stool every day, try using a suppository and increasing the laxative.  They can also practice doing the Valsava maneuver (where you hold your breath and bear down to have a bowel movement) which will also help them push out the stool which should be soft. If your child is in school you need to discuss these strategies with the teacher so that the child has adequate bathroom time when needed. By working on all 3 areas encopresis can be treated and successfully cured while saving the child embarrassment and anxiety that often comes with it. No one wants to have “poopy pants” they just need the tools to fix the problem. For very difficult cases you may need to ask your pediatrician about using a behaviorally trained pediatric psychologist for assistance. That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Feeding Your Baby

1:30 to read

Under the heading of “learning new things everyday” comes some information on feeding your infant. Have you heard of “paced bottle feeding?”  If you are a new mother and are breastfeeding and either supplementing your baby with formula or breast milk you may already be doing this……

 

There are many advantages and benefits to breastfeeding your baby, but not everyone is able to breast feed or desires to breast feed. While I am a huge advocate for breast feeding, I am also supportive of “ a mother’s right to choose” and have some patients who just prefer to bottle feed their baby with formula.  The most important issue is really about nutrition and healthy weight gain for a newborn…with either breast or bottle feeding. 

 

So…a new mother was telling me that she was using “paced feeding” for her baby. I admit I looked at her and said “what”?  It seems that this is a feeding method used when a breast fed infant takes a bottle. It is supposed to more closely mimic the sucking and swallowing pattern of an infant when they breast feed.

 

With paced feeding the infant is held in an upright position and the bottle is held horizontally and the baby is  paused after feeding every few minutes…which is what typically occurs during breast feeding.  This method also encourages the  caregiver to turn the baby from one side to the other midway through the feeding….again like a breast fed infant. This will encourage eye contact and changing the head and neck position of the infant during their bottle.

 

Paced feeding is also supposed to help the baby not over-eat. By pausing “you are letting the cues for being full reach the baby’s brain.”  Mothers have also told me “paced feeding will not stretch a baby’s stomach.” I am not sure that there is science supporting this…and I do feel that in general most babies will not overeat ….they pause and turn away from the bottle as they get full…whether you breast or bottle feed you will notice that your baby really “leads the feeding”. When parents try to “fill their baby up before bedtime” they almost seem to try and force feed the baby and typically that only leads to a cranky baby that might spit up as well….watch your baby’s cues.  Amount fed does not necessarily correlate with longer sleep!

 

Try this and see what you think….again, I don’t think there is truly one way to feed every baby as they are individuals too and you will figure out what works best for your own baby. I think most babies are “pacing themselves” even without you realizing it…

 

Daily Dose

Breastfed Babies & Diaper Rash

1:30 to read

I was shopping at Target just the other day and happened to be in the “baby aisle” looking for one of those snack cups with the lids to let little fingers get in and not let the puffs fall out.  I needed it as part of a baby gift basket.  Useful for sure!!

So…while I am browsing, I see a young mother and her mother looking at diaper creams and obviously trying to decide which one to buy. I could’t resist offering help (always worry about being intrusive). When I asked what they were trying to treat the mother said, “ my new baby has this raw and red diaper rash right around his bottom”.  “He is just 12 days old and I change his diaper all of the time….how could he possibly get a diaper rash? What am I doing wrong?”

As we say in Texas, “bless her heart”!!! I asked if she was breast feeding,  and she was,  then I immediately knew what she meant. A breast fed infant will poop ALL OF THE TIME.  Many times you change a new diaper and as soon as the next diaper is put on the baby stools again. There are many times when your infant may poop a bit of stool during sleep and when you get them up they have a dirty diaper…all normal. No new mother guilt!!

The good news is that a newborn who is stooling a lot is probably getting plenty of breast milk as well…and that means they are gaining weight too!  The flip side is that it is not uncommon for a newborn to get that raw red bottom during the first month or so of breast feeding.  After that time, the stools do slow down a bit and diaper rash is less common.

The best remedy I have found for treating that tender new bottom is a combination of a diaper cream that contains zinc (Destin, Dr. Smith’s, or Boudreaux’s Butt Paste) and a bit of a liquid antacid (Mylanta, Maalox, Gaviscon). I put  a blob of diaper cream in my palm and then pour a bit of the antacid into it and mix….you can’t use too much of the liquid or it will run off.  Then I take that combo and coat the baby’s bottom. You can’t over do it. Use it with each diaper change.   It seems to do the trick and is easy. Several years ago I told a mother about the concoction (she had 4 children and was very sleep deprived) and I  just said use some antacid if you have some. She called later in the day and said she had tried to crush up the tablets and mix it with diaper cream and it wasn’t working.  I have since learned to be a bit more specific about a LIQUID antacid.  

 

 

 

 

 

Daily Dose

Colic

1:30 to read

I just read an interesting article in the journal Pediatrics on the subject of infant colic. It was a review of over 5600 articles that looked at the “mean duration of fussing and crying an the presence of colic in infants in the first 3 months of life”. If you have had or currently have a “colicky baby” this is quite interesting, as it looked at the incidence of “colic” in numerous countries as well.

 

The study evaluated the” mean total fuss/cry duration during 24 hours at ages 1-2 weeks (11 samples), 3-4 weeks (6 samples), 5-6 weeks (28 samples), 8-9 weeks (9 samples), and 10-12 weeks (12 samples).Interestingly the peak fussy crying period was highest in the first 6 weeks of life (17-25% of infants) and dropped by 8-9 weeks of age (11%)  and by 10 -12 weeks less than 1% of infants were reported to be “colicky”.  On average, babies around the world cry for around 2 hours per day in first two weeks, peak at 2 hours 15 mins at six weeks - and crying reduces to 1 hour 10 minutes by week twelve. (My son was not in this study…as he was colicky far longer than this study reported!!)

 

The study also found that infants in Denmark, Germany and Japan had less fuss/cry duration than infants in Canada, Italy and the United Kingdom.  What is that about?  It could be any number of variables including genetics, climate, socioeconomics and cultural factors….but I can remember feeling so helpless with an infant with colic (yes, even as a pediatrician…may have been worse knowing that there was not an answer) that I might have considered buying a plane ticket to Denmark!! Desperate times require desperate measures.

 

This study did not solve the mystery of colic nor did it give any answers to how to “treat” the fussy/irritable/colicky baby….but it did help to reassure parents around the world that this phenomena is universal…and that these babies do improve with time. You only wish that your baby could verbalize and explain to you what was going on in those first few months….but that may happen one day in the future…for now it is just an unknown, stressful situation for a parent…and the baby seems to outgrow it and has no memory of this experience.  (I have asked my own son who just looks at me with a puzzled expression?).

 

In the meantime parents with colicky fussy babies do require extra support and reassurance that their baby will be fine,  and ask their pediatrician if  their baby is growing and developing normally. But with all of that information …are there any “bargain fares” to Denmark and Japan???

 

 

 

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Daily Dose

Codeine & Children

1:30 to read

I order to keep us all safe, the FDA is constantly monitoring drugs and their side effects.  For many years codeine was prescribed for children for pain relief as well as to suppress coughs.  Over the last few years there has been more and more discussion about limiting the use of narcotics in children, but I continue to see some children who come from seeing other physicians and have received a prescription that contains codeine.

 

The FDA just issued new warnings against using prescription codeine in children and adolescents. The FDA reviewed adverse event reports from the past 50 years and found reports of severe breathing problems and 24 deaths linked to codeine in children and adolescents. Genetic variation in codeine metabolism may lead to excessive morphine levels in some children.

 

The FDA also performed a literature review which noted excessive sleepiness and breathing problems, including one death, in breast-fed infants whose mothers used codeine.

 

Due to these findings the FDA is now recommending that “codeine should not be used for pain or cough in children under 12 years of age”. They have also issued a warning that codeine should not be used in adolescents aged 12-18 “who are obese or have conditions associated with breathing problems, such as obstructive sleep apnea or severe lung disease”. In retrospect, codeine was prescribed to more than 800,000 children younger than11 years in 2011. Amazingly, codeine is currently available in over-the-counter cough medicines in 28 states.  

 

Lastly, the FDA “strengthened the warning” regarding codeine and breast feeding. They now recommend that breast- feeding women do not use codeine…which may change the post delivery pain protocol. Nonsteroidal anti-inflammatories (Ibuprofen) and acetaminophen (Tylenol) are preferred and are effective for mild to moderate postpartum pain. As a pediatrician it is important that I discuss this with new breast-feeding mothers as well. 

Daily Dose

Spring Allergies

1:30 to read

It is definitely allergy season around the country. The weird weather this year has made all things blooming start early, with sky high pollen counts. Some areas have had a few recent super cold days, but warmer temperatures are starting again.  While the cherry blossoms really suffered, the oak, elm, mulberry and ash trees are all just starting to spread their pollens and causing a lot of runny noses, itchy eyes and scratchy throats.

 

If you know that your child is a spring allergy sufferer or if they seem to be developing allergy symptoms (which often occurs after the age of 2 years), there are many products now available over the counter.  The mainstay of allergy treatment is the use of nasal steroids, which actually act as a preventative. They are used on a daily basis during allergy season.  There are many different nasal steroid sprays available including Flonase, Nasacort, Nasonex and Rhinocort.  Both Flonase and Nasacort now have a children’s brand and may be used in children as young as 2 years. While the word “steroid” scares many parents, these steroids are not “the bad”  ones associated with bodybuilding. The steroid is sprayed directly into the nasal lining and therefore very little is absorbed systemically, so there are few side effects. Some children do not like sprays and “water up their nose”, but each brand is a bit different in how it is delivered, so you might switch around and see which brand is easiest to use.

 

Many of the allergy symptoms that occur including the runny nose and watery eyes are related to the allergic cascade and histamines that the body produces in response to exposure to the pollen.  So….anti-histamines are also a mainstay of treatment. Again, many of the previous prescription anti-histamines are now all available over the counter. This class of drugs includes second generation non sedating anti-histamines such as Allegra, Zyrtec and Claritin and now the newest Xyzal.  First generation anti-histamines are more likely to cause drowsiness and sedation and the best known of these is Benadryl (diphenhydramine).  For those with severe allergy symptoms I sometimes use a morning non-sedating anti-histamine followed by Benadryl at bedtime. 

 

For those children who have significant allergies, particularly year round, and who do to respond well to typical treatment with nose sprays and antihistamines, it may be time to see a pediatric allergist. I recently sent one young boy for allergy testing. The testing is usually well tolerated and not painful.  When I saw him for follow up he told me he had gone to the “pokemon” doctor…as he had gotten lots of pokes on his back!! 

 

 

 

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Daily Dose

Omega-3 Fatty Acids

1:30 to read

Many of the patients that I see who have problems with attention and focus as well as other behavioral and learning issues have been started on all sorts of different medications. For some children their medications seem to be “working well”. But, for some children it has been difficult to find the “right” medication to alleviate all of their symptoms.  Studies have shown that anywhere from 10%- 30% of children with ADHD do not respond favorably to stimulant medications. Therefore,  it is not uncommon for their parents to inquire about the use of alternative or complementary medications. In several cases their parents have already started “dietary supplements”, which at times they are reluctant to admit to, or ask for my opinion.  

Interestingly, there is recent data regarding dietary supplements that parents and pediatricians should be paying attention to…and open to discussing.  A study that was presented last fall at the American Academy of Child and Adolescent Psychiatry showed that omega-3’s “could augment the response in children aged 7-14 years who were receiving psychotherapy for depression and bipolar disorders”. There have been  studies as well that have shown “significant improvements with Omega-3’s relative to placebo for problems including aggression as well as depression and anxiety symptoms”.  There are also numerous studies looking at ADHD symptom improvement in those using Omega-3’s, and again the results have been mixed, made even more difficult by the fact that ADHD is a subjective diagnosis.  

Another issue that requires more study is how these fatty acids actually work within the body and brain. Omega-3’s are an important building block of the brain and it is present in the brain's cell membranes, where it is thought to facilitate the transmission of neural signals.  Current thought is that these fatty acids may change the cell membrane fluidity and may also have anti-inflammatory effects….but a lot of research continues on the issue of mechanism of action. 

Several of the studies looked at dosage of the Omega 3 fatty acid supplements and “it seemed that there were more positive trials related to higher daily doses of  certain omega 3 fatty acids including eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA).  There need to be further studies to address the amount and ratio of these Omega-3’s as they are used for supplements. 

So while the research continues as to the effectiveness of Omega 3’s on focus, mood, behavior and learning it is important for all children to consume enough Omega-3 fatty acids in their diet. Eating fatty fish a few times a week would be beneficial for the health of all children - and the decision to supplement beyond that may be a topic for discussion with your own physician. 

 

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