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Daily Dose

Why Babies Develop Jaundice

It is not unusual to see a newborn appear slightly jaundiced during their first week of life.

I received an email via our iPhone App from a mom who asked "why babies get jaundice and why we check a bilirubin level on newborns?"

Most babies will develop physiologic jaundice (noted by yellow discoloration to their skin and whites of their eyes) due to the fact that a your-baby's liver is still not working at full speed when first born. Bilirubin, a breakdown product of the red blood cell, is metabolized through the liver. It is also excreted in the stool, and the young newborn is just getting all of those organ systems up and running in the first 24- 2 hours of life. As cute and snuggly as a brand new your baby is, it does take a few hours to days for everything to ramp up to full working speed. So, it is not unusual to see a newborn appear slightly jaundiced during their first week of life, and how I learned with my own first child, yellow is not a good color on most newborns. Stick with pink and blue. Sometimes babies will develop higher bilirubin levels than expected, (numbers in the teens) and depending on how old they are may require phototherapy to help breakdown the bilirubin. You might have seen those babies basking under the glow of "sunlamps" wearing your-baby sunglasses. The blue lights breakdown bilirubin in the skin. Excessive bilirubin can lead to a condition called kernicterus, and may actually cause brain damage. By following an infant's bilirubin levels and treating promptly you can avoid this, and I have never seen an infant develop kernicterus. Your pediatrician will discuss bilirubin levels with you while you are in the hospital with your newborn. If they don't bring it up, typically there is nothing to worry about. If you have concerns, you should ask. If your your baby seems to be getting more jaundiced once you are home, give your doctor a call, it may mean they need to have another bilirubin level drawn as occasionally a your-baby will develop more jaundice once they have been discharged. That's your daily dose, we'll chat again tomorrow. Send your question to Dr. Sue!

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Daily Dose

Mumps Outbreak!

1:30 to read

The latest infectious disease outbreak is in the Boston area where several colleges have reported cases of mumps. Mumps is a viral illness that causes swelling of the salivary glands as well as other symptoms of fever, fatigue, muscle aches and headache.    Harvard University has been hit the hardest and has now documented over 40 cases this spring.  Boston is a city with numerous colleges all in close proximity, and there are documented mumps cases at Boston University, University of Massachusetts  and Tufts as well.  These Boston area colleges are all in close proximity and are merely a walk, bike or train ride away from one another, so these students, while attending different universities may all co-mingle at parties and athletic events.

Mumps is spread via saliva (think kissing), or from sharing food, as well as via respiratory droplets being spread after coughing or sneezing. It may also be spread via contaminated surfaces that will harbor the virus. People may already be spreading the virus for  2 days before symptoms appear and may be contagious for up to 5 days after their salivary glands appear swollen….so in other words there is a long period of contagion where the virus may inadvertently be spread. It may also take up to 2-3 weeks after exposure before you come down with mumps.

All of the students who have come down with mumps had been vaccinated with the MMR vaccine (mumps, measles, rubella).  Unfortunately, the mumps vaccine is only about 88% effective in preventing the disease. Despite the fact that children get two doses of vaccine at the age of 1 and again at 4 or 5 years….there may be some waning of protection over time. This  may also contribute to the virus’s predilection for young adults in close quarters on college campuses. Something like the perfect infectious disease storm!

In the meantime there are some studies being undertaken to see if adolescents should receive a 3rd dose of the vaccine, but the results of the study are over a year away.

In the meantime, be alert for symptoms compatible with mumps and make sure to isolate yourself from others if you are sick.  Harvard is isolating all of the patients with mumps for 5 days….which could mean that some students might even miss commencement.  Doctors at Harvard and other schools with cases of mumps are still on the watch for more cases …stay tuned.

 

 

 

 

Your Child

FDA Bans Certain Cough Medicines for Kids

2:30

 

The U.S. Food and Drug Administration (FDA,) has added strict restrictions to the use of children’s cough medicines that contain opioids, such as codeine or oxycodone.

"After safety labeling changes are made, these products will no longer be indicated for use to treat cough in any pediatric population and will be labeled for use only in adults aged 18 years and older," the FDA said in a news release.

The country is in the middle of an opioid abuse epidemic that is devastating families in just about every state. An updated Boxed Warning label will also warn adult users "about the risks of misuse, abuse, addiction, overdose and death, and slowed or difficult breathing that can result from exposure to codeine or hydrocodone," the agency added.

FDA Commissioner Dr. Scott Gottlieb said the agency is concerned about exposing children to opioids unnecessarily.

“We know that any exposure to opioid drugs can lead to future addiction. It's become clear that the use of prescription, opioid-containing medicines to treat cough and cold in children comes with serious risks that don't justify their use in this vulnerable population,” Gottlieb said in the press release.

The new rules announced Thursday were "based on an extensive review of available data and expert advice," the agency said.

They go much further than the 2017 labeling rules -- restricting use of codeine-containing products to everyone under the age of 18, and including cough-and-cold products that contain a second drug, the opioid oxycodone.

In any case, there's little that can or should be done to ease most children's cough and colds, the FDA said.

"Experts indicated that although some pediatric cough symptoms do require treatment, cough due to a cold or upper respiratory infection typically does not require treatment," the agency said. "Moreover, the risks of using prescription opioid cough products in children of all ages generally outweigh the potential benefits."

The press release also pointed to known side effects of opioid medications, "drowsiness, dizziness, nausea, vomiting, constipation, shortness of breath and headache."

The FDA recommends that parents currently using these medications for their child should speak with their child’s doctor about alternative therapies

It's always important to read medicine labeling, too -- even if it's not obtained by prescription.

"Caregivers should also read labels on non-prescription cough and cold products," the FDA said, because "some products sold over-the-counter in a few states may contain codeine or may not be appropriate for young children."

Story source: EJ Mundell, Health Day Reporter, https://www.webmd.com/drug-medication/news/20180111/fda-bans-opioid-containing-cough-meds-for-kids#1

Daily Dose

Treating an Upper Respiratory Infection

1:30 to read

With so much illness circulating right now (not all of which is flu) parents continue to ask what is the best way to treat their child’s cold and congestion?

 

Despite so many advances in medicine the treatment of viral respiratory illnesses has not changed that much over the years. But, we have become smarter and know that over the counter cough and cold medications are not recommended for children under the age of 6 or 7 years and may have side effects. Personally, I don’t recommend these products for older children or adolescents and don’t even take them when I get a cold.

 

The treatment of congestion and runny noses is symptomatic. You actually want your child’s nose to run and have them blow their noses once they are old enough to figure out how to “blow out rather than sniff in”. This keeps the upper airway and sinuses clear and also will help to prevent ear infections. Young children when congested, are more prone to ear infections for several reasons including the fact that their eustachian tubes don’t drain as well and that they cannot blow their noses which helps to keep the eustachian tube open and clear. It is a myth that green or yellow nasal discharge means you have a bacterial infection and need antibiotics. During most upper respiratory infections the color of the mucous will change from clear, to yellow/green, to cloudy before resolving….which usually takes a good 10-14 days. Green runny nose does not necessarily mean a trip to the pediatrician.

 

I like to have children of all ages take a steamy bath or shower to keep the nose running and then use a cool mist humidifier in their rooms at bedtime. I do not recommend running a humidifier continuously for weeks as this may promote mold growth, but use it while your child is ill.  I don’t recommend warm vaporizers either as they may cause burns in children. 

 

Nasal suctioning is also a good way to clear a baby or young child’s nose which will help them breathe more easily.  My patients parents LOVE the NoseFrida and many are “obsessed” about suctioning their child - even when they don’t have a cold.  I think our new grandson has a “NoseFrida” experience daily.  You really cannot “over suction” but if your child starts to dislike the nasal suctioning/bulb that you use and they cry constantly while suctioning their nose, especially children over 12-15 months of age, they will actually make more mucous and the whole suction experience may be counter productive. I also use a nasal saline like Little Remedies® Nose Drops or Spray, which helps to loosen and thin the mucous before I suction.  

 

I am also a big fan of Vicks or Mentholatum, which has been shown to relieve congestion. I remember my grandmother rubbing my chest and neck with Mentholatum and then putting a warm washcloth over it before I went to bed. It brings back memories of lots of “TLC” and also of feeling less congested before heading to bed. Many of my patient’s parents also like to put Vicks on their children’s feet and then put their socks on before bedtime.  

 

If your child’s nose is “stopped up” if may make it seem like they are having trouble breathing as it “sounds funny”. Look at their chest if you are concerned and make sure that they are not having any distress, with their ribs pulling in and out as they breathe or using their tummy muscles. Any labored breathing requires immediate evaluation!  In many situations all of those upper airway noises may go away after you suction their nose.  You should also watch your child’s overall color, they should be nice and pink and look comfortable despite all of the congestion in their nose. 

 

 

Daily Dose

Constipation

1:30 to read

Constipation is a topic that every pediatrician discusses….at least weekly and sometimes daily. It is estimated that up to 3% of all visits to the pediatrician may be due to constipation. Constipation is most common in children between the ages of 2 and 6 years. I have been reading an article on updated recommendations for diagnosing and treating common constipation. The most important take home message is “ most children with constipation do not have an underlying organic disorder. Diagnosis should be based on a good history and physical exam for most cases of functional constipation”.

 

Like many things in medicine….the evaluation and treatment of constipation has also changed a bit since the last guidelines were published in 2006. It is now appropriate to define constipation with a shorter duration of symptoms (one month vs two) and some of the most common diagnostic criteria (Rome IV Diagnostic Criteria) include the child having less than 2 stools/week, painful or hard bowel movements, history of large diameter stools (parents will tell me their 3 year olds “poops” clog the toilet), and some may have a history of soiling their underpants. 

 

By taking a good history you can avoid unnecessary tests..including X-rays which are not routinely recommended when evaluating a child with possible constipation.  In most cases physical findings on the abdominal exam will confirm the diagnosis in combination with the history. I often can feel hard stool in a child’s left lower quadrant and when asked the last time they “pooped”, no one can really recall. 

 

The preferred treatment is now polyethylene glycol (PEG) therapy. PEG is now used to help “disimpact a child” as well as to maintenance therapy.  Where as enemas were often previously prescribed, PEG therapy has been shown to be equally effective in most cases, is given orally and is much less traumatic (for parent and child!). PEG works by drawing more water into the stool, causing more stool frequency. There are many brands of PEG including Miralax and GoLytely among others. Miralax works well for children as it is tasteless and odorless and can easily be mixed in many liquids without your child knowing it is there. 

 

The guidelines now state that for children with functional constipation maintenance therapy with PEG should continue for as least 2 months with a gradual tapering of treatment only after a full month after the constipation symptoms have been resolved. I usually tell parents that this is equivalent to about how long it takes for them to forget that they have been dealing with constipation….and then begin tapering.

 

Lastly, there is no evidence that adding additional fluid or fiber to a child’s diet is of benefit to alleviate constipation….although it may “just be good for them in general”.

 

 

Daily Dose

Ear Tubes

1:00 to read

I had been seeing a 3 year old VERY verbal patient for several months as he would intermittently complain to his mother that his “ears were ON?”.  He would tell her this off and on but could not explain what he meant by this statement. He did not say his ears hurt, he did not have a fever, he was sleeping well….but he seemed to be bothered enough to talk about it from time to time.

 

His mother brought him in to see me a few times and his exam was normal…but one day when she brought him in I noticed that he had clear fluid behind his ear drum(serous otitis). His eardrum was not inflamed and his exam was otherwise normal.  When a child has fluid behind their ear drums it is not always a sign of infection, and in this case you watch and see if the fluid goes away on its own. 

 

Well, he continued to talk to his mother about his “ears being ON”, and he even told his teachers a few times.  Because he continued to talk about it ( over about 3 months) I sent him to see a pediatric ENT.

 

When the ENT saw him he also noted that he had some fluid behind one of his ear drums. Because he had had persistent fluid it was decided to place ear tubes….

 

And guess what? Once he had ears tubes placed he told me his “ears had turned off”!!  I guess he sometimes felt funny or heard sounds differently and that was his way to express his ear issue - on and off! What took me so long?

Children continue to amaze me. 

Daily Dose

Flu View

1:30 to read

Dr. Sue’s flu view:  The entire country continues to experience high rates of influenza and what are also known as ILI ( influenza like illnesses).  The CDC reported that the Influenza A- H3N2 virus is still the most prevalent strain of flu and also causes more serious complications, especially in those over 50 years of age. People who have been vaccinated are definitely not getting as sick as those who chose not to get the vaccine.

 

In Texas we are also starting to see more cases of influenza B strains of flu, and in most cases the people who get sick with flu B are not as sick as those with flu A. Interestingly, in my practice, the children with flu A or flu B both have very similar symptoms with fever, cough, congestion, sore throat and headaches. I have seen some children who do not even have fever over 100 degrees have positive flu tests….which is surprising. Overall, they do not seem any sicker this year than during previous flu seasons and once again we have not had any patients who required hospitalization.  

 

Several schools in our area were closed due to high rates of flu, but in some instances the closures were also necessitated not only due to students being sick, but so many teachers also with flu like symptoms that they could not get enough substitutes to keep classes in session.  While the students are out the schools are doing “deep and thorough” cleaning in hopes of decreasing exposure to the virus. Unfortunately, the minute the children return to school the virus is back in that classroom. Bottom line, don’t send your child to school if they are sick, or even if you “think they are getting sick”. Some parents have told me that they went ahead and sent their child to school, even as they were already complaining of not feeling well - during this time of year err on the side of caution and keep them home for a day to see what happens. You are already contagious as you start to feel “yucky”, even before the fever has started.  School nurses are on “high alert” and are sending most students home who complain of any upper respiratory symptoms and not feeling well. Not all of those children need to head straight to their pediatrician.

 

There have been 7 more pediatric deaths reported as of last week, but you need to understand that they did not all occur last week. Several were from late December and early January and are just now being reported. Again, in comparison to the number of people who have the flu and the number of deaths reported, the pediatric mortality rate is not alarmingly high. These deaths are tragic, but parents need to be reassured that most of these children had underlying health issues as well. During the 2009 Swine Flu epidemic, sadly over 225 children died. 

 

It is still not too late to be vaccinated against the flu as there are typically 6 -8 more weeks of flu season ahead. The influenza A virus that is circulating doesn’t seem like it “wants to leave the country” anytime soon. My practice has run out of flu vaccine for those children over the age of 3, and there is not more vaccine available to order. We continue to vaccinate all babies as they reach 6 months of age!

 

Take home message again: If your child has fever, cough, sore throat and congestion but seems to respond to fever reducing medications, is hydrated, perks up and can play when their fever comes down and has no difficulty breathing, you may treat their symptoms at home and keep a close eye on them. The CDC does not recommend Tamiflu for everyone, but rather for those children who are at high risk of complications due to underlying conditions such as asthma, heart disease, diabetes or neurological problems. You would know if your child has one of these conditions.

 

Keep washing those little hands and teaching your children how to cough into the their elbow…i have been impressed by how many little ones have learned how to “cover their coughs!” 

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