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When is it time to worry about the cough?

Written By Jennifer Shaer MD, FAAP, FABM, IBCL

CoughIt seems like kids cough all winter long. When is it time to worry about the cough? When can you treat it at home and when should you go to the doctor?

There are many causes of coughing in children. Most commonly, a cough is caused by a viral upper respiratory infection. However, coughs can also be caused by asthma, pneumonia, croup, bronchiolitis, whooping cough, sinusitis, allergies, reflux and even an inhaled foreign body. This article will review the …

Viral upper respiratory infections

This is the common cold. A cough from a cold will typically last two weeks. There is commonly some productive phlegm toward the end of a cold. Antibiotics do not help viral illness so it is best to let this type of cough run it’s course. It is common to have some fever with a viral upper respiratory infection for the first few days. However, you should visit the doctor if the fever lasts more than a few days. You should also be seen if the cough lasts more than a week or the fever comes back after having stopped.

Whooping cough (pertussis)

Recently there has been a resurgence of pertussis. Pertussis will start off looking like the common cold. However, instead of getting better, the cough gets worse. Children with pertussis will cough many times in a row.

They will often lose their breath and take a big “whoop” breath at the end of a series of coughs. Babies with pertussis will sometimes stop breathing and turn blue. Pertussis is extremely dangerous to babies and is preventable by vaccine. It is important to make sure that your baby gets all his pertussis vaccines. In addition, we now give teenagers and adults a pertussis vaccine.

Asthma

A cough from asthma is usually not associated with a fever. Kids with asthma will cough more with exercise and at night. Asthma is usually triggered by a cold so children who have a history of wheezing should always see the doctor when they are coughing.

Bronchiolitis

Bronchiolitis is when a viral upper respiratory infection moves into your baby’s chest and causes wheezing. Signs that your baby’s cold might be bronchiolitis include trouble nursing or taking a bottle, heavy or fast breathing and wet sounding cough. In general, babies with a cough should see the doctor.

To learn more about coughs, or any other medical conditions your child may be facing, visit HealthyChildren.org.

Dr. Shaer is a pediatrician and a board certified lactation consultant (IBCLC). She is director of the Breastfeeding Medicine Center of Allied Pediatrics of New York.

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How Do I Know If My Child Needs Ear Tubes?

Written by Jesse Hackell MD., FAAP.

imageEar tubes, or more properly known by their medical name, tympanostomy tubes, represent the most common surgical procedure performed on children in the United States.

Over 600,000 children undergo ear tube placement every year, in a simple procedure under general anesthesia, with the attendant risks of surgery and anesthesia as well as the costs associated with these procedures having a significant impact on these children and their families.

The arguments for and against tube placement have been debated for years, and various guidelines have been proposed in order to develop some degree  of a rational approach to the medical issues which lead to ear tube surgery.

The American Academy of Otolaryngology–Head and Neck Surgery has recently convened a panel of experts in several fields of medical care, as well as experts in hearing and audiology and consumer protection, in order to develop a set of clinical practice guidelines on tympanostomy tubes in children.

This panel, of which I was a member, met several times over the course of a year, and was charged with reaching a consensus opinion on how best to apply the scientific evidence in the literature to the decision-making process regarding the placement of ear tubes in children.

The panel’s research and deliberation has resulted in a comprehensive article on this topic, which includes a thorough discussion of the nature of middle ear disease, as well as specific recommendations regarding the decision to place ear tubes in children who fall into a number of distinct categories. The complete article has been published in the journal Otolaryngology–Head and Neck Surgery (Otolaryngol Head Neck Surg July 2013 vol. 149 no. 1 suppl S1-S35) and can be accessed online here: http://oto.sagepub.com/content/149/1_suppl/S1.long .

Some of the recommendations made by the panel relate directly to acute otitis media (ear infections) and otitis media with effusion (ear fluid), which as we all know are very common complaints and findings in children.

For example, one recommendation is that ear tubes NOT be placed when the ear fluid has been present for less than three months.

However, this is complemented by the recommendations that hearing testing should be performed if the fluid lasts three months or longer, and that tubes should be offered if the fluid has persisted for more than three months and hearing loss is found to be present.

The guidelines further recommend that children with fluid but without hearing loss should be re-evaluated on a regular basis, watching either for resolution of the fluid or development of a hearing loss.

Another guideline recommends NOT placing tubes in children with repeated episodes of acute ear infections, unless persistent fluid is seen between episodes of acute infection.

Of particular note in these guidelines is the attention paid to children with special needs, such as cranio-facial abnormalities and chromosome abnormalities such as Down’s Syndrome. In these children, the guidelines recommend a much more liberal use of tubes, since they have a greater incidence of hearing loss and are at greater risk of secondary problems developing as a result of even brief periods of ear fluid and hearing loss.

Two additional recommendations of particular interest to parents whose children have already had tubes placed are, first:

that acute drainage of fluid from an ear with a tube in place should be treated only with antibiotic ear drops, and not with oral antibiotics, unless the child appears systemically ill with a complicated course of the infection, and, second, that water protection, such as ear plugs, is NOT recommended when children go swimming after they have had ear tubes placed.

Because these evidence-based principles are guidelines, of course, they serve as a starting point for dealing with the question of tympanostomy tube placement, and should not be taken as the absolute and final word on the subject.

Children and their illnesses are unique, and each and every case may not fit clearly into one of the guideline categories. For this reason, each of the recommendations emphasizes the role of shared decision making between the clinician and the parents.

As a panel member and an author of the report, I would suggest that if your child’s physician is suggesting that ear tubes be placed in your child, it would make sense to at least make sure that the physician is familiar with these new guidelines, and is willing to discuss how your child fits in with these new recommendations.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.

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6 Simple Back-to-School Tips For Parents

ImageMost kids are back in school. But that doesn’t mean we can’t make on the fly improvements to help us get back into a routine. Here are 6 quick tips to help you get back on track:

  1. Restart the bedtime routine: It’s hard to get up for school the first day unless you start back into a normal bedtime routine now.
  2. Set up a place for homework: Set expectations now and get organized. Kids thrive on routine and organization.
  3. Talk to your child’s teacher, school psychologist or nurse: If you have ANY concerns about your child academically, socially or medically, reach out in advance. Being proactive is always better than being reactive.
  4. Prepare for sick days: Kids will inevitably get sick at the beginning of the school year as they come back together in such close quarters. Kids who have asthma often benefit from restarting their controller medications in anticipation of this. Visit your doctor to discuss this or any other medical needs before school starts.
  5. Consider helping kids in school districts with less: DonorsChoose.org makes it easy to help classrooms in need. Public school teachers post classroom project requests. Find a project that has some meaning to you and your family.
  6. Don’t stress: Back to school can be stressful for everyone. Try and relax and take it one day at a time.

Dr. Shaer is a pediatrician and a board certified lactation consultant (IBCLC). She is director of the Breastfeeding Medicine Center of Allied Pediatrics of New York.

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Can I Spoil My Newborn?

Written By Jennifer Shaer MD, FAAP, FABM, IBCL

Parents of newborns often ask me if holding their baby too much will spoil him or her. The answer to this question is a resounding “No”.

Newborn babies are accustomed to being held 24/7. This was their existence during their entire gestation. Any amount of time that a newborn is not being held can be stressful. An infant does not need to learn and cannot learn to be independent immediately after birth. Newborns do not have the capacity to be lazy or manipulative at this stage.

The best way to comfort and care for a newborn is to imagine recreating the feeling of being in utero. If your baby falls asleep on your chest, enjoy it. Newborns regulate body temperature, heart rate and breathing best when lying chest to chest with mother or father.

Because of this, baby wearing has become popular of late and is a great way to nurture your baby hands free while taking care of yourself and even your other kids.

However, this does not mean that you need to be a slave to your baby. If you need to put your baby down and he cries, it will not harm him in the long run.

My advise is to follow your instincts. Hold your baby whenever you want to without the guilt that you are spoiling him.

Cherish this time. All too soon he will be grown up. On the other hand, do not fret if you have to or want to put him down to take care of something. Consider using a sling which will allow you to multitask.

As babies grow up, this advice changes. Older babies do benefit from learning how to self soothe. For now, enjoy those first few months. Forget the laundry, cooking, entertaining and other chores unless critically important. Spend this time bonding with your newborn and enjoy every moment while it lasts.

 

Dr. Shaer is a pediatrician and a board certified lactation consultant (IBCLC). She is director of the Breastfeeding Medicine Center of Allied Pediatrics of New York.

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My Child Has A Fever, Should I Be Afraid?

Written By Jennifer Shaer MD, FAAP, FABM, IBCL

Everyone gets nervous when their child has a fever. However, fever is not dangerous. There are many myths surrounding fever. Here are some facts about fevers:

Fever helps the body fight infection. Fever helps slow growth of bacteria and viruses. It also enhances the immune fighting cells in the blood.

A high fever does not necessarily mean that there is a serious disease. Many viral illnesses can cause very high fevers. While these fevers might be high, they will go away without any help in three to five days.

Fevers do not cause brain damage.

Again, fever is a normal physiologic response. The only time that fever is dangerous is when it is from heat stroke or hyperthermia. Symptoms of heat stroke are red hot dry skin with no sweating and confusion.

Infections and illnesses that cause fever do not cause heat stroke and are not dangerous. It is true that a small percent of children who get a fever will have a febrile seizure. Febrile seizures occur in about 4% of kids. They can be very scary to watch but they do not cause brain damage.

Medicines to lower fever are not expected to bring the temperature down to normal.

Ibuprophen and acetaminophen are often used to bring down fever in children. However, these medicines will only help the child feel better for a short time.

When the medicine wears off, the fever will return. Your child will continue to have fever for as long as the illness lasts (usually 3-5 days). Also, these medicines will lower the fever but they are not expected to bring the temperature back to normal.

It is expected and helpful to have some fever while your child is sick.

Of course you want your child to be comfortable and you do not want your child to get dehydrated from a high fever but remember that the fever is helping your body fight infection.

Also when your child is sick, he or she should be resting. If you bring the temperature back down to normal with medicine than he will want to run around a play. The goal in using medicine for fever control is to keep your child comfortable while his body is fighting the illness.

Fevers will not continue to rise without treatment. The brain has a “set point” temperature that it will reach and then start to come down, even without medicine.

Medicines to bring down fever will not prevent a febrile seizure.

One in twenty five children will have a febrile seizure. It is impossible to predict and it is impossible to prevent. Remember that while they are scary, they are not dangerous.

Do not use medicine to try and prevent a seizure. Medicine for fever should only be used to keep your child comfortable.

It is most important to determine the cause of your child’s fever.

Fever is just a symptom.

If the fever is from strep throat or an ear infection then he might need antibiotics. If the fever is from a virus, then it will need to “run its course”.

You should bring your child to the doctor to help determine the cause of the fever. Once you know the cause, you can relax.

Medicines come in many shapes and sizes and they are dosed based on your child’s weight. To determine how much medicine your child should take, visit Allied Pediatrics – Med Dosage Resource

Dr. Shaer is a pediatrician and a board certified lactation consultant (IBCLC). She is director of the Breastfeeding Medicine Center of Allied Pediatrics of New York.

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My Child Has Ear Wax In His Ear, Should I Be Worried?

Written by Kristen Stuppy MD. Dr. Stuppy is a practicing pediatrician in Kansas. She feels privileged to be able to help families keep their children healthy and she loves watching entire families grow!  Dr Stuppy is active on Facebook and puts a more personal touch to pediatric topics on her blog.

5085250_f520We make ear wax, also known as cerumen. Many people are annoyed by wax buildup, but it has a purpose! Wax grabs all the dust, dirt, and other debris that gets into our ears.

It also moisturizes the ear canal ~ without it our ears become itchy. It even has special properties that prevent infection. That’s all good stuff, so don’t be too frustrated with a little wax!

Most often the wax moves from the inner part of the ear canal to the outer edge of the canal on its own.

It is amazing to me how our bodies are put together so perfectly: it is designed so the wax is made deep in the canal, then skin cells and wax migrate to the outer edge of the canal, taking with them debris! Some people naturally make dry wax, others make wet wax.

This can be due to genetics and other factors. The important thing to remember with this is how your wax tends to build up and how to best keep it from building up.

If wax builds up it can cause pain, itching, ringing in the ear, dizziness, decreased hearing, and infection. Inappropriate cleaning with hard and/or sharp objects (such as an cotton swabs or paperclips) can increase the risk of infection or even perforation of the ear drum.

Even special cotton swabs made “safe for ears” can push wax deeper and cause a solid collection of wax plugging up the canal.

How can parents help babies and kids keep their ears clean?

  • Routine bathing with clean warm water allowed to run into the ear followed by a gentle wiping with a cloth is all that is needed most of the time.
  • Ear drops made for wax removal with carbamide peroxide can be put in the ear as long as there is no hole in the ear drum or tubes. The oily peroxide acts to grab the wax and bubble it up. Then rinse with clean warm water and a soft cloth (see syringe tips below).
  • If there is excessive buildup, daily use of drops for 3-5 days followed by weekly use of the drops to prevent more buildup is recommended. (For particularly stubborn wax, using drops 2-3 times/day for 3-5 days initially can help.)
  • Make your own solution of 1:1 warm water:vinegar and gently irrigate the ear with a bulb syringe.
  • Mineral oil or glycerin drops can be put in the ear. Let a few drops soak for a few minutes and then rinse with warm water and a soft cloth.
  • Occasional use of a syringe to gently irrigate the ear can help. Using the bulb syringe:
  • First, be sure it is clean! Fungi and bacteria can grow within the bulb ~ you don’t want to irrigate the ear with those! While they can be boiled, they are also relatively inexpensive and easily available, so frequent replacement is not a bad idea.
  • Use only warm water /fluids in the ear (about body temperature or just above body temperature is good). Cold fluids will make the person dizzy and possibly nauseous!
  • If using drops first, put the bottle in warm water or rub it between your hands a few minutes (as if rubbing hands together to warm them, but with the bottle between the hands). Don’t overheat the fluid and risk burning the canal!
  • Have the child stand in the tub or shower.
  • Pull up and back gently on the outer ear to straighten out the canal.
  • Aim the tip slightly up and back so the water will run along the roof of the canal and back along the floor. Do NOT aim straight back or the water will hit the eardrum directly and can impact hearing.
  • Don’t push the water too fast ~ a slow gentle irrigation will be better tolerated. If they complain, recheck the angle and push slower. If complaining continues, bring them to the office to let us do it to be sure there isn’t more to the story.
  • Refill the syringe and repeat as needed until the wax is removed.
  • Use a soft cloth to grab any wax you can see and dry the ear when done. Some people like to use a hair dryer set on low to dry the canal. Just be sure to not burn the skin!
  • If wax continues to be a problem, we can remove it in the office with one of two methods:
  • After inspecting the ear canal carefully with an otoscope (or as I call it with the kids: my magic flashlight), we can use a curette (looks like a spoon or a loop depending on provider’s preference and wax type) to go behind the wax and pull it out.

This is often the fastest method in the office, but is not always possible if the wax is too flaky or impacted into the canal leaving no room for the curette to pass behind the wax. It should only be done by trained professionals… don’t attempt this at home!

  • If the wax is plugging up too much of the canal, the canal is very tender, or if the wax is particularly flaky and breaks on contact with the loop, we will let the ear soak in a peroxide solution then irrigate with warm water.

This process takes longer but is better tolerated by many kids and they think it is fun to “shower their ear”. We often must follow this with the curette to get the softened wax completely out.

My biggest tips:

  • Never use cotton tipped swabs, pipe cleaners, pencils, fingernails, or anything else that is solid to clean the ear! (Note: I still don’t recommend them if the package says “safe” ~ they aren’t!)
  • Don’t put liquid in the ear canal if there is a hole in the ear drum (tubes are included in this). Pus draining from the ear is a sign that there might be a hole.
  • Ear candles are not a safe solution. Burns are too big of a risk!
  • The ear canal is very sensitive, especially if wax buildup has been there a while and has caused an infection of the skin in the canal. Anything put into the ear can increase any pre-existing pain.
  • If the skin is friable from prolonged wax and/or infection there is often bleeding with cleaning. If you notice this at home, your child should have the ears evaluated in our office.
  • We will look for holes in the ear drum, scratches on the skin in the canal, and signs of infection needing antibiotic.
  • Some people who suffer from itchy ears can help themselves by NOT cleaning their ears so much!
  • Earwax usually can be left alone. Only try to clean it out if there are signs of problems with it (ear pain, ringing in the ears, decreased hearing, etc).
  • If kids don’t tolerate removal with the methods above, bring them in for us to take a good look. There might be more to the story that needs to be addressed.
  • If there is significant ear pain, pus or bleeding from the ear, or an object in the ear, bring your child in to the office to have us assess and treat.
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13 Tips to Help Parents Address Prom Night

Written by Nelson Branco MD and Nell Branco, MPH, LCSW

PromProm season and graduations are here. Any adult who works with teens or has a teen in their life wants them to fully enjoy this big event while somehow managing to keep it in perspective.

The prom is a time to dress up for a fancy event planned just for them. Kids get to celebrate their friendships and the years they have spent together. We all have memories (good, bad or indifferent) from our high school years, and I’ll bet the prom picture is the first one grandma whips out when she’s trying to embarrass you with your kids.

High school juniors and seniors are young adults, and prom is another opportunity to build trust and foster their ability to be self-reliant. It’s also a good opportunity for parents to communicate clearly about your expectations. Here is a list of issues and suggestions for making prom night stress-free, safe and fun for all.

Planning for prom may be stressful or frustrating for your teen.

Try to be open and supportive through the ups and downs. There may be a logistical or social aspect of the prom that is worrying your son or daughter. Let them problem solve, using you as sounding board, but don’t try to fix it for them.

Don’t side-step the topic of drugs, alcohol, and safe sex.

If you have reasons to be concerned about these issues, bring them up. The emphasis should be on making responsible decisions in addition to having fun.

Discuss rules for the prom; your own rules, the school rules, and consequences for breaking them.

The goal is not to lecture. You want to have a discussion to set positive expectations for a fun and safe night. Tell your teen that you trust their ability to made good plans and reasonable decisions, and that you know they want the night to go well. Begin the conversation with “I know we’ve discussed this before…” or “I know you know this already but I think it is a good idea to review ….”

Make a plan with your teen that you can both stick to.

You might agree to one phone call check-in vs. multiple calls or texts through the night. For older, more independent students a check-in may not be necessary.

Ask who they are going to be with.

It’s reassuring to know your son or daughter’s date, and if they plan to go with a group of students you already know. Have the name and cell phone of one other person in the group as a backup contact.

If your teen is going to a pre-prom or after party, find out who is hosting and who is supervising.

You should feel free to talk to those parents beforehand if you have questions. There are lots of reasons to call each other; to thank them, to offer help, to arrange a pick up time, etc. Often, students and their parents have put a lot of planning into these parties and have rules and guidelines that guests are expected to follow.

Have a backup plan for getting home.

Even if your teen is going with a group in a limo or bus, make sure they have money for a cab or another ride if needed.

Does your teen know how to contact you throughout the evening?

Tell them where you plan to be and how they can reach you. Some parents and teens set up a code or agreed upon phrase that will cue parents to pick them up, no questions asked.

Plan for changes.

If their plans for the evening change (and they may) make sure they know to check in and let you know the new destination and who they are with.

Renting hotel rooms for students is not recommended.

Not only are there issues of supervision and cost, but a large group of teens may run afoul of hotel noise policies and have a negative impact on other hotel guests.

If you are hosting a party review your town’s Social Host laws.

Parent hosts are often responsible for the safety of their guests. For more information about social host laws, see http://www.socialhostliability.org or http://en.wikipedia.org/wiki/Social_host_liability

Driving safely.

Reinforce the message that they shouldn’t ever drive if they’ve been drinking or using drugs, and shouldn’t let their friends dot it either. It’s also worth reminding your teen that driving while tired can be just as dangerous as driving while they are intoxicated.

Most importantly – with all the excitement (and worry) don’t forget to say

“I love you and have a good time”

as they get ready to leave, and take lots of pictures.

 

Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP. Ellen Branco is a School Counselor and Health Educator in the San Francisco Bay Area. She has been working at independent high schools and counseling since 2001.