What Causes Nosebleeds in Children?

Written by Jennifer Gruen MD

The purpose of the nose is to warm and humidify the air that we breathe in. The nose is lined with many blood vessels that lie close to the surface where they can be injured and bleed.

Once a vessel starts to bleed, the bleeding tends to recur since the clot or scab is easily dislodged. Nosebleeds, called epistaxis, can be messy and even scary, but often look worse than they are.

Many can be treated at home, but some do require medical care. Most nosebleeds occur in the lower, inner, anterior portion of the nose (the nasal septum) where multiple blood vessels meet to form the Kiesselbach’s plexus

Common causes of nosebleeds in children include:

  • Dry, heated, indoor air, which dries out the nasal membranes and causes them to
  • become cracked or crusted and bleed when rubbed or picked or when blowing the nose (more common in winter months)
  • Dry, hot, low-humidity climates, which can dry out the mucus membranes
  • Colds (upper respiratory infections) and sinusitis, especially episodes that cause repeated sneezing, coughing, and nose blowing
  • Vigorous nose blowing or nose picking
  • The insertion of a foreign object into the nose (we have seen legos, crayons, peas…)
  • Injury to the nose and/or face
  • Allergic and non-allergic rhinitis (inflammation of the nasal lining)
  • Tumors or inherited bleeding disorders (rare)

How are nosebleeds stopped?

Follow these steps to treat a nosebleed:

  • Have your child sit with her head slightly forward. This will keep the blood from running down the throat, which can cause nausea and vomiting.
  • Do NOT have your child lay flat or put her head between her legs.
  • Have your child breath through her mouth.
  • Use a tissue or damp washcloth to catch the blood.
  • Use your thumb and index finger to pinch together the soft part of the nose. Make sure to pinch the soft part of the nose against the hard bony ridge that forms the bridge of the nose. Squeezing at or above the bony part of the nose will not put pressure where it can help stop bleeding.
  • Keep pinching the nose continuously for at least 5 minutes (timed by clock) before checking if the bleeding has stopped. If the nose is still bleeding, continue squeezing for another 10 minutes.
  • You can spray an over-the-counter decongestant spray, such as oxymetazoline (Afrin®, Dristan®, Neo-Synephrine®, Vicks Sinex®, others) into the bleeding side of the nose and then hold apply pressure to the nose as described above.

WARNING: These topical decongestant sprays should not be used for more than 2-3 days.)

  • For several days after a nosebleed (or on a regular basis if your child tends to have nosebleeds frequently) apply Vaseline with a cotton swab to the inner, lower third of each nostril to help protect the mucosa from drying out and rebleeding.

When should your child be seen for nosebleeds?

  • Bleeding persists after more than 15 to 20 minutes of applying direct pressure.
  • Repeated episodes of bleeding.
  • The bleeding is rapid or the blood loss is large (exceeds a coffee cupful).
  • The bleeding was caused by an injury, such as a fall or other blow to the nose or face, and is not easily stopped.
  • The blood goes down the back of your child’s throat rather than out front through the nose even though she is sitting down with body and head leaning slightly forward.
  • (This may indicate the rarer, but more serious, “posterior nosebleed,” which almost always requires a physician’s care. This condition occurs more frequently in older people).
  • Nosebleeds accompanied by unusual bruising all over the body, or other types of bleeding (heavy periods, frequent bleeding with toothbrushing, etc.)

How to prevent nosebleeds:

  • Use a saline nasal spray or saline nose drops two to three times a day in each nostril. These products can be purchased over-the-counter or made at home. (To make the saline solution at home: mix 1 teaspoon of salt into 1 quart of tap water. Boil water for 20 minutes, cool until lukewarm.)
  • Add a humidifier to your furnace or run a humidifier in your child’s bedroom at night.
  • Place water-soluble nasal gels or ointments in your nostrils with a cotton swab.
  • Bacitracin®, Vaseline®, or Ayr Gel® are examples of over-the-counter ointments that you can use. These gels and ointments can be purchased in most pharmacies.
  • Teach your child to sneeze through an open mouth (into the crook of the arm).
  • Teach your child not to put anything into their nose, including fingers and cotton applicators.
  • If nosebleeds seem to worsen with allergen exposure (pollens, molds, animal dander) your child may need a prescription nasal spray- please call for an appointment.

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties

2

Child Proofing Your Home: 21 Tips

By Jennifer Gruen, MD

By the age of six months you need to think very seriously about protecting your children from the world around them, before they become mobile explorers.

The best approach to childproofing is to think in terms of multiple barriers.

The first barrier between a child and any danger is generally you, always watching out of the corner of your eye. But that doesn’t always work- particularly with the distractions of ordinary life such as phones, computers, and other children.

Unfortunately, we cannot avoid such distractions, but we can create additional barriers. For example, a second barrier is to keep the door to a dangerous room closed at all times, and maybe locked.

But sometimes that might be left open. So, a third barrier is to keep the dangerous stuff high in a cabinet. But sometimes an older child will be visiting and might climb up there and offer that forbidden substance to your child. So, a fourth barrier is to keep it locked.

Most protective measures you will be able to figure out for yourselves with a trip to the childproofing section of ToysRUs, Target, or children’s store. Here are a few tips to get you thinking:

1. Get down on your hands and knees and crawl thru your home- you will get a child’s eye view of what is easy to access.

2. Use the “toilet paper roll rule”- if it fits thru the tube, it can be choked on.

3. Put all dangerous items (medicines, cleaning agents, knives, small choking hazards) up high- and preferably in a locked cabinet (remember your child will one day climb!)

4. Beware of where you put what you are drinking. Coffee cups belong far out of reach of toddlers. Pots on the stove should have their handles turned inward. If you have a party, don’t leave your drinks around afterwards .

5. DO NOT USE WALKERS-they allow children to access dangerous areas such as stairs.

6. Sharp objects, especially little ones such as toothpicks, are dangerous. Keep them well hidden, preferably locked and at a height.

7. Electrical outlet covers are essential- I prefer the kind that require you to insert a plug in partway, then turn to access the holes of the outlet. Plastic plug-in protectors are often easily removed by an adept toddler.

8. Keep electrical appliances such as blow dryers and toasters unplugged when not in use.

9. Never leave a child unattended in a bath, even for a minute.

10. All children should learn to swim by the age of five to seven; we also have brochures for a terrific water safety program for children as young as infants in the office. The more barriers between a pool and your child the better- think safety covers, pool alarms, and multiple fences at least 5 feet high.

11.Turn down your water heater, if you can, to a maximum temperature of 120 to 130 degrees. At these temperatures accidental water burns will be much less severe.

12.All stairs need two sets of gates- at the top and bottom. Gates at the top of stairs must be bolted to the wall, and have vertical slats so that a child cannot easily climb them.

13. Cut window-blind cords, or use safety tassels and inner cord stops so children can’t get entangled.

14. Lock stove knobs- keep kids from igniting stove burners by using protective appliance knob covers.

15. Hide all cords (electrical, computer, phone.)

16. Don’t use bumpers in the crib, nor have blankets or toys in there. Once a child can sit up, lower the mattress down to the lowest level. Once a child can climb out of the crib, take the side off to create a toddler bed, or put a mattress on the floor. Put a gate in the doorway to prevent wandering toddlers at night.

17. Secure furniture (bookcases, chest of drawers) that can topple to the wall.

18.Avoid choking foods for infants and toddlers, and never let your child wander while eating. Worst offenders: hot dogs, whole grapes, popcorn, dried fruits such as raisins, small candies.

19. Help older children store small items and toys in labeled bins that are put out of reach of toddler siblings- if they have their own room, allow them to gate it off from their younger sibs.

20.Put stickers with the poison control # on all phones: 1-800-532-2222. If you fear your child has ingested a poison, or taken too much of a medication, call poison control rather than the pediatrician- PC is much better equipped to calculate whether there is a need to seek medical help. Never give a child ipecac or any other liquid after an ingestion without calling poison control first. If your child appears to be in distress (difficulty breathing, choking, trouble swallowing, drooling) FIRST CALL 911, then poison control.

21. LEARN CPR. We can arrange for individual classes with our certified CPR instructor, or help you find a class.

With all these necessary precautions, we still have to strike a balance and leave our children room to wander. One of the best places to do this is in a controlled area- try to make one central room a safe place to explore, and a location where you can safely deposit your child should you need to run to the bathroom, or answer a call.

Fill your bottom kitchen cabinets with pots, pans, Tupperware and other items that your child can discover and play with. Let your child have adequate floortime to explore in a safe environment (walkers and exer-saucers actually delay a child’s walking !)

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.

4

Top Ten Newborn Questions, and Answers

Written by Jenn Gruen MD

1. Does my baby have a cold?

Many, if not most, newborns have a congested nose and frequent sneezing for the first month or so. Unless you see mucus coming from the nose, it’s usually not a cold. Unless your baby has difficulty with feeding due to nasal congestion, you do not have to use the nasal bulb syringe. In fact, if you use it frequently, you may irritate the nose linings and make the congestion last longer.

2. What about my newborn’s peeling skin?

It looks so dry—should I use lotion? This is normal – most newborns “peel like a snake” and this requires no treatment. If there is some cracking or excessive irritation around the ankles or wrists, you can lubricate with a little Vaseline or diaper ointment.

3. Should I worry if my baby is breathing funny?

Well, yes and no. Normal newborn breathing can seem strange. Sometimes they will stop breathing for a second or two and then breathe very quickly for several seconds. Sometimes they sound funny because they snort due to a congested nose (see #1).

Sometimes they make a high-pitched whistle when they breathe in due to a flexible windpipe (tracheomalacia). However, if you see very fast breathing (more than 70 times a minute) that persists, or if the baby has to work very hard to breathe, or you have worries about his or her breathing, don’t hesitate to contact us.

4. What if there is oozing or blood when the cord falls off?

A bit of yellowish wet gunk at the site of the cord that dries over a few days is normal, as long as the skin around the base of the cord remains normal color (if it becomes increasingly red, call us immediately).

You do not need to use alcohol. A few drops of blood on the diaper as the cord is falling off is also normal. If it bleeds a whole lot (which almost never happens), apply pressure to stop the bleeding and call us.

5. How many bowel movements are normal?

Breastfed newborns generally have 3 or more bowel movements per 24 hours by day 3 or 4. Formula fed infants generally have at least 1 bowel movement per 24 hours. But some infants can have up to 20 per day and still be normal! And normal breastfed newborn stool is extremely loose.

In an adult, this would be called diarrhea, but it is normal for a newborn. Formula fed stool tends to be more pasty. Any color from bright yellow to green to brown is normal. By age 3 to 6 weeks, the frequency of stool decreases (even once a week for a breastfed infant at this age can be normal as long as it is soft and passes easily).

6. Is the discharge from my baby girl’s vagina normal?

Yes, it may be clear, white or bloody, and it is from withdrawal from the mother’s hormones. You don’t have to wipe it away, but you can if you want to (top to bottom).

7. Is it normal for my nipples to hurt (for breastfeeding mothers)?

It is normal in the first week to have pain for the first 1-2 seconds of latch on, but if you have pain in the nipples beyond the first second or two, ask us about it.

8. Can my baby see me?

Baby’s sharpest vision is the distance from the breast to the face. Babies recognize their mother’s faces within a short time after birth. They can identify their mother’s breastmilk smell immediately, and will recognize the voices (and soon the faces) of close family that they heard talking while in the womb, like fathers or siblings.

9. Is it normal that my baby lost weight after birth?

Yes, most babies lose weight after birth and this is normal. We will tell you if we are concerned that the weight loss is too much.

10. When should my next appointment be?

Usually 1-2 days after you leave the hospital, we would like to see you back in the office to check your baby’s weight, color, and heart.

If your baby has a fever more than 100.4 rectally (only take temperature if baby seems warmer than usual), is irritable, lethargic or not feeding well, call right away. If your baby seems yellow other than the eyes/gums/face (i.e. chest/abdomen/legs), call us during office hours. Also call during the day if your infant is not having normal stool (see #5).

Have your baby sleep on the back or side. Make sure that your car seat is correctly installed and used, call 1-866-SEATCHECK or go to seatcheck.org for a free car seat checkpoint near you.

CONGRATULATIONS! ENJOY YOUR BABY

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.

1

Fall Colds: What To Do, And When To Take Your Child To The Pediatrician

Written by Jennifer Gruen MD

The fall cold and cough season seems to be in full swing. The ragweed pollen and mold in the air is also causing a lot of congestion and cough symptoms. Below are a few hints on how to make your child feel better, and when you need to bring them in for a visit:

 What constitutes a common cold?

  • Runny nose, mild cough, sore throat, decreased appetite, occasionally low grade fever (<101.)
  • Children can have 7-10 colds in one season, particularly the first year they are in any sort of a daycare or school setting.
  • Colds are most contagious in the first two days – usually accompanied by a clear runny nose.
  • The change in color of the mucous to yellow or green after 5-7 days (in the absence of fever or headache) usually signifies the end of the cold and will be gone in 2-3 days. Green noses don’t automatically need antibiotics!

Is it an allergy or a cold?

Visit this link to read more on the diagnosis and treatment of allergy symptoms.

What will help?

For children under one use nasal saline, bulb syringe, elevating mattress (put rolled up towels underneath the head of the mattress) or allowing to sleep in car seat if they can breathe more easily this way. Use nasal saline drops, with suctioning only if there is a lot of loose mucous, before feeding and sleeping. A warm bath will help bring break up the mucous.

For children 1-3, nasal saline washes may help (try Simply Saline or the NeilMed sinus rinse for children). A trial of Benadryl may be necessary to relieve congestion. (click here for dosage information.) It is especially helpful at night if cough is interrupting sleep.

For older children (>4) with congeston try mint tea with 1 teaspoon of sugar or honey to soothe sore throats and help break up congestion. For difficulty breathing through nose at night try Breathe Right strips for children. (Dr. Nikki loves them!) For persistent nighttime cough try humidifier, elevation and possibly Benadryl. Other cough syrups that we have found help include Delsym and long acting single ingredient dextromethorphan preparations.

“Just a spoonful of sugar….”- sucking on a lollipop or a teaspoon of honey has been shown to decrease sore throat as much as cough medicines. Tylenol or motrin is appropriate for fever or sore throat, but doesn’t work for cough.

When to worry?

  • Any fever >100.4 in infants less than 6 months old – call for an appointment
  • Fever for greater than 3 days in any age child
  • Fussiness, not eating well, pulling on ears, breathing quickly or pulling in at ribs when breathing.
  • Green, yellow nasal discharge that is accompanied by fever, headache, sinus pressure or that persists more than 5-7 days.
  • Drainage out of ear canals.
  • A cold that persists longer than 2 weeks, or that after several days is suddenly accompanied by a fever.
Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.
1

New Year’s Resolutions in October?

Written by Jennifer Gruen MD

Most people make resolutions on New Year’s, but I find winter too depressing to embark on ambitious, life changing projects. Instead, I view October as a chance to work on change. It is a good time for kids to try a new sport or set goals for school, and for parents to resolve to change the way they approach the new school year.

Resolutions are notoriously hard to stick to. Remember to make your goals POSITIVE. State what you WILL do, not what you won’t do… “I will eat fruit for dessert 5 days a week,” instead of “I will eat less candy.” Make your goals specific, as in “I will run 30 minutes a day, 5 days a week,” instead of “I will exercise more.” And make goals measurable- “I will do an outdoor activity with the kids 20 minutes a day,” instead of “I will get the kids outside more.” Set end dates when possible- “I will organize my closet by next Saturday.” This approach works better for children too: they can make a chart and visually document their progress in areas such as reading, exercise, or eating more fruits and vegetables. Build in positive rewards such as special trips or choosing a meal.

Perhaps your family has overindulged on ice cream at the beach this summer. Fall is a good time to reassess your children’s eating habits and make simple, step-wise changes in what they consume. Make a single change at a time. First, cut out juices and sweetened drinks. The next week introduce whole grain breads and pastas. The third week show your kids how to fill half their plates with fruits and vegetables at each meal. Resolve to pack a healthy lunch for school or work once a week. Then twice. Swap out the potato chips for dried fruit chips. Allow your kids chocolate milk once a week rather than everyday. Change your family’s milk jug from whole milk, to 2%, to 1%, and then skim- do it over time, cover the label, and they won’t notice the change.

Is your child spending too much time inside playing video games? Brainstorm ways to get them outside and moving. Be creative- if your child doesn’t want to do a team sport (or you would rather not spend a lot of money on classes or time driving there) challenge her to run around the house a few times, and see how many more rounds she can do each day. How many continuous jumps can he do with a jump-rope? How many hoops can she shoot without missing? The more interesting the activity, the more it will engage and challenge your child. My son hates playing soccer, but will do the same running around outside pretending to be Harry Potter playing Quidditch with his friends. A few hoops on sticks and we had a field!

The key to making all these resolutions work is making changes small and steady. How many pledges to lose 25 pounds in the New Year work? Aiming for a 5 (or even 1) pound weight loss is much more achievable, and avoids the feeling of failure that dooms many a diet. These small changes are also more likely to persist, and your whole family will feel a sense of accomplishment long before 2012 rolls around!

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.

Does My Child Need Vitamins?

By Jennifer Gruen, MD

This is one of our most commonly asked questions at well-child checkups.

Vitamins and minerals are important elements of the total nutritional require­ments of your child. Because the human body itself is unable to produce ade­quate amounts of many vitamins, they must be obtained from the diet. The body needs these vitamins in only tiny amounts, and in a balanced diet they are usually present in sufficient quantities in the foods your youngster eats.

Breast fed infants need vitamin D supplementation until they are able to eat foods containing at least 400 IU of vitamin D a day. Children in homes with well water may need a fluoride supplement to support dental health — ask your dentist or us for a prescription if your child does not consume fluoridated water elsewhere, such as school or daycare. Otherwise, in middle childhood, supplements are rarely needed.

For some youngsters, however, we may recommend a daily sup­plement. If your child has a poor appetite or erratic eating habits, or if she con­sumes a highly selective diet (such as a vegetarian diet containing no dairy products), a vitamin supplement should be considered.

These over-the-counter supplements are generally safe; nonetheless, they are drugs. If taken in excessive amounts (in tablets, capsules, or combined with other supplements), some supplements — particularly the fat-soluble vita­mins (A, D, E, and K) — can be toxic. Scientists are finding that in some special situations and diseases, vitamin supplementation can be an important con­tributor to health.

However, so-called megavitamin therapy or orthomolecular medicine — in which vitamins are given in extremely large doses for conditions ranging from autism to hyperactivity to dyslexia — has no proven scientific validity and may pose some risks. Vitamin C, for example, when consumed in megadoses in hopes of undermining a cold, can sometimes cause headaches, diarrhea, nausea, and cramps.

As much as possible, try to maximize the vitamins your child receives in her regular meals. Click here to read more about some of the vitamins and minerals necessary for normally growing children, vitamin rich foods and recommendations for specific supplements.

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.

2

Is Bigger Better? Considering A Hybrid-Concierge Model

Written by: Jennifer Gruen MD

In today’s medical practice environment, many will argue that the bigger the practice the better.  Better to pool resources, share call responsibilities, disperse the ever-increasing costs of technology and office staffing.

But what if you like small?  What if you went into medicine dreaming of knowing all your patients by name, being a part of their lives beyond the few minutes of their yearly physical, having time to chat about those Yankees instead of rushing off to the next, and the next, room…

My business partner and I were those dreamers.  We had each spent years at large pediatric practices- well run for sure, but not professionally satisfying for our personal needs.  We met working as associates for a small “country doc”, who operated a low volume pediatric practice in the suburbs of Connecticut, making ends meet by working out of a home office, and pretty much operating in the red until the day he retired.  Clearly not a business model we wanted to adopt.

Add the fact that we both wanted to work “part-time” (we each put in 3 office days a week- many more hours at night on the business, but at least we have daytime hours to spend on household needs and kids.)

We spent a long time debating how to set up our own practice, reading SOAPM posts religiously for any helpful hints.  We debated becoming a concierge practice, fee-for-service/no-insurance or hybrid concierge model.  What we settled on was a pleasing mix that has sustained a growing practice in the 2 ½ years we have been open.

We settled on a few basic ideas- first, we would limit insurance to a few select plans that paid appropriately for our services.  Given our history with a variety of insurance companies, Oxford/United was never considered.  We would rather see one better paying plan X patient for a relaxed visit, than jam in two patients with plans that paid half of X’s rate.  Many of our patients on Oxford/United still elect to see us out of network for our service.  Second, we agreed that we would accept a small number of managed medicaid patients- we had a dedicated group of wonderful patients with this plan, and we were willing to sacrifice some income to continue serving these families.

We started out as a 2 person partnership, with a goal of adding a third, but no more than that.  This rubbed my business minded husband the wrong way- why not expand if you are growing and successful?  For a few simple reasons- we never wanted to be so large that we couldn’t each know the majority of our families by name.  We had also agreed not to use an after-hours telephone triage service, and that meant limiting patient number to limit phone calls to a reasonable amount.  Three docs meant every third weekend on call- not so onerous if our small practice generated only a few weekend visits sandwiched between our kids’ soccer games and birthday parties.  The stress of seeing 40-60 patients on a Saturday in my previous practice would ruin those weekends for me, even if I was on-call fewer weekends out of the year.

Most importantly, we decided early on to charge a mandatory “added benefits” fee- a modest per child charge to cover the many and varied uncovered costs of practicing medicine.  This was a lesser voluntary fee initially- promoted to the patients as a way of prepaying for multiple school and camp forms, and helping subsidize our somewhat unique (for the area) practice of not using after-hours nurse triage.  After a year, it became clear that we were providing these services for all patients though only a minority opted to prepay.  Also, by now these patients were well-acqainted with our quality of service, and word was beginning to spread.  We decided to limit our practice numbers, typically seeing 20-25 patients at most during an average day.  To make this financially feasible, we instituted our mandatory benefits fee, careful to be clear that it was for “uncovered fees” such as ACCESS to the physicians after hours (not the phone calls themselves, which we could rarely charge for anyway as those were usually related to a past visit, or resulted in a visit the next day.)  Also included are unlimited camp/school forms.

But underlying this charge was the emphasis on it allowing patients to experience convenient, personalized and unhurried medicine- something commercial insurance plans would never be able to cover.  Note that we live in an upscale area of Connecticut, making this fee affordable to most.  Our patients, in fact, draw from across the economic spectrum.  Very few objected to the fee, even fewer left the practice because of it.  Several have returned. Patients new to the practice accept the fee generally without question, often knowing what they will receive is priceless- that extra few minutes in the room with a physician, and many fewer minutes out in the waiting room with a sick child.  Time is money to many.

We waive the fee for parents with significant financial difficulties.  Because we tend to know our families well, we know when a parent has lost a job or is ill, placing financial strain on the family.

So is smaller better?  No, just different.  And better for me and my preferences.  Better seeing those 60 weekend patients spread out over 10 weekends instead of just one, making weekend call a quick trip to the office between gymnastics drop off and grocery shopping, an evening on call a message or two between dinner and homework help instead of in my office on the phone continuously between 6 and 12 pm while my husband handles the kids on his own.  And by charging the added benefits fee, I feel better knowing I am in some way compensated more appropriately for all the little extras I do for my patients day in and day out (and nights too….)

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.