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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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Why Feeding Your Child With A Spoon Is Better For Her Development

Written by Jesse Hackell MD

messy face2

Growing up in the sixties, outer space was truly the final frontier. We greedily devoured all sorts of arcane facts about the nascent space program, from the rigors of pre-flight training to the seemingly more mundane details of how, exactly, one managed to eat and drink in the zero-gravity confines of outer space.

We knew that the astronauts drank Tang, which no self-respecting parent today would ever mistake for fresh-squeezed, locally sourced, organic and pesticide-free orange juice.

And astronaut foods were freeze-dried, and provided in pouches. When water was added to the pouches, the food was rehydrated and reconstituted, and the space explorers “ate” by sucking the resulting slurry out of the mouthpiece of the pouch.

Fast forward fifty years, and pouches aren’t just for astronauts any more. All sorts of fruits, vegetables and combinations thereof, in flavors which would certainly have thrilled early spacemen, are now seemingly the food deliver mechanism of choice for today’s on the move infants and toddlers.

No longer does feeding your baby on the go require a high chair, bib, bowl, spoon and yards of paper towels for clean-up.

Just pop off the top (don’t hand the top to the baby, although the caps are ingeniously designed to prevent choking should the little one happen to get hold of it and have it lodge in the airway), hand the pouch to your child, and–slurp–4 ounces of highest quality, organic produce goes down the hatch.

That’s progress, no? One prediction of the future made in the sixties actually coming true in the twenty-first century!

But I am not so sure that this new feeding mechanism actually represents progress for babies. They are born knowing how to suck nutrition out of a “container”–breast or bottle.

Progress in feeding, for an infant, comes not only in learning about new tastes and textures, but also in learning about new, more mature means of getting their comestibles out of the container and into their mouths.

These pouches (along with so called “sippy cups” with spouts) are really just bottles in disguise. (They are also a whole lot more expensive than either store-bought jars or homemade baby foods.) We do not generally recommend putting puréed foods in baby’s bottle, so why create a new bottle substitute?

Let me make a plea for a return to the older, admittedly messier, mealtime, with the baby sitting upright, wearing a bib, and being fed with a spoon. It will encourage the baby to learn new mouth movements and new positions for eating. And it will provide lots of opportunities for those adorable, messy face baby photographs!

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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Why would a six-month old infant still need to be fed every four hours through the middle of the night?

Written by Jesse Hackell MD

Ah, yes, one of the most vexing new-parent questions, brought on by, yes, six months of interrupted sleep, daytime drowsiness and increasing irritability.

Why, indeed?

The answer is that it is usually a habit engendered in the infant, learned by the repeated feedings that he or she has received at all hours of the night. But how, and when, can this habit be broken?

Remember, first, that no one—not the parent, not the doctor not the grandmother—can determine when and how much a baby needs to eat.

Only the baby knows that for sure, based on the body’s need for growth and maintenance. And worst of all, those needs are not the same every day—a baby’s growth is not the same from day to day, nor is his energy expenditure.

But nature built in a wonderful system for appetite control—if given access to food throughout the day, an infant will eat what he needs, and then stop. Healthy babies do not starve themselves; neither do they overeat, unless they have been taught to do so by repeatedly being fed when they are not asking to be.

Think of a baby’s nutrition needs—for protein and calories, mainly– in terms of a 24 hour day.

Based on internal signals, the baby will require a certain amount of nutrients during each 24 hour period. If you feed the baby every four hours by the clock, the baby will essentially divide these needs into six portions, and eat one portion at each feeding time—which might well lead to one or more middle-of-the-night feedings.

But if the baby gets larger feedings during the daylight hours, her needs will have been met by bedtime, and there will not be the same signals prompting eating during the wee hours.

This will not occur instantly, however. In order to prompt the baby to eat more during the day, he needs to be hungrier than usual for those daytime feedings. So the first step should be to begin skipping the early morning feeding, and allowing the child to cry himself back to sleep. Then when he wakes a few hours later, he will be ravenous, and eat more than usual—which in turn will lead to a longer break before the next feed, a hungrier baby again, and greater intake through the day.

Then on the following night, secure in the knowledge that your child has taken more food than usual that day, the tired and sleep-deprived parent can be comfortable forgoing the nighttime feeding yet again. And with a small amount of manipulation, voila—your baby has given up the middle-of-the-night chowdowns.

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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Top 10 Pediatric Post of 2011

We had some really great post this year. But only 10 made it to the top. Below are our TOP 10 post of 2011.  Hope you enjoyed them as much as we enjoyed writing them.

  1. Why Can’t Pediatricians Prescribe Medicine Over the Phone?
  2. If a patient can charge for her time, why can’t the doctor charge for his?
  3. She has a fever, her temperature is 99.2. Is It Normal?
  4. Michele Bachmann Is Not a Doctor (she reveals), But Pediatricians Are
  5. What I Wish Parents Knew About Medical Billing
  6. Things Your Mother Told You That Were Wrong
  7. In Defense of Cough
  8. Six Reasons You May Want to Bring Your Child to the Pediatrician’s Office Instead of a Retail Based Clinic
  9. Are High Fevers in Children Dangerous?
  10. What is the most important thing I can do to make sure my child is as healthy as possible?

Well, there you have them. Do you have a favorite one? We’d love to hear your thoughts.

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Contagious Diseases and Siblings

Written by Jesse Hackell MD

In the fall of 1957, the Asian influenza pandemic was spreading across the country. My younger sister had just been diagnosed with that flu, and my grandmother had arrived shortly thereafter to help at our home when my mother entered the hospital to give birth to another sister. In those days, one could count of a solid seven days in the maternity hospital, even for an uncomplicated delivery.

Knowing the extremely contagious nature of the flu (she had lived through the devastating influenza pandemic of 1918), my grandmother set out with every weapon known to modern grandmotherhood to prevent my father and me from getting sick, fearing the consequences for my mother and newborn sister. With isolation, chicken soup and constant scrubbing and disinfecting, my father and I were spared the disease, as were my mother and sister, and, as long as she lived, my grandmother delighted in telling the story of how she confounded the pediatrician who had predicted that we would all very soon be ill.

Flash forward fifty-four years to 2011. What are the risks to siblings today when one member of a family contracts a communicable disease, and how should we respond? I think that the answer depends on many factors, one of which concerns the nature of the particular illness that one person has contracted.

Viral Illnesses

Some viral illnesses are highly contagious, even without direct contact. Certainly chicken pox and measles used to spread through families like wildfires, but immunization has largely reduced the occurrence of these diseases, primarily by greatly reducing the amount of disease in circulation, and, further, by producing immunity in children who might somehow be exposed. The same goes for influenza, the bane of my grandmother; since universal influenza immunization was recommended a few years ago, the burden of disease has been reduced, although not as much as it could be if everyone actually did get their flu shots.

Contagious Illnesses

How about other types of infectious, contagious illnesses? The common cold is just that, common, and most people will suffer one or multiple episodes each year. Unfortunately, there is no effective preventive immunization, and it does tend to spread readily; fortunately, it tends, in most people, to be relatively  mild and of short duration.

Strep Throat

Strep throat is another common contagious illness, especially in children. There certainly are families where multiple members will get strep in close temporal relationship to each other, and these may be the result of spread within the family.

But it is also possible that multiple family members were exposed at school or work, and contracted the illness elsewhere.  But strep is harder to spread than some of the illnesses discussed previously, and there are many cases where one family member gets it, and no one else becomes sick. This is one illness where good handwashing, and avoidance of sharing of food, utensils and so on, can be a useful preventive measure.

Infectious Mononucleosis

The same can be said for infectious mononucleosis–“mono,” also known as the “kissing disease,” primarily for its reputation as a common occurrence during adolescence. Yet in most of the families where one child has mono, it is very uncommon for other siblings to also contract it. Thus simply sharing a room, or time at the dinner table, is generally not enough to transmit an illness like mono.

Pneumonia

Pneumonia in children is also common, and the vast majority of cases are viral in origin–and they are often caused by the same viruses which cause the common cold. I tend to think of most cases of pneumonia as “a common infection in an uncommon place,” and generally feel that, while another member of a family might catch the same virus, it is far less likely to be caught as pneumonia. Rather, it might cause a head cold, sore throat or ear infection in someone else.

So why does this matter?

Rare is the day which goes by that I am not asked a question like “his brother has strep (or pneumonia of the flu or…), so why can’t you just treat all my kids for it without having to see them?” In response, it is important to point out that every person who gets a fever after being in contact with someone who has strep is far from guaranteed to have strep as the cause of that fever; most illnesses are just not that contagious, and most fevers require individual evaluation regardless of the person’s exposure.

The same thinking goes into my response to the schools who send home notices every time someone in a class is diagnosed with strep, ostensibly warning parents to be on the lookout for strep in their children. About the only thing these notices accomplish is the wasting of paper.

I would far prefer that parents react to each of their children’s illnesses in a vacuum, paying no attention to what the child might have been exposed to (assuming, of course, that the child has been fully immunized, thus pretty effectively–but not 100% completely– ruling out those preventable illnesses as a cause of the fever.)

What to do when your child is ill

When your child is ill, pay more attention to how he or she is acting, how sick he or she appears, and how well the illness is being handled by the child, than to what diseases he or she might have been exposed to.  Discussing that information with your pediatrician will enable you to better decide what y our next course of action should be for evaluating the illness in that child.

 

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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How to get your child to eat vegetables

Written by Jesse Hackell MD

Let me start by saying that I am not of the belief that the job of a parent is to FORCE a child to eat any particular food. Attempts to do so usually result in mealtimes which are unpleasant and stressful for both parents and children, and negate any attempts to have family meal times as a time of sharing and interaction.

That said, we all know that children are often picky in their accepted food choices, and that they do not always cooperate in eating the variety and selection of foods which we, as parents and physicians, would like. There is no dispute that a child’s diet should include fruits and vegetables, for many reasons: These foods provide vitamins lacking in other foods, they contain fiber which is needed for normal intestinal function, and they are generally lower in calories than processed foods, while still providing the same feelings of fullness, and thus may help to change the continuing trend towards childhood obesity.

Getting your child to accept and eat vegetables is a lifelong process, starting when the very first foods other than breast milk or formula are presented (it could even be suggested that breast-fed infants are introduced to vegetables through the maternal diet, knowing as we do that maternal intake does contribute to the taste and quality of the milk, but that is a different topic.)

There has recently been a change in what is recommended as first foods for infants. In the past, processed single grain cereals were the starting food, followed by the addition of vegetables and fruits. Now, however, researchers believe that the order in which foods are introduced to an infant makes little difference in eventual food tolerance. Thus it would make sense to introduce a child to foods such as vegetables which are both less processed and less sweet than other foods, and to let the child learn that these tastes (and some vegetables certainly do have strong flavors!) are just a natural part of eating. Adding whole grain baby cereals, as opposed to processed white cereals, further introduces stronger flavors, and makes them a part of the child’s diet from the start, and might well lead to better acceptance in the future.

As your child gets older, individual preferences become stronger. We can hope that early exposure might make this transition a non-issue, but that is not always the case. So we need to have techniques to make vegetables more palatable to toddlers and older children as well.

Many vegetables benefit from brief cooking, which softens them and make them more readily manageable by toddlers. Offering cooked or frozen and reheated pieces of many vegetables, such as carrots, will make them easy to handle for your children from their first attempts at self-feeding. And the nutritional value of these vegetables is far greater than the ubiquitous “puffs” of carbohydrates so often given to young children. Later, cooked and cooled broccoli spears, asparagus and carrots can be offered as a snack. Some children like to “dip” their vegetables in some sort of sauce, and I would suggest the use of plain balsamic vinegar as opposed to the common ranch dressing, which has far more fat and calories. For a child who will not eat a traditional tossed salad, vegetables and dip is a good prelude to dinner, and often can satisfy a hungry child home from school or play for long enough to enable the entire family to eat dinner together.

I do not believe that we need to “trick” our children, or disguise vegetables so they do not know that they are eating them, as so many people (such as “The Sneaky Chef”) are advocating. Nonetheless, common foods can and should be made with added vegetables, to benefit every member of the family. One favorite includes the use of vegetables in any dish made from ground meat—meat loaf, burgers, tacos or meatballs, for example. Using one pound of any ground meat (beef, veal, pork or turkey), take one cup of shredded carrots, one cup of shredded broccoli stalks (having steamed and cooled the florets for use with a dip), and one cup of shredded onion. Saute these in a little olive oil til soft, and mix with the meat, adding an egg if desired to hold things together. Add some bread crumbs, or even better, some rolled oats (not the instant variety), to add soluble fiber and beta glucans, which are thought to help control cholesterol, and form into a loaf, patties or balls, and cook as usual. The vegetables add moisture to the meat, as well as fiber to the diet, and they make the meat stretch further. You can also use chopped spinach or chopped artichoke hearts, which do not even need sautéing. Top with a tomato sauce, also prepared with added vegetables, for even more benefits.

I think the key here is to start doing this from the very first time your child eats these foods. Get them used to the fact that meatloaf simply has these flecks of orange and green in it, and they will not question the presence of the vegetables when they find them. If it becomes second nature for you to incorporate vegetables in everything you prepare, it will become second nature for your children to eat them as well.

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Why does my child need to have a physical exam every year?

Written by Jesse Hackell MD

This is a question I am asked several times each year, especially during the annual rush to get overdue physical exams done in the weeks before the start of the school year. A large part of pediatric practice is, indeed, devoted to regular physical exams (and well child exams in the early years.)

What is it, exactly, that makes them such a necessary part of pediatric medical care?

School Requirements

One obvious answer is that these exams are required by one authority or another. Schools require physicals at certain grade levels, as defined by each state’s education law. Participation in school sports, in most states, also requires an examination and health history review, at least every twelve months (if not more often.) Summer camps, employment and working papers and other extra-curricular programs may also demand a physical exam for participation. The value of these exams is clear: If you want to participate, you must have an exam.

 In Search of Abnormalities

Outside of these mandated exams, however, why do we do annual exams when we most often do not find any physical abnormality? Abnormalities are, fortunately, rare in the pediatric population. But hernias, tumors, heart disease, abnormal growth patterns suggesting inflammatory bowel disease or endocrine abnormalities—they all do occur in pediatrics, and I have found all of them, more than once, during my career. Sure, these things would eventually manifest themselves, and prompt a visit for evaluation, but with regular examinations, they can often be found earlier, before they have had a chance to cause significant distress or dysfunction.

Healthy Eating Habits

Poor eating habits are all too common in children today. Obesity rates continue to rise, and while this may not cause an immediate health problem, difficulties are ahead for the child who does not bring his or her obesity under control. The opposite problem is also increasingly common: Eating disorders manifest themselves in adolescence, sometimes as early as nine or ten years of age, with anorexia and bulimia. These, too, can have life-long effects on the health of a child, and often the manifestations will be apparent on a regular annual exam well before severe wasting and weight loss which would otherwise bring a child to medical attention. Both obesity and eating disorders are very difficult to treat, but early diagnosis and intervention may make this treatment process easier.

Invisible Diseases

These are conditions which can have a very significant effect on a child’s well-being, yet not be manifested in a way which calls the parents’ attention to them. Depression, anxiety, peer relationship problems and ADHD may be having a major impact on a child’s life, and yet not be obvious to those closest to that child. These problems may be picked up simply by observing a child’s demeanor, or during the confidential discussion that we like to have with our patients as soon as they are ready and comfortable to do so. Even though we will not violate a child’s confidence, we can often help to provide a way for a child to discuss troubling issues with his or her parents, and enable the child to see that there are adults available to help him or her through any difficult times.

Behaviors

Finally, the annual exam gives the pediatrician a chance to address behaviors in the adolescent which may pose significant risks to health or well-being. Sexual behavior and substance abuse problems are questions we try to address with our patients. We hope to be able to provide guidance as the adolescent navigates through the minefields which are a normal part of growing up.

Pediatricians Know Your Child

One of the best things about pediatrics is the opportunity that we pediatricians have to know your child on a long-term basis, from infancy through young adulthood, and to watch that child grow and progress through many stages of life. Besides the enjoyment that many of us derive from this type of relationship, we also have the chance to monitor this growth and development, and be aware of any difficulties which may be occurring along the way. The annual physical exam gives us a chance to touch base with your child, and observe and monitor for any potentially harmful deviations from the normal developmental path. It gives us a chance as well to reassure both the child and the parent when things are going well, and suggest intervention when they are not.

My colleague Dr. Richard Lander has discussed why your child would be better served by seeking medical care in your pediatrician’s office rather than in a retail-based clinic. While many of these clinics may even claim to do “physical examinations,” and may seem to be very convenient in order to get that physical for the school sports team, these clinics do not have your child’s history at hand, may not have his or her immunization record available in order to provide any needed immunizations, and do not have the long history that many of us have with our patients. While they may be able to check off the proper box to qualify your child to play a sport, that clearance is only a small part of the value of the annual physical exam, as provided at your child’s medical home, your pediatrician’s office.

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.