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Daily Dose

When Your Child Has RSV

Dr. Sue discusses what a parent can do if their baby has RSV, pneumonia and a double ear infection.I received a question from Brooke (via our new iPhone App). Her six month old has RSV, pneumonia and a double ear infection.

As we discussed yesterday, it is RSV season and children under one year of age seem to have the greatest problem handling the virus. It is not uncommon for a young child to develop an ear infection after developing RSV, and secondary pneumonias are also a problem . Unfortunately, there is not a vaccine to prevent RSV infection and only high risk infants are eligible to receive Synagis (a monoclonal antibody against RSV) to help prevent serious infection. The treatment for RSV is also supportive, with IV fluids and supplemental oxygen used for hospitalized infants. The use of bronchodilators and steroids has been controversial, and does not seem to be therapeutic. Antibiotics are used for secondary ear infections. Younger children have a higher incidence of secondary problems. There is not a “perfect” way to prevent RSV, but limiting your baby’s exposure to other children (daycare, public places) and to make sure that no one smokes around your child is helpful. The older your child is when they develop RSV (about 80% of children by 1 year of age) typically makes it easier for them to handle the virus.  Unfortunately, you can get  RSV more than once during RSV season. The season usually ends about April, so we are getting closer! That's your daily dose for today. We'll chat again tomorrow!

Daily Dose

RSV is Here

1:15 to read

RSV (respiratory syncytial virus) is here and seems to be hitting hard this year. RSV causes 64 million upper respiratory infections worldwide each year and some days it seems that every child in Dallas/Ft. Worth under the age of 2 has RSV. While there is has not been a lot of flu reported to date, RSV is being widely reported across the U.S. so I am sure your pediatrician’s office is busy as well. RSV season usually lasts until spring, so there are more weeks ahead.

RSV is a pesky virus and for most people causes symptoms of a “common cold”. Lots of congestion, runny nose, fever and a cough.  Bothersome, but not life threatening. But for some, especially those under 2 years of age, and for children with underlying medical conditions such as prematurity, heart disease, lung problems and other chronic medical issues, RSV may be more severe. While almost everyone under the age of 2 acquires RSV, 25-40 % may go on to develop wheezing and an illness known as bronchiolitis. In some cases RSV causes respiratory distress and a baby/child may need to be hospitalized for supportive care including oxygen…and in really severe cases an occasional child may require ventilatory support in the intensive care unit.

The local news in our area has been reporting that the ERs and hospitals are overwhelmed.  So what do you need to know about the course of RSV and when do you need to go to the doctor or ER? In a young child the illness starts off with a runny nose and congestion, but may progress to a frequent cough and wheezing.  While most children are uncomfortable and cranky, they handle the virus without any noticeable difficulty with their breathing. But, some children will develop signs of respiratory distress where their breathing is rapid, short and their chest wall pulls in and out (retractions) and their tummies move up and down with each breath. This is called “working to breath” and are signs of respiratory distress….which requires immediate medical care.

You also need to watch your child’s color…as some babies and children may turn dusky blue when coughing.  Most parents complain that their child turns bright red when they cough, but while some babies may only have a bit of a cough they may turn blue when they cough or even seem to gasp. Red is good, your child is oxygenating, but blue is bad! This is another reason to seek immediate care.

Lastly, make sure that your child stays hydrated….so if they have a good moist mouth, drool, tears and wet diapers (may not be soaking) you are keeping up with their fluid needs.  This is important as your baby/child will probably not nurse or take a bottle or fluids as well when they are sick .

Because RSV is a virus it is NOT treated with antibiotics. While there is a test to identify RSV it is not routinely recommended, as the treatment is symptomatic. The test may be run in certain situations when a child is hospitalized. Simple treatments such as suctioning your child’s nose, using a cool mist humidifier and treating fever with acetaminophen or ibuprofen (depending on their age) are all helpful As always, call your doctor if you have questions or concerns. 

What’s on the horizon…hopefully a vaccine one day!

Daily Dose

Treating RSV

If only there was a vaccine for RSV everyone would be happier.Last thoughts about RSV and the VIRUS that seems to spread like a wildfire in California. If only there was a vaccine for RSV everyone would be happier. Unfortunately that is not on the near horizon and we will continue to see RSV in doctor's offices and hospitals every winter.

Babies who were born prematurely, or who have underlying cardiac defects, or lung problems may meet criteria (check with your doctor about specifics) to receive RSV immune globulin, which is called Synagis, during the winter months. By now you should know if your your-baby fits that description, as this is a shot that is given monthly to help prevent RSV in high risk babies, or at least lessen their symptoms if they acquire the virus. This shot is expensive and unfortunately is not given routinely. As the name implies RSV is a virus and therefore does not respond to antibiotics. It really doesn't seem to respond to much except supportive care, and tincture of time. Numerous studies have been done about using steroids, bronchodilators and other medication for treating RSV and most show that these drugs do not help speed the recovery from RSV. When parents feel baffled as to "why can't you do something to make my your-baby better", I explain that we can support them with oxygen if necessary, and even with intubation and mechanical ventilation for the most seriously ill. But even then, we just wait for the your-baby's lungs to get better. Being in the hospital does not provide immediate recovery, there is still a lot of wait and see how quickly the virus decides to go "away". The other worry with RSV is dehydration. As with any illness these children don't really feel like eating as well, and on top of that they are coughing and having trouble breathing. RSV also causes a huge amount of secretions and fluid loss that way too. It is important that your your-baby eat enough to continue to have the drool, watery eyes and nose and wet diapers. That may require feeding them more frequently as they may take less at each feeding (think how you feel when you are sick, not much appetite). If you think your your-baby is not getting enough fluid and has a dry mouth or decreased urinary output, even if they are not having respiratory distress you need to call the doctor. Lastly, RSV seems to peak each year before flu and for some reason as RSV diminishes influenza rises. If your your-baby is six months or older, make sure you are getting their flu shots NOW! That's your daily dose, we'll chat again soon.

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Got a Virus? Treat it with TLC

1.30 to read

I was on call this week and I think I saw “a million” kids with colds!

Everyone, from 3 months – 20 years, seemed to have runny/congested noses and coughs.  Interspersed with all of these colds were a lot of wheezing kids too, as these winter viral upper respiratory infections will trigger a lot of wheezing in very young children or those with asthma. Thankfully, none of them were “very” sick.

We have all been fortunate this year as most of the country is not seeing much flu, and I have my fingers crossed that this trend will continue!  Flu will usually make children (as well as adults) much sicker than these upper respiratory viruses.

Parent after parent kept asking me, “what is causing all of this?” “ If not flu, then what?”  Well, I can tell you that we are seeing RSV, rhinoviruses, para-influenza virus and metapneumovirus, just to name a few.

Unfortunately, there is not “a magic treatment” to cure these viral infections. With that being said, the treatment is entirely symptomatic. In other words, treat the symptoms with fluids, fever reducing meds if needed, rest, cool mist humidifiers, hot steamy showers, chicken noodle soup, and anything else that makes the symptoms seem to improve. (I am currently into ginger tea for my sore throat.)

So, after explaining viral infections and treatments, I often end the discussion with, “your child just needs some TLC”.  Well, I know I have said before that many of my “young” parents were not quite clear what TLC stood for. But this weekend I really had to laugh!

As I explained colds and symptomatic treatment to a mother with a 2 year old I told her to try a little TLC.  She looked at me slightly puzzled and said, “I have to go to THE LEARNING CHANNEL to find out what to do for this cold?”  “Do they have shows about treating colds?”

Just another reminder that not everyone knows the same acronyms! I just laughed (LOL) and told her that I meant Tender Loving Care and that she did not have to search her TV guide for treatment of colds!

I’m on call again next weekend, so be prepared for a few more funny stories as I tend to get a bit slap happy after being sleep deprived.

That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

'Tis the Season for RSV

RSV, those three letters bring a lot of concern to families with young children. RSV, which stands for respiratory syncitial virus, causes winter colds and in babies may cause bronchiolitis. This is a condition of the lower respiratory tract that will cause thousands of infants to wheeze this winter, and is especially serious in younger infants and those babies who may have other underlying problems. RSV has been around for a long time, but due to the internet, school notices and mother's communication, RSV is now a common topic of discussion among the parent groups.

It is not unusual for me to be asked by a mother, "do you think this is RSV" before I have even finished examining a your-baby. Until about three years ago, I almost always started that discussion; they now beat me to it. The information era is impressive. The interesting thing about RSV is that about 70 - 80% of children will develop RSV antibodies in the first year of life, which means that they have had RSV. The majority will only have cold symptoms and a pretty significant cough. The cough in young children has a certain quality to it, and when I am walking around the mall or grocery store, I am always commenting, "that child has RSV." Just hearing the cough is often diagnostic during the RSV season. That is the reason that pediatricians recommend not taking a newborn infant into crowded, enclosed places during the winter months. The germs are airborne and easily transmitted from person to person. No one intentionally wants to get your new your-baby sick, but just being exposed in close proximity is enough to pass the virus. So, bottom line, keep your newborn as isolated as possible for those first six to 12 weeks especially at this time of year. It is RSV season and will be for the next few months. That's your daily dose, we'll chat again tomorrow!

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Do Not Travel When Kids Are Sick

1.30 to read

While I have been busy working during the holiday season, I have not been the most popular doctor around town.  With that being said I need to explain. 

As everyone knows the Christmas holidays fall right at the beginning of the winter SICK SEASON. The pediatrician’s office never really stops and if anything it gets busier as families are trying to get out of town, or are trying to get well in time for holiday activities which may include big family plans which may include out of town guests.  This is a perfect storm to spread germs as well as families fly around the country and gather together.

While working over the holidays, I have found myself having to be the “bad guy” by recommending that families cancel their airline flights and trips to see the grandparents or for others to cancel their vacations to far away destinations. All of these cancelled plans were due to children in the family who were too sick to travel. The majority of these patients have one of the numerous viral upper respiratory infections that are currently TNTC (too numerous to count). 

I am seeing children with rhinovirus, respiratory syncytial virus (RSV), meta -pneumovirus and the first few influenza cases of the season. These viruses may sometimes cause children to wheeze and some of the sicker children may even be hospitalized.

In most of these cases, children may be treated at home with rest, lots of fluids and some children may need nebulizer treatments to help their breathing. For those in the hospital the treatment is the same although the hospitalized children typically need oxygen.  The rest of the treatment is really about letting the virus run its course, and that is really frustrating, as there is not a doctor around who can tell you what a virus is going to do.

Since you can never tell “when and if” a child’s breathing will deteriorate, I had to recommend that several families cancel their trips.  What if you are in the middle of a plane flight at 30,000 feet and your child who has already been coughing and wheezing suddenly turns blue?  It is just too risky.

At the same time I had to put a child in the hospital who had travelled from out of town to visit family, and once here they worsened and required hospitalization.  They are now in the hospital far away from home and the dreams of a big family reunion were squelched, unless you can fit everyone into a tiny hospital room and let them all be wearing a mask in the family picture. (Not the best picture for the holiday card).

With all of this being said, I know that all of these children will ultimately be fine and their plans will get re-booked or re scheduled, but disappointment is never fun, especially during holidays.

So if your child is sick and your doctor recommends that you stay home or change your plans just remember that they feel as badly as you do, it is never fun to be the “scrooge” during the holidays.   

That’s your daily dose for today.  We’ll chat again tomorrow. 

Daily Dose

What to Look For in RSV

The office is just full of coughing and wheezing kids of all ages, much of which is RSV.Boy oh boy, RSV is really here and so more thoughts on that topic. The office is just full of coughing and wheezing kids of all ages, much of which is RSV. But the ones I am really concerned about are the infants and babies under the age of one year. They have a harder time with the virus and this infant age group is the group that statistically gets hospitalized more often. The buzz among moms about RSV continues (but at least less buzz about vaccines). They are all concerned and confused about when they need to come and see the pediatrician and also what "they" as parents need to watch for. Both of these concerns are important.

As we talked about before, almost all children get RSV by one year of age. In most cases it will just be a bad cold, but in some babies they will develop bronchiolitis (or airway inflammation of the lower respiratory tract) and they have a classic, frequent, non-productive cough, lots of secretions and often have a wheeze when listened to with the stethoscope. In most cases these babies are fairly "pathetic" and cough and awaken throughout the night, may not eat quite as well, and just feel "puny" and require a lot of parental care and TLC. Babies and therefore their parents don't get a lot of sleep when RSV is around. The babies I worry about are those that have true difficulty breathing. They not only cough frequently, they have signs of increased work of breathing which is evident by "pulling or retracting" while breathing. When you take off their shirts (which is what you should do at home too to look at how they breath), you see their ribs pulling or their abdomens working to help them breath. They look uncomfortable, not just while coughing, but also while just trying to get a breath. If this gets worse they may even grunt with each breath. I also worry about the your-baby that coughs and coughs and has "duskiness" with their cough. Most parents report that their your-baby gets bright red with cough, and eyes water and they may even vomit with cough. But a your-baby that turns even A LITTLE dusky needs to be seen immediately. Remember, red is good, blue is bad! Unfortunately RSV is here for a while. This is the peak season in most of the country and will be for weeks. Keep those young babies away from others and if your your-baby develops cold symptoms, look at how they breathe. If in doubt, take them in. That's your daily dose, we'll chat again tomorrow.

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Wheezing & Respiratory Distress

2.00 to read

What is that hissing noise in the air? Plenty of wheezing and coughing ushering in upper respiratory season.  With all this noise, I’m on the lookout for respiratory distress. As I start to see more and more sick kids, my office becomes a cacophony of coughing.  While many of the coughs sound horrible, fortunately most of the children I will see do not have any real respiratory distress.

I will spend a lot of time this respiratory season talking to parents about respiratory distress and what to watch for. Just like so many things in parenting, observation is the key. Watching your child’s breathing when they are coughing or even wheezing is the most important thing you can do. But knowing what is “distress” or “shortness of breath” really often means you need to know what to look for.  

I just saw a precious little girl in the office, my first patient of the morning. She had a history of a few episodes of wheezing, and did have a nebulizer and medications at home. She had been well all summer and the mother hadn’t thought about wheezing, but noted that her daughter started to cough over the weekend and had then gotten worse and had coughed all night, which made her come to the office bright and early the following am.

When I walked into the room I immediately could see that the little girl was in a bit of respiratory distress. Not only was she coughing (which every other patient seems to be doing), she was also retracting or “pulling”.  She was still happy and playing but you could see that she was “working” to breath. Her tummy was moving in and out and you could see her ribs pulling in and out a bit. She was still well oxygenated and pink.  

Her mother had not looked at her chest and had forgotten about her daughter’s nebulizer (you know, out of sight out of mind), as she had not used it for 6 months and was not “clued” back into coughs and respiratory season.

A quick review and she remembered what we had discussed last winter and realized that she should have pulled out the nebulizer over the weekend. It is repetition that makes you remember “the home wheezing action plan” and if you only do it once a year it is easy to forget.

Any time your child is coughing, whether they are 2 days or 20 years old, you want to look at their color (pink, not blue) and at their chest. You want to see if they are using their ribs or tummy to breathe. The sound of the cough is not as important as LOOKING at their chests. Whether it is during the day or the middle of the night, take off their shirts, (turn on a light) and look. That is what your pediatrician is doing throughout the season.

Any type of retractions, pulling, or respiratory distress means a phone call and visit to the doctor or ER.  Coughs are usually okay, but never respiratory distress.

That's your daily dose for today.  We'll chat again tomorrow.

Daily Dose

Protecting Your New Bundle of Joy

When I see newborns in my office this fall I am already thinking into the winter season ahead.

As I see new parents in my office this fall, bringing in that most precious newborn for their first pediatric visit, I am already thinking into the winter season ahead. Infants born during fall and winter are exposed to more upper respiratory viruses and flu in their first six months of life. Infants under six months of age are at more risk of complications from viruses like RSV and flu. Unfortunately, infants under six months cannot receive flu vaccine.

But a recent study showed that mothers who received a flu vaccine during pregnancy reduced influenza illness in their newborns. That study is important in reminding pregnant mothers of the importance of receiving flu vaccine during their pregnancy. Unfortunately, in my practice, I do not see this information being given to pregnant mothers while they are in for their OB visits. It is also important that new parents are vaccinated against whooping cough with a newer vaccine which is given to adults called a TDaP. If you are pregnant or thinking about becoming pregnant this winter discuss these vaccines with your obstetrician. If they do not have the vaccines in their office, your local health department has them. The best way to protect that new bundle of joy is by immunizing those around them. This would also apply to grandparents, aunts, uncles and cousins. Spread the word about flu vaccine and TDaP and not the germs. That's your daily dose, we'll chat tomorrow!

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