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Daily Dose

Vomiting Kids

1:30 to read

Pick a virus ….and it is probably circulating in your area!  Seems we are at the peak of upper respiratory season, influenza like illness season and also vomiting and diarrhea season. In other words, lots of sick kids right now.

 

I just started seeing a lot of vomiting again!!  It is the worst for both the child and the doctor’s office where it seems many a child has vomited either in the car, coming up the elevator or in the exam room.  YUCK for all.

 

Remember, norovirus is the most common virus that causes vomiting and diarrhea and it is VERY contagious. Not only via “dirty hands” but it is also airborne…so in other words, those standing near by a child who is vomiting (parents, other sibs) are probably being exposed as well. That is the main reason you probably see an entire family who gets sick almost simultaneously.  

 

If your child vomits….DO NOT give them anything to eat or drink for at least 30 min. I know that is hard as they are asking for a drink,  but you need to give their tummy a minute to “recover” before challenging them with a few sips of Pedialyte or Gatorade.  A SIP is the key word too….tiny amount to start in hopes that they do not vomit again.  

 

I just saw a 6 year old little boy who had been vomiting several times during the night.  His Dad said that he had given him Zofran to help stop the vomiting (this is a prescription).  I use a lot of Zofran in children who are vomiting as it can go under the tongue.  But after the Zofran his son felt better….so he gave him strawberries and a waffle!! Surprise? He vomited again!!

 

Don’t be fooled and start trying to feed your child too quickly after they are vomiting. I know parents worry that “their child is not eating”, but fluids are the important part of staying hydrated. As one little boy told me, “ it feels like there are grasshoppers in my tummy”!! So well put. I grumbling tummy needs time to heal and frequent sips of clear liquids (no dairy) are the best way to prevent dehydration. As your child tolerates a small volume you can go up a bit and gradually increase the amount that they take.  I usually wait a good 4-6 hours after a child has successfully tolerated fluids before I even consider giving them food. Then I start with crackers, noodles or something bland (that I also don’t mind cleaning up) in case they vomit again.  

 

You are just wanting to make sure your child stays hydrated…tears, saliva and urine!  Keep washing those hands. 

Daily Dose

School & Infectious Disease

1:30 to read

I received an email this week from a patient…subject line: “potential exposure to Herpangina”.  In the body of the email was the following:

Dear Parents,

We want  to inform you that a case of Herpangina disease has been reported for a child at ….. room #112.  This is a contagious disease that  is spread by direct contact with another person or contaminated objects.  Herpangina is an illness caused by a virus, characterized by small blister-like bumps or ulcers that appear in the mouth, usually in the back of throat or the roof of the mouth. The child often has a high fever with the illness. We have attached further information about this common childhood illness published by Children’s Hospital in Boston. Our teachers are carefully disinfecting their room to help prevent further spread of the disease.

The mother of the child that sent me the email was “freaked” out and “worried” about  sending her child back to pre-school.  

My question is this, when did it become a “rule” to notify parents in a pre-school or day care setting that there were viral illnesses circulating?  It certainly seems unnecessary to me to send notification of EVERY childhood illness that occurs and for most of my families only serves to cause anxiety.  Some of the schools in our area post a sign on the entry that says something to the effect:  “there are cases of diarrhea, RSV, hand foot and mouth and fevers being reported in children that attend this school.”  Really, is it that surprising or necessary? Seeing that many of the numerous viral illnesses that children get these days are spread via respiratory droplets and contact with surfaces, such as toys and tables that everyone touches (computers too), children are exposed to things all of the time.  Do you go to work and ask your co-workers in a conference room..have you had diarrhea, a cough or a sore throat in the last day?

I understand notifying parents of illnesses, such as meningitis, measles, mumps…even chickenpox that are infectious and may be serious or life threatening. Thankfully, there are very few cases of these illnesses to report, now that the MAJORITY of children receive vaccines to these diseases. 

By putting these emails, texts and notices out for every parent to become alarmed about…and then to come to the doctor out of concern that their child  “may get sick….even before they have a symptom”,  serves no purpose. Herpangina and Hand Foot and Mouth are very similar viral illnesses, and both are caused by enteroviruses. It is at times hard to distinguish one illness from the other. But, with that being said, the treatment is solely symptomatic. In other words, treat the fever, make your child comfortable and don’t let them go back to school until they are fever free for 24 hours.  

Lastly, your child is going to catch a lot of these viruses, no matter what you do when they go out to play, shop or go to school. Each time they catch a viral illness it actually helps them to build antibody in order that their immune system may get stronger and stronger. I think the better note is….as winter comes children will get more coughs, colds and viral infections…if you think you child is not feeling well or running a fever, please keep them home from school for the day.  It is just a normal part of childhood…we don’t need any more anxiety in this world.   

 

Daily Dose

How to Treat A Vomiting Child

We are definitely in the throes of "sick season" in our office and with that comes a lot of kids with vomiting. I remember the first time that one of my own children vomited.

We were in Target, he was about two and he had said he "was sick". Now, seeing that he was not very specific and did not elaborate, I just went on shopping. Several minutes later, as he sat in the cart (with seat belt fastened), he just looked at me wide eyed and suddenly vomited. This is the moment as a parent that you understand the difference between babies that "spit up", and true, projectile vomiting! Now what do you do once your child has vomited (besides rush out of Target as fast as you can)? Once a child has vomited it is important not to give them anything else to eat or drink, for at least 30 to 45 minutes. That means even if they are "begging" for a drink, as you will probably see it come right back at you if you do. After waiting, you want to begin re-hydrating with clear liquids. Not a good idea to pull out the milk or food yet. In an infant you can use Pedialyte, which is an oral electrolyte solution, and instead of breast milk or formula you can try feeding your infant about an ounce of Pedialyte every 10 to 15 minutes and see if they can keep Pedialyte down. In toddlers and older children I use Gatorade, as it is not quite as "salty" and kids seem to take it better. Again, frequent small sips of Gatorade while you wait to see if the vomiting is persistent. Don't go too quickly on giving them larger volumes. The key is small amounts, frequently, which are easier to handle. As your child keeps down the Pedialyte or Gatorade you can increase the volume that they are taking and decrease the frequency. The main thing you are trying to do with a child of any age is to keep them from getting dehydrated and their vomiting is typically due to a viral illness affecting their GI tract. Because it is typically a virus that is the culprit for nasty vomiting, it just takes time to get through the illness. There is no "miracle" cure, and watching your child vomit, or cleaning up the vomit that invariably is usually not in the toilet, is one of the worst parenting jobs. That being said, there are very few children who will not experience vomiting at least once or twice during their childhood, so you need to keep "clear liquids" on hand in the pantry. Having powdered Gatorade around is a lifesaver at 2 a.m when your four-year-old wakes up and throws up. If you are giving the clear liquids, and your child tolerates larger volumes, but then vomits again later on, you just back up and start all over with smaller amounts more frequently. It is somewhat like a "balancing act" to give enough that they are hydrated, but at the same time to not give too much at one time that they vomit again. Slow and steady is the mantra. You should always be looking for your child to have tears, a wet and moist mouth (put your finger in there, it should come out with some saliva on it), and urine. It is often hard to tell if a child in diapers has had a wet diaper as they will not be "soaking" the diaper and smaller amounts of urine are "wicked" with the new super absorbent diapers. Children will also be pitiful after vomiting and may seem "lethargic" to you, but if they are an infant and can smile and make good eye contact or they are an older child who can tell you they feel terribly and don't want to drink Gatorade or play with their blocks they are probably not dehydrated. If in doubt, give your doctor a call to discuss what is going on. After using Pedialyte and Gatorade, and your child has not vomited for six to eight hours you can try adding some formula or breast milk, or other liquids such as chicken soup or a Popsicle. I still would not start solid food until the child has kept down other liquids. We parents all worry if our children don't "eat" but the fluids are the important part, and as we all know, a day without out chicken nuggets or peanut butter will be okay. Keep up the fluids!! If your child continues to vomit despite your best efforts with "slow and steady" fluids you need to call the doctor. We have plenty of patients that we see everyday to make sure they are hydrated, and to even watch them while they take fluids in our office. Occasionally, when all else fails we will have to hospitalize a child for IV hydration. Oh yes, remember to wash your hands frequently as these nasty viruses are contagious and parents will often find themselves getting sick after their children. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Dealing with Warts

1.30 to read

Warts are one of the most common skin lesions seen in pediatric practices. Warts also drive parents and some kids crazy!  According to one study up to about 1/3 of school children have warts.  

Warts are viral infections of the skin which are caused by human papilloma viruses (HPV).  There are more than 100 types of HPV and different types of HPV cause different types of warts. The most common warts on hands and knees are caused by HPV types 1,4, 27, 57.  These are not the HPV types that cause sexually transmitted infections 

Some people seem to be more prone to getting warts than others, and it is not uncommon to see several children in one family dealing with warts. The HPV virus is spread through skin to skin contact or through contaminated objects or surfaces. In other words, they are hard to prevent.  HPV can also have a long incubation period, so when parents ask, “Where and when did my child get this wart virus?”, my answer is typically, “not even the CIA will be able to tell you that”.  

I many cases if the warts are left alone they may resolve on their own in months to years (one study showed two thirds remission in 2 years) ......but with that being said, most teens (especially girls) want those warts to “be gone!” 

There are several different ways to treat warts and one of the most effective is with over the counter (OTC) products that contain salicylic acid.  Salicylic acid acts as an irritant that activates an immune response against HPV.  There are tons of different OTC products and in many studies there was not one product that proved superiority over another, so I would buy an “on sale” salicylic acid for starters. I know from using these on my own children that you have to be consistent and persistent in their use....but it did work. 

If OTC products don’t seem to be working the next step for those who are determined to try and get rid of the wart,  is to head to the doctor who may try freezing the wart with liquid nitrogen or using cantharidin.  Unfortunately, there is typically a little pain involved with these products. 

Like so many other things, sometimes it may pay to just to wait it out and see if the virus just gives up and goes away!

Daily Dose

The Truth About Antibiotics

1:30 to read

Despite warmer than normal temperatures in much of the country it is certainly already cough and cold season. Our office background music is already a lot of coughing coming from children of all ages…and a few of their parents too. In fact, a few of our nurses and docs are fighting a fall cold as well.

 

This makes it timely to discuss (once again) the difference between a cold which is a viral infection and a bacterial infection (example strep throat).  Viruses are NOT treated with antibiotics!! In other words, antibiotics are not useful when you have the common cold. Asking your doctor to put you on an antibiotic “just in case “ it might help is not advised, and doctors should be taking the time to explain the difference between a viral infection and a bacterial infection, rather than writing an unnecessary antibiotic prescription.  

 

While some people (fewer and fewer young parents) still think an antibiotic is necessary, the overuse of antibiotics has been called “one of the world’s most pressing public health problems”s, by the CDC. Not only does the overuse of antibiotics promote drug resistance, it may also cause other health concerns as well. While antibiotics kill many different bacteria, they may also kill “good bacteria” which in fact help the body to stay healthy. Sometimes, taking antibiotics may cause diarrhea and may even allow “bad bacteria” like clostridium difficile to take over and cause a serious secondary infection.  

 

At the same time that there are too many antibiotic prescriptions being written for routine viral upper respiratory infections, a new study in JAMA also found that bacterial infections (sinusitis, strep throat, community acquired pneumonias), are not being treated with appropriate “first line” antibiotics such as penicillin or amoxicillin.  Of the 44 million patients who received an antibiotic prescription for the treatment of sinusitis, strep throat, or ear infections, only 52% were given a prescription for the appropriate first line antibiotic. When a doctor prescribes a broader spectrum, often newer antibiotic, instead of the recommended first line drug, they too are responsible for increasing antibiotic resistance.

 

So, you should actually be happy when your pediatrician reassures you that your child does not need an antibiotic, and that fever control with an over the counter product, extra fluids and rest will actually do the trick to get them well.  I “brag” about my patients who have never taken an antibiotic…..as they have never had a bacterial illness, and tell their parents how smart they are for not asking for an antibiotic “just because”.

 

At the same time, if your child does have a bacterial infection, ask the doctor if they are using a “first line” drug and if not why…? It could be because your child has drug allergies to penicillins, or that your child has had a recent first line drug and has not improved or has had ‘back to back” infections necessitating the use of a broader spectrum antibiotic.  Whatever the reason, always good to ask.

 

Keep washing those hands, teach your child about good cough hygiene and run don’t walk to get your flu vaccines….November is here and flu usually won’t be too far behind.

 

 

  

Daily Dose

Fever

1:30 to read

It’s starting….fever, fever, fever season and lots of concerned parents, so figured it was a good time to talk about fevers….AGAIN.  

 

Remember that fever is simply a symptom that your body’s immune system is working, and in most cases, in children, it is fighting a viral infection.  We docs call a fever a temperature above 100.4 degrees…but I do realize that day care and schools will send your child home when they have a temp above 99.5 degrees ( in some cases even lower). Some parents “explain” to me that their child’s body temperature is always lower than 98.6 degrees so a 99.9 degree temperature is abnormal for them….I’m just saying. 

 

The first thing to try and remember is that the thermometer is simply showing you a number and that the number should not scare you…it is only a number and a higher number does NOT necessarily mean that your child is any sicker.  Some children do tend to have a higher temperature with an illness than another, and even in the same family.  Again, the number should not make you concerned that one of your children is sicker than another…it is still just a fever.

 

Parents always ask…”what degree of fever is dangerous, and when do I go to the hospital?”  The number that registers on the thermometer should not be the deciding factor as to how sick your child is. They will look and feel worse with a higher temperature ( as do you when you are sick), but the important thing is to always look at their color (never dusky or blue), how they are breathing (you do breath faster and more shallow with a higher body temperature, but do not appear to be in any distress), and if they are hydrated (you do need more fluids when you are running a fever).  If all of this seems to be okay, the best thing to do is treat the fever with either acetaminophen or ibuprofen.  Once their temperature comes down a bit, and that may not be 98.6, look at your child again…children with lower temperatures typically “perk up” for a bit and may play or eat and drink for awhile, until their fever returns and they look pathetic again.  I would always check with my doctor before heading to the ER just because of a fever.

 

Parents also worry about their child having a seizure due to a fever…and this is true some children may have a febrile seizure. But, they can have a seizure with a temperature of 100.8 or 104.2…it does not seem to be the higher the temperature causes a febrile seizure. Febrile seizures do seem to “run in families” and they are also most common during the toddler years. (see another post on this).

 

So… as we are getting into sick season make sure you have an acetaminophen and ibuprofen dosing chart handy and always dose your child’s medications based on their weight and not age. I would also make sure to have a “working” thermometer, and I prefer a rectal thermometer for children under 12 months of age. Rectal temps are really easy to take and in my experience far more accurate (when I am really concerned if a child has a fever) than a tympanic or temporal thermometer. 

 

Be ready and relax….it is just a fever and having an anxious parent is not going to make your child feel better any faster.

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Daily Dose

Home From School

1:30 to watch

I continue to talk about it being  the “sick season” and thankfully it is now February!  Parents are all tired of having sick children and I can now at least assure them that we are halfway to the end of upper respiratory and flu season.

 

But, with that being said that means I am still seeing children with RSV, Flu and every other virus I can think of. Remember, the majority of the illness I see every day in my office is VIRAL.  It really doesn’t matter if you can put a name to the virus, as the treatment is the same. Rest, fluids, fever control and watch for any respiratory distress or symptoms of dehydration. As I told one young mother who said that her other child had been tested for RSV (by another doctor), testing the child I was now seeing will not make any difference in how we treat the illness. So, why make the child uncomfortable when doing the swab and also drive up health care costs, for no change in treatment recommendations.  I think people are confused about what the test actually does….it does not change how a child is treated, and it also causes a lot of “alarm” as the mother of one patient goes home to tell her friends that her child has RSV and then the school starts sending out emails and parents become more anxious and alarmed that they may have been exposed….as they are every day all over our city.

 

So…when do you know it is time to keep your child home from day care or school as we all know these viruses are spread at home, school and work as well.  

 

If your child has a fever over 100.5 degrees (by any method of taking their temperature) they should not go to day care or school for at least 24 hours after becoming fever free (without fever lowering medication).

 

If your child is vomiting, 2 or more times in the last 24 hours, they should stay home. Some young children may vomit after coughing as well, but if infrequent they may attend school. 

 

Diarrhea as defined by two or more loose, watery stools that are “out of the ordinary stool pattern” for your child. Any child having diarrhea that does not stay contained within a diaper should stay home. A child who has blood in their stool should not attend day care or school (and should see the doctor).

 

Children with strep throat may return to school after 24 hours if they are fever free and have received the appropriate antibiotic therapy.  (Newer article suggests 12 hours if they are feeling well).

 

Your child does not need to stay home due to a cold, cough, runny nose (of any color) or scratchy throat if they do not appear ill and do not have a fever. Look at how your child is behaving…some times a day of rest may be needed (even when you get sick, right?) 

 

Most importantly, it is not necessary to name the virus that your child might have, but to follow the guidelines for keeping them home (as well as out of stores, church, and after school activities) until they are feeling better. Wash hands, cover coughs and yes….still get the flu vaccine. It is not too late…the ground hog even said we still have a lot of winter left.

 

 

 

Daily Dose

Homemade Cure for Coxsackie?

1:30 to read

Desperate times call for desperate measures…or so it seems according to several of my patient’s mothers who have resorted to all sorts of “cra-cra” stuff to “treat” their child’s “HFM” - hand foot and mouth infection.  Remember, HFM is a viral infection that most children get in the first several years of life. It may cause all sorts of symptoms but in a classic case the child develops a macular-papular (flat and/or raised) vesicular rash on the palms, soles and buttocks. In some children the rash is fairly mild and in others it can look pretty disgusting and uncomfortable…but it has to fade away on its own…with time.

 

There has been a lot of HFM in our area and much anxiety among parents about this infection….fueled a lot by social media identifying who has HFM and where they go to school and how many cases there are. (too much information!!). Parents are even posting…places to “stay away from”. So, some of my patient’s parents are scouring their child looking to see if there might be a bump..and could this be HFM and if so, what do I do to “stop” it!  That would be “nothing” besides good hand washing..as this is a viral infection and you may be exposed to it almost anywhere.

 

Since coxsackie virus has been around for years, this means that most adults had the virus when they were young.  But, several moms and dads whose children have HFM have also shown me a rash on their palms and soles, that I presume may be HFM? They are kind of freaked out and may be uncomfortable too…but this is not life threatening.  Even so,  several parents are resorting to THE GOOGLE to get their medical information… and one young mother kindly brought me all of the stuff that she had gotten to treat her son’s HFM as well as hers.  She was earnest in hoping that this was the “cure”…and did I know about all of these remedies?

 

Here we go, her potions!  Epsom salts for baths as this is an “antiviral”, turmeric and ginger in veggie juice, crushed garlic which she was mixing with small amounts of orange juice and squirting into her toddlers mouth with a syringe, lavender essential oil and lastly “virgin” coconut oil massages.   

 

I was most impressed that her sweet toddler was eating, drinking and bathing in all of this!!! Unfortunately, despite her best efforts it took about 2 weeks for his rash to totally disappear and she kept him under house arrest for most of that time!!  He really could have gone out long before that as he was over his acute illness, but she wanted every “mark” to have faded. She was most chagrined to hear that he might get HFM again. I am not sure the her “voo-doo” did any good, except in her mind. 

 

Lastly, if you do resort to “internet medicine” remember the oath, “first do no harm” and check with your pediatrician about some of the advice you might find on-line, not everything may be safe.

 

Daily Dose

It's the Sick Season

1:30 to read

Well, the New Year is starting off with a flood….of illness that is.  It is a typical winter in the pediatrician’s office with a bit of every virus you can name. RSV, flu, norovirus, just to start the list.  While so many parents want to name the virus, it is typically not necessary as you treat many viruses in the same manner, symptomatically.  

 

So, if your child is coughing and congested it may be due to any number of upper respiratory viruses, but the most important thing to remember…..how is your child breathing and is your child having any respiratory distress?? I sound like a broken record in my office as I remind our nurses to have parents take off ALL small children’s shirts, gowns, onesies and look at how they are breathing as you never want to miss a child who may be “working to breath”. In many cases, the visual of a child’s chest as they take breaths is more important than any cough they may have.  So remember this: “visual inspection and not just audible”.  Sending me a video of a child coughing is rarely helpful, but a video of their breathing is very important when trying to decide how to guide a parent.

 

Another tip: In most cases if your child is having respiratory distress they are quiet, as they are conserving their energy…which means they are not fighting with their sibling or running around the house, but are often sitting quietly. This also means that when they come to the doctor they are not screaming and yelling in anticipation of the doctor…again, they are usually sitting quietly in their parent’s lap. While a happy quiet child is a pleasure at my office, in a toddler it is not typical.

 

Lots of diarrhea and vomiting in our area as well. In this case, I am always trying to make sure that a child is not getting dehydrated. So, the things to look for include if your child has tears, saliva in their mouth and if they are urinating (having wet diapers).  If your child is vomiting you have to remember to wait about 30 minutes after they have vomited before giving them anything to drink….even if they are “begging for a drink”. Once they have not vomited you need to give them TINY sips of clear liquid and keep offering sips every 10 - 15 minutes. If you do this, in most cases you can keep the child from vomiting repeatedly.  Once they are keeping down sips you can go up in volume.  It is like the turtle and the hare….slow and steady wins!!  

 

With diarrhea alone it is more difficult for your child to become dehydrated, as you can have them keep drinking to keep up with the loss in their stool. Many parent “worry” as their child does not want to eat…and that is ok, the fluids are the most acute issue. You can go without food for quite some time…..don’t you ever skip a meal?

 

Keep washing those hands…and I hope you had your flu shot as I promise…it will come. 

 

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DR SUE'S DAILY DOSE

Can you use homeopathic products to relieve your child's illness?

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Can you use homeopathic products to relieve your child's illness?

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