Listen in as I talk about ADHD. I even throw in several stories from my own experiences in parenting a child with ADHD.
I was recently interviewed about parenting a child with ADHD. I encourage parents of kids with ADHD to listen.
As a pediatrician I have the benefit of seeing many families affected by ADHD, and that has helped me to be a better parent. It has also given me support when things don’t go well because I know I’m not alone.
If you’re feeling frustrated with parenting, especially when it’s related to those issues common to kids with ADHD, I encourage you to listen.
I hope that you will feel like you’re not in this alone.
When your family gets sick, what can you do before running to the ER or clinic?
When cold and flu season is in full gear, it’s helpful to know common things that can help us prevent and treat whatever is in town. Many of the viruses that run around each season don’t have specific treatments, but there are things that we can do at home to treat symptoms and keep people more comfortable. There are also things we can all do to prevent the spread to other family members or back into our community.
What can be done to feel better?
Remember that nothing can be done to treat most viruses. Our body’s immune system will take care of that, but we can do things that help us feel better during the illness.
It’s hard to make them better, but we can make them feel better
During the cold and flu season, it can seem like kids are sick every day for months because they catch one on top of the other. Some of these days they might simply have a runny nose, and those days can last most of the year in young kids.
It’s when they seem uncomfortable or distressed that we need to do more. Treat the symptoms that bother them.
Identify the symptoms that are concerning, such as difficulty breathing or dehydration, and seek treatment at your doctor’s office for those.
What about fever?
Notice I did not list fever as one of those symptoms.
Doctors don’t do anything special for fever in vaccinated children over 2 months of age.
Fever can accompany other symptoms that may be concerning, but it in itself is not the concern unless it is a newborn, unvaccinated child, or one with a chronic condition that you’ve been warned has increased risks.
Remember the goal is not to bring temperatures to normal, but to keep kids comfortable. If they’re in pain from sinus pressure, a headache, sore throat, body aches, or earaches, it is okay to give a pain reliever even with a normal temperature.
Get the mucus out
Suction your infant’s nose before feeding and before putting him down to sleep. This helps clear the mucus from the airway and makes breathing easier. Encourage nose blowing for those old enough to know how to blow.
Encourage your family members over 6 months of age to drink more water than normal when sick. Kids often won’t eat well when they’re sick. That’s okay. It is important that they drink well though so they can stay hydrated.
Young infants should not drink water, but you can encourage more of their milk or formula when they have cough and colds.
If your child has vomiting or diarrhea, avoid cow’s milk products. These often lead to more vomiting. Breast milk can be offered in small amounts frequently to infants who are breastfeeding. Electrolyte solutions (with sugars and salts) can be given to infants and children for hydration.
DO NOT let anyone smoke around your child or in your home. Smoke can make the wheezing and coughing worse, even if done in a separate room in the home.
Smoke residue on hair and clothing can cause irritation to your child’s airways. I can usually identify smokers or people who spend time with smokers when they’re in my clinic. (Thankfully that isn’t often.) It isn’t unusual for me to start coughing when they’re in a clinic room with me. If you must smoke, go outside and wear a jacket that can be removed to minimize what is on your shirt when you go inside and hold your baby.
I’ve even started coughing when around someone who was vaping. I know people claim that the vapor is safe around others, but my lungs don’t like it. Keep it away from your kids. Talk to your kids about the risks of vaping so they don’t start the habit.
Encourage those who are sick to get extra rest. We often sleep poorly at night and need daytime naps to get enough sleep when we’re sick.
A cool mist vaporizer or humidifier can help your child breathe easier. Change the water every day. Clean the machine per the manufacturer recommendations.
It just isn’t possible to keep kids from being contagious when they have a virus. They love to touch everything and share germs, so keep them home until they’re well enough to return to normal daily activities.
Our health department now recommends that everyone with influenza stays home for 7 days following the start of symptoms.
You can return to work, school, and activities with other illnesses when the fever is gone (without using fever reducers) for 24 hours, there’s no vomiting or diarrhea, and you’re generally feeling well enough to return. If not, stay home and rest or visit your doctor.
Cover the cough!
Teach kids to sneeze and cough into their elbow or a tissue. Wash hands after handling tissues.
Wash, wash, wash
Good handwashing can help decrease the spread of viruses.
Wash hands often. If soap and water isn’t available, use hand sanitizer. The more things you touch, the more often you should wash.
Teach kids to wash properly. Have them rub soap on their hands for 15 – 20 seconds- be sure they scrub palms, backs of hands, fingers, spaces between the fingers and even under the fingernails.
Before preparing food
After toileting or changing a diaper
When they’re obviously soiled
After sneezing or coughing into hands or wiping nose
Before and after touching eyes
When taking care of a wound wash your hands before and after washing and treating the wound
Often when taking care of someone who is sick
After touching trash or soiled objects
Consider having separate towels for each family member in your bathrooms to decrease the spread of germs when they wipe their mouth after brushing their teeth.
Hand sanitizer is a good option when washing isn’t available, but it is not helpful against some germs, so handwashing is preferred.
Use lotion as needed to keep your skin moisturized. Dry skin damages the barrier that helps prevent germs from getting into our bodies.
Germs can live on objects and surfaces for 2 or 3 hours – sometimes longer. Clean your child’s toys often with soap and water.
Don’t touch your face. Eyes, ears, and noses are the doors into our body.
Avoid handshakes and other hand to hand contact. Try a fist bump or wave!
Avoid taking young children to large groups of people during the cold and flu season, especially if people are showing signs of illness.
We can help prevent many of the most serious illnesses by staying up to date on our vaccines.
I’ve been asked what the single best parenting tip I’ve gotten as the parent of a child with ADHD is. After a lot of consideration, I’ve decided that it involves setting expectations. When we re-frame things that are appropriate for their developmental age, it alleviates so many fights and frustrations. These expectations can vary if they’re on medication at the time, how much sleep they’ve had, and more.
We typically measure a child’s age by how long it’s been since they were born. This is their chronologic age.
We assume that kids will be able to understand more complex ideas and master new tasks as they get older. There are certain milestones that are associated with various ages, such as a social smile by 2 months or walking by 15 months of age.
Your pediatrician will ask developmental questions at routine well visits to be sure your baby is on track.
These questions help us to identify if your child is developing at a normal rate or if there is a delay. At some ages there are specific standardized developmental screening tools to be administered.
As long as a child meets expectations, their developmental age and chronological age match. If they are delayed, we can give a developmental age to help identify their stage of development.
We know that ADHD is one cause of delay of areas of the brain that are important in executive functioning. At this time there are no standard screening tool recommended at all well visits to assess this development. It is important to bring up any concerns from home or school with your physician.
What are executive functioning skills?
Executive functions are the things we use to help us use and act upon information.
Being delayed in executive functioning areas of the brain is not the same as being academically delayed or having a low IQ. Parts of our brains grow at different rates.
Even your child that excels in certain areas can be delayed in others.
A child who can do math several grades ahead of classmates might not be able to remember something as simple as turning the homework in the next day.
Another child who reads grade levels ahead might not be able understand why a certain behavior is considered undesirable.
A child who is gifted in the arts can struggle significantly remembering all the things that must happen to get ready to leave the house in the morning on time.
It’s easy to get angry at kids for having missing assignments, when they forget to brush their teeth, or when they’re always running late. It can be difficult to help kids understand why they cannot blurt out answers or tell others what to do or how to do it.
Negative feedback leads to increasing problems
Unfortunately, kids with ADHD often hear negative feedback when they fail to do what’s expected, which can lead to rejection sensitivity.
Kids often develop unproductive ways to buffer the negativity that follows their failures. They can act out, become the “class clown,” decide to stop trying because of the fear of failure, and more.
I’m asked all the time how to set expectations with kids, especially those with ADHD.
It’s understandably difficult to parent when your child, who otherwise looks and acts like kids of the same age, doesn’t have the same abilities in areas of focus, organizing, prioritizing, completing tasks, and self care issues.
Visible differences are easy to spot
When kids look different due to a genetic or physical condition, it’s easy to see what accommodations are needed.
If a child has an obvious trait that makes it difficult to do a task, we modify our expectations. A wheelchair bound child would never be expected to run upstairs to grab something.
Invisible differences still exist
For those who look “normal” but are neurodevelopmentally different, it’s easy to fall into the trap of setting an expectation based on the typical expectation for their age, not their level of development.
A child who has problems with working memory might also struggle to run upstairs to grab something. It’s not a form of defiance when they go upstairs and forget what they’re supposed to be getting or when they don’t return because they get distracted by something else.
Many kids are simply not there yet.
They can’t act their age because that part of their brain is not at that stage.
Most will get there, but it takes them longer.
Set appropriate expectations, and when they struggle, show patience and help them learn. This is much more effective than setting the bar too high, resulting in punishments and anger.
Delays of executive functioning
Dr. Richard Barkley has shown that kids tend to develop executive functioning skills about 30% slower than neurotypical peers. This adds up to about 3-5 years at most ages.
This might mean that your 12 year old might struggle doing what another 12 year old has already mastered. They might only be able to handle things expected of an 8 year old.
Set expectations according to skills, not age
The single tip that helps de-stress parenting more than any other that I’ve heard is to adjust expectations by skill.
Chronologic age is less important when deciding what a child is capable of and what they’re ready to learn.
this doesn’t mean letting them get by with anything…
As a child grows, you will watch their successes and failures.
You learn what they can and cannot handle. Help them with the things they cannot do while letting them do as much as they can.
SEt expectations and supports
One child can be expected to get dressed and brush teeth without reminders.
Another child of the same age will need a chart listing all the routine things that need to be done.
And yet another child of the same age may need reminders to look at the chart.
All of these same age kids can be smart and have good intentions, but they need different levels of reminders.
I recommend this video to parents often. It shows very clearly what it means to parent a child who is delayed in executive functioning. Parents of kids with ADHD will most likely identify with it.
Bronchiolitis (often called RSV) is an infection of the respiratory tract that leads to wheezing and difficulty breathing. Learn why it’s scary to many parents and what you can do about it.
Bronchiolitis is an infection of the respiratory tract that leads to wheezing and difficulty breathing, most often in infants and children under 2 years of age. It’s often called simply “RSV.” While it’s often caused by a virus called Respiratory Syncytial Virus (RSV), it’s not always. Let’s talk about what it is and what we can do about it.
Symptoms of bronchiolitis
Bronchiolitis often starts off just like a common cold, with a runny nose or congestion. In older children and adults it progresses just like a cold. Because it is.
In infants and young children symptoms can progress to make them more significantly sick. Day 3-5 of illness often is the worst.
Symptoms include (but not everyone has all):
Rapid heavy breathing (more than 60 breaths per minute – always count for a full minute in babies because they can pant or hold their breath, which throws the count off)
Wheezing (tight breathing with a whistling sound)
Retractions (the skin between ribs suck in during inspiration)
Nasal flaring (where the nostrils widen with breathing)
Belly breathing (the abdomen moves up and down more than usual)
Cough (which can occasionally cause vomiting)
Lots of mucus from the nose and mouth (lots!)
Decreased appetite (which can lead to dehydration, so offer frequent liquid feedings)
RSV is a common cause, which is why the condition is often simply called RSV. Most of us have had RSV by the time we’re 3 years old. It doesn’t always cause the symptoms of bronchiolitis. Sometimes it just looks like a common cold, especially in older kids and adults. This is why it’s really important to protect young infants around people who are just a little sick.
Bronchiolitis can be caused by many of the viruses that cause upper respiratory tract infections. Rhinovirus, metapneumovirus, adenovirus, influenza, parainfluenza, and coronavirus are some of the other culprits.
Who’s at risk?
Symptoms tend to be worst in babies who are higher risk. This includes infants who were born prematurely, those who have certain heart defects, the very young, or those with other chronic conditions.
Infants are more at risk of having simple cold viruses cause the more severe symptoms of bronchiolitis. Their narrow airways contribute to this because they become plugged with mucus more easily than larger airways.
All viral illnesses are more common among infants who are in daycare or around lots of people. The more people, the more likely they’ll be exposed to a person sharing germs. Infants also put their hands and toys in their mouth often, which helps them get germs into their body.
Those who are around cigarette smoke are also more at risk because of the chronic airway irritation caused by smoke. Even babies who are around people who smoke prior to being with the child can get third hand smoke exposure from hair and clothing.
Standard infection control protocols can help avoid spread.
Wash hands frequently or use hand sanitizer. Teach kids to get all parts of their hands clean. Wash hands even when you’re not feeling sick… we share germs before we know we have them and we need to protect ourselves from catching new ones!
Have separate towels (or disposable towels) in the bathroom. After brushing your teeth, you don’t want to wipe on a towel that was used by someone who’s brewing germs!
Don’t kiss babies on their face, hands, or feet. The top of the head is best!
Avoid cigarette smoke – even second hand and third hand smoke (on surfaces) can cause airway irritation. This irritation makes it harder to fend off germs, which leads to more infections.
Germs can live on surfaces and objects for 2 or 3 hours or longer. It’s a good idea not to share toys because babies put them in their mouth all the time. Clean your child’s toys often with soap and water.
Cover coughs and sneezes properly.
There are tests that can be done on mucus from the nose to see which virus is the culprit, but they aren’t usually required.
Knowing if it’s RSV or another virus doesn’t make the symptoms change. We treat symptoms.
Testing can be used for infection control measures when babies are admitted to the hospital, but aren’t always necessary.
Tests are expensive, and unless they change something we’ll do, they aren’t generally recommended. Why waste your money? (Even if you think insurance will cover it, the money comes from somewhere… you’ll pay more in premiums if you spend more.)
It is common to check oxygen levels when kids (and adults) are sick. Pulse oximeters are an inexpensive tool to help us assess how well a person is compensating when having trouble breathing.
Most infants and children with bronchiolitis do not need a chest x-ray, but they are sometimes used to assess for pneumonia or foreign bodies (such as a swallowed coin) that can cause wheezing.
Blood tests are not usually needed to diagnose or treat bronchiolitis but they can help to identify if there’s a need for antibiotics due to a bacterial infection. Sometimes we check blood if we’re worried about dehydration.
The virus must run its course and symptoms can last several weeks, so what can you do to help ease symptoms?
You can use fever reducers if your baby is uncomfortable. These include acetaminophen if your baby is over 2-3 months and ibuprofen or acetaminophen if your baby is over 6 months. I don’t recommend fever reducers before babies get their 2 month vaccines because you can mask symptoms of serious disease. See your physician if your unimmunized child has a fever!
Remember that a fever is the body’s immune system at work, so your goal is comfort, not getting rid of the fever.
Babies with bronchiolitis often seem as if their nose is a faucet. All that mucus interferes with breathing and feeding. They can’t blow their nose, but you can suck it out!
I’m not a fan of bulb syringes as a nasal aspirator. I find that they have too narrow of a tip to get an effective seal in the nostril until you force it up so far that it causes trauma in the nose. They also run out of suction power before the mucus is all out, which means you must break the seal, empty it out, and resume. This gives your child a chance to suck back some of the mucus you brought forward. Not to mention some of the really gross photos I’ve seen of what grows inside those things!
Here’s a review of various nasal aspirator types and brands. I like the review in general and have no ties to it. She does link to sales, but you can buy from your favorite retailer.
Use one of the aspirators to suction your infant’s nose as they need it. It’s especially helpful before feeding and before they go to sleep, but think of how often you blow your nose when you’re sick. It can be helpful quite often!
Saline can help thin out mucus and decrease the swelling of nasal tissues.
Raise the head of the bed to help with drainage of mucus. Don’t put your infant on a pillow because that can obstruct breathing. Raise the head of the bed by putting something solid under the legs of the bed or roll a blanket or towel and place it under the mattress at the head of the bed.
I remember many nights of sitting up holding my children when they were sick so they could be upright and sleep. That doesn’t mean I slept well, but that’s what moms do sometimes. You do need to be careful with this – babies can be dropped if a parent falls asleep holding them.
Encourage your child to drink fluids in small amounts. This can be breast milk or formula, or water for older infants and children.
Many babies tire out drinking, so they need to drink more frequently than normal to get in a decent volume.
If your baby isn’t drinking well and looks dehydrated, talk to your physician.
Humidify the air
A cool mist vaporizer or humidifier can help your child breathe easier.
Change the water every day.
Clean the machine per the manufacturer recommendations to prevent it being a source of germs.
Things to avoid
Never use menthol products around infants. They have been shown to increase mucus production and worsen symptoms, especially in children under 2 years.
Don’t demand antibiotics. It cannot be cured with antibiotics. No viral illness can.
Decongestants thicken mucus and can lead to more difficulty breathing, sleep disturbances and irritability.
Historically we have tried medical treatments when infants present with bronchiolitis. These include breathing treatments with bronchodilators, steroids, and more.
A single treatment with a bronchodilator can be used to see if there’s response to decrease wheezing, but should not be continued if there’s no benefit.
Steroids have not been shown to help unless there’s a history of asthma.
Oxygen is a standard treatment that can help if the oxygen level is low or to ease the work of breathing.
Intravenous (iv) fluids are often required if hydration from feedings is not successful.
Suctioning is a primary treatment in the hospital setting, much like at home.
When should kids be seen?
Infants and children should be seen relatively quickly if the following criteria are met:
Infants under 2 months of age should be assessed by a physician. They often require hospitalization because of the risk of apnea. Apnea is when they stop breathing and is a risk of very young infants with bronchiolitis.
Respiratory rate over 60 breaths/minute consistently. It’s common to breathe faster with a fever, so if you can bring it down and their breathing is less labored, that’s okay. They also temporarily breathe faster after eating or crying. Again, if it slows within a few minutes, that’s okay.
Dehydration. Signs of dehydration include no tears, thick/pasty or no saliva, or fewer than 3 wet diapers in 24 hours.
The color of the child’s lips or skin looks blue.
The infant looks uncomfortable or is inconsolable.
Infants under 3 months (or an under-vaccinated child) with a temperature over 100.4F.
If your child simply isn’t getting better after several days or if earache develops, make an appointment during regular office hours.
Pharmacogenetic testing involves testing a person’s genetics to find out how a certain drug would work in that person. Learn the pros and cons of this testing.
I’ve recently seen increasing numbers of parents who want testing to decide which medication to use for their child’s condition before trying any medicines. Many admit that they don’t know much about it and want to learn more. Pharmacogenetic testing involves testing a person’s genetics to find out how a certain drug would work in that person. While that sounds like it would be fantastic to know, it has many limitations. We’ll talk about the pros and cons below.
Traditional dosing of medicines
Before they can be approved to be used, drugs are tested in large groups of people.
Dosing schedules are determined based on safety and efficacy of the medicine, but this is in a group. It relies on information gathered from a mass of people, and majority rules. This means that whatever works for most people is what becomes the recommendations.
Although this works for most people, any individual can have a variation that is not seen with the large numbers in a group. We all know people that can’t tolerate certain medicines. In the past we use family patterns to help predict tolerability. If a family member (or especially if multiple family members) report that certain medicines require lower or higher doses to be tolerated and effective, then we use that in our decision making for prescribing medicines. Of course it isn’t a perfect way to do things, but it can help.
What is pharmacogenetic testing?
Pharmacogenomics is the study of how genes affect a person’s response to drugs. It’s a growing field that involves using what we know about the person’s genetic make up and how they will metabolize a medication. This can allow the prescriber to use certain medicines and not others, or begin with overall higher or lower doses than standard recommendations suggest.
It is personalized to a person’s genetic makeup, so it’s often called personalized medicine or precision medicine.
Many medicines work well for most people, but there are people who will metabolize certain things slowly, allowing the medicine to build up to toxic levels when dosed per standard amounts. Other people may require higher doses due to a very rapid metabolism. Some people should avoid certain medications all together. Knowing these dose adjustments and risks before even starting a medicine could be very beneficial!
Certain proteins affect how drugs work. Pharmacogenetic testing looks at differences in genes for these proteins. These proteins include liver enzymes that chemically change drugs. These changes can make the drugs more or less active. Even small differences in the genes for these liver enzymes can have a significant impact on a drug’s safety or effectiveness.
What are some uses in general pediatrics?
I’m limiting this discussion to uses that a general physician would use this type of testing. There are other uses for chronic diseases that are managed by specialists and beyond my scope.
Please realize that these are the commonly requested uses, not recommended uses.
The most common time that I’m asked about this type of testing is for kids with ADHD.
Many parents are afraid of side effects of stimulants and have heard of other children who needed many adjustments of medication, both type of drug and dosing.
Starting a new stimulant medication can be frustrating, especially if it takes weeks or months to find what works. Parents would like to avoid that and start with the best.
Unfortunately the tests currently available do not predict which medicine will be most effective. They test how it will be metabolized.
Many people who show best tolerability for a certain drug may find that drug ineffective in managing their symptoms. This is due to many factors, but in the end still leaves us with the need to do a trial of various medicines to find the best one.
Failure to find a beneficial medicine based on these trials may lead to reassessment to be sure the diagnosis is correct. Proper diagnosis is not tested with the pharmocogenetic tests.
Anxiety and depression
Anxiety and depression medications are another type of medicine that has many options, and some respond to one better than another.
The traditional way to start is to look at family history (which is also a study of genetics, although included in the cost of your visit and doesn’t include a lab). Unfortunately, many people do not know of family member’s specific health details, especially what medicines they were on and what their reactions were.
When we pick a medicine, we start with low doses, and increase as tolerated and needed. If the first medication doesn’t work or isn’t tolerated, it is stopped and another is tried. This can prolong the time it takes to feel better, which is significant, and likely the reason people want a quick answer with a lab test.
Unfortunately, much like the ADHD testing mentioned above, the tests don’t predict which medicine will manage symptoms best. They only predict how they will be metabolized.
Should you get tested?
I am excited for the future of personalized medicine.
We may no longer need to try multiple medicines to be able to see which are better tolerated. Starting near the target dose, rather than starting at a low dose and titrating up, which prolongs the time it takes to get to an effective dose, would be welcomed in many people.
Unfortunately, I think psychopharmalogical testing is not yet for prime time.
The FDA agrees. They’ve sent out warnings that these tests should not be used to help choose a medicine.
Just because your body will metabolize a medicine more slowly or rapidly doesn’t predict if it will be effective to treat your symptoms.
It is still very costly and insurance companies resist paying for it. With high deductible plans, many people must pay the cost. With the new FDA warning, it is unlikely that insurance companies will cover the cost of these tests anytime soon.
It is being widely used in cancer and HIV patients and has helped to prevent significant side effects that often lead to hospitalization. From an insurance company standpoint, they’re saving money by covering the test for these purposes. From a patient standpoint, they have added security that they will respond well to the treatment.
Have you read all of the most popular 2018 posts from Quest for Health KC?
At the end of the year I like to take a look at which posts were popular to help identify what I should write about in the next year. It also gives me the opportunity to share with readers all the best posts they might have missed along the way.
10. Help! I’m sick and I have a baby at home!
Parenting is a tough job, even when you’re not sick. When you have an infant and you’re sick, not only do you have extra sleep needs, but you have to try to keep your baby healthy despite being around your germs. What can you do when you’re sick with a baby at home?
During the summer months one of the most uncomfortable reasons I see boys is that their penis and/or scrotum is swollen significantly. Learn what Summer Penile Syndrome is and what to do about it.
7. Dark Under Eye Circles
When kids have circles under their eyes, parents worry that something’s wrong. Sometimes there’s a treatable reason, sometimes not. Learn all the most common causes of under eye circles and what to do about them.
6. The flu shot doesn’t work
I’m pro-vaccine, so this title might surprise you. I hear the argument that the flu shot doesn’t work so often that it deserves to be addressed.
5. Flu Season Fears: What should you do?
Every flu season as we start to hear reports of kids dying from influenza the fear surfaces. This was written during one of the worst outbreaks in recent history. Be protected against each flu’s season fear with a flu vaccine and healthy habits!
When saliva gets on our skin, it breaks it down. Licking the lips leads to increased cracking and bleeding. Some kids have a wide ring of dry skin around their mouth from lip licker’s dermatitis. Learn what you can do to help them heal their smile.
I’m surprised at the popularity of a few of these and sad that some of my personal favorites didn’t make the list.
I wish more people would read what fever is so they worry less about a number. Learning the evolution of illness might also help parents understand why exam findings are different on different days. I hear far too often that an ear infection was missed, but it’s more likely that they developed since the first exam.
I’ve also written a little on insurance and the business of medicine, but it doesn’t surprise me that those are not as popular. Sadly, we all need to understand the intricacies of billing and insurance as well as how the business of medicine works. As more and more private practice physicians sell out to large corporations, we’ll all feel the negative impacts.
When kids start to get sick, don’t you wish you could nip it in the bud before it gets worse?
If your kids have ever been sick, you know it can go from an annoyance to a fairly scary ordeal pretty quickly. When should you bring your kids to the doctor so we can prevent their symptoms from getting worse? We all want to know when we can nip it in the bud!
Can we prevent progression and spread of illness?
Mom: We’re here because my little one has a cold. It always settles in her ears, so I want to get on top of things and nip it in the bud this time.
Me: Her ears look great today, so keep doing what you’re doing. I’m glad you’ve started giving extra fluids, using saline in her nose, and letting her stay home from preschool to rest.
Mom: But we have family coming into town. They have a new baby, so I don’t want the baby to get sick. Can’t we just have an antibiotic now to help everyone?
Me: There’s no sign of a bacterial infection. She has what’s most likely a cold from a virus. Antibiotics don’t help.
Mom: But can’t we just try? She always gets an ear infection.
Me: It doesn’t work that way. Antibiotics don’t prevent ear infections. They don’t even treat the large majority of ear infections, since they’re viral.
Mom: But we’ll be around a baby.
Me: An antibiotic would give a false sense of security. Your daughter would still be contagious from the virus. Viruses can be very serious in newborns. Your daughter shouldn’t be around the new baby until she’s well.
Mom: But …
This circular conversation can continue indefinately.
I hear requests like this all the time. Unfortunately, illness doesn’t work that way. We don’t give antibiotics to prevent ear infections. They don’t stop the spread of most infections because most are from viruses.
If your doctor gave you antibiotics for your last cold “just in case” and you felt better, it’s likely you would have felt better anyway. That’s what happens with colds.
I realize when your baby has had several ear infections it seems tempting to give a treatment to prevent this cold from turning into another ear infection. But it doesn’t work that way.
Prevent the spread of viral illnesses.
Keep an illness from changing from a virus to a bacteria.
Make all sinus infections go away.
Treat all ear infections.
Make people feel better immediately.
Come without risk.
You take risks every time you use an antibiotic.
We need to use antibiotics wisely. Antibiotics are generally safe and most of us tolerate them well. But sometimes they lead to side effects, such as rashes and diarrhea. They can also cause true allergic reactions.
Over time bacteria can learn how to avoid being killed by antibiotics, called developing resistance. This can put us all at risk of deadly bacterial infections that have no cure.
But we have to get better fast!
Your teen has finals.
You must get back to work.
The baby being up all night fussing is wearing you down.
Your family has a big trip coming up.
You’re pregnant and you don’t want a sick family member in the home.
Whatever the circumstance, we can’t make someone not contagious anymore. It takes time for the symptoms of a virus to go away. There’s just no short cut. No way to prevent the natural course and progression.
Next week we’ll talk about what to do when you or your family is sick and how to prevent illness in the first place. (Prevention is always best!)
The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.
Many parents get scared when they hear the barky cough of croup. I’ve even been scared when my own children have it. I know what it is, but their breathing gets so labored that it’s scary.
Sounds of coughing
Parents describe many coughs as “croupy” but most of the time they’re mistaking a wet, mucous-filled cough for croup.
It can be difficult to sort out all the various sounds of coughing, which is why I previously gathered a number of videos into one blog.
The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.
What is croup?
Croup is a distinctive set of symptoms that occur due to inflammation around a young child’s voicebox in the larynx and trachea.
Many people describe a croupy cough as a seal bark sound. They often make a hoarse or squeaky sound called stridor when they inhale.
Croup often starts suddenly in the middle of the night.
What causes croup?
Croup is usually caused by viruses and tends to be most common in the Fall. The viruses that cause croup are common and usually cause runny nose or congestion and sometimes cause a fever.
One child may get full-blown croup, but another will get a simple cold with the same virus. Some kids seem to get croup often, while others may never get it.
Can older kids get croup?
Croup is most common in kids less than 5 years of age, but older kids can occasionally get it.
Older children and adults tend to get laryngitis with the same viruses that cause croup. Their airways are bigger, so the swelling that occurs near the voicebox isn’t as severe.
Croup is tricky
Croup often looks like a simple upper respiratory tract infection or cold during the day. Nothing to worry about…
In the middle of the night you will hear a sudden barking sound, much like a seal barking. A child with croup looks distressed and very sick at night, but seems much better the next day.
For many kids, it’s just one night of this scary cough, but it can last several nights in others.
Some kids continue to have what is called stridor or trouble talking during the day. Stridor is a hoarse sound that you can replicate by breathing in while tightening your vocal cords. It sounds like a squeak or wheeze as kids breath in. Stridor is due to the swelling near the vocal cords that’s found in croup.
This is a simple yet very helpful video to hear the sound of croup and for management tips.
How is croup diagnosed?
Croup is what we call a clinical diagnosis. No lab or x-ray is needed.
A doctor or nurse will ask questions about various symptoms, and if we hear the classic cough or stridor, it supports the diagnosis.
How is croup treated?
If you recognize croup, there are many at home treatments you can try.
Taking kids outside into the cool night air often helps soothe the airway.
If the weather isn’t appropriate, you can open your freezer door and let them breathe in that air. (This has never been my favorite advice because it means a sick kid will be breathing on the frozen food and then there’s the wasted energy…)
The airway can also be soothed by taking kids into a bathroom, closing the door, and turning the shower to the hottest setting. Just sit in the bathroom – not in the shower.
Usually after 10-15 minutes breathing normalizes.
One thing I learned when my son first had croup: don’t leave the bathroom as soon as breathing calms down. Turn off the shower and just sit there for awhile. We had a rebound croup that was less scary, but unnecessary, when we tried to get him back to bed quickly. Letting the room get closer to the home’s normal air quality before going back into the hall and bedroom is time well spent.
Humidifiers and vaporizers
When we’re sick in the dry weather months, I always recommend adding a vaporizer or humidifier to the bedrooms. This is especially helpful if a child is at risk for croup due to age.
What about medicine?
If kids are uncomfortable, you can use acetaminophen or ibuprofen as a pain reliever. These do not help the cough, but they can help with comfort.
Since steroids decrease inflammation, they are often used when kids get croup. These can only be used with a prescription and your doctor’s instructions. See your doctor if you’re interested in any prescription medicine.
Croup is often mistaken for wheezing, but it is not treated with a bronchodilator like asthma.
The swelling near the voicebox is much different than the smaller airway narrowing that occurs with wheezing, and the bronchodilators (albuterol or levalbuterol) work on the smaller airways.
If kids have asthma, they can wheeze from the same virus that leads to croup, and in that case their asthma medicine helps.
In the hospital or ER setting some kids will get a breathing treatment of epinepherine. This should only be done in a supervised setting so they can be properly monitored.
Croup is usually caused by a virus, so antibiotics don’t help.
There is also something called spasmotic croup, but that also is not treated with antibiotics.
When should kids go to the ER or their doctor?
Since croup is worst at night, most of the kids who need to be seen end up in the ER. If your child has stridor during the day, they can be seen at their usual doctor’s office.
If the above home treatments don’t work after about 15-20 minutes, you should take your child to be seen.
Kids who seem very anxious due to breathing difficulties will also benefit from a proper medical exam and treatment.
Trouble swallowing along with difficulty breathing should be evaluated by a physician.
If you notice that your child seems better leaning slightly forward while sitting, he should be seen.
Any child who is not up to date on vaccines, especially the Hib vaccine, should be seen with labored breathing. Epiglottitis is now rare, thanks to vaccines, but if a child isn’t vaccinated, it is still possible to get this. It can cause stridor, fever, difficulty breathing, and other similar symptoms to croup. Be sure the physician knows your child isn’t vaccinated!
One abnormal lab we see in otherwise healthy kids is a low absolute neutrophil count (ANC). This is also called neutropenia. Know when you should worry.
It is recommended to screen for anemia (low red blood cell or hemoglobin levels) around one year of age. Our office orders a complete blood count (CBC), which checks for red blood cells, white blood cells, and platelets – the main components of our blood. Sometimes we find things that we weren’t looking for. In the winter months, neutropenia is one of those things.
What is neutropenia?
One relatively frequent abnormal lab we see is a low absolute neutrophil count (ANC). A low ANC is also called neutropenia.
What are neutrophils?
Neutrophils are a type of white blood cell that fights bacterial infections. When their numbers get too low, it can increase the risk of serious bacterial infections.
While some people have low ANCs that cause significant immune deficiencies and can lead to infection, the most commonly seen low ANC we see are brief dips after a viral infection.
What causes neutropenia?
Most causes of neutropenia are due to infection, drugs, severe malnutrition or immune disorders.
The most common cause of neutropenia we see in otherwise healthy kids is due to a recent infection. In most cases this type of neutropenia quickly resolves without any treatment.
Some viruses, such as hepatitis B, Epstein-Barr, and HIV, are associated with prolonged neutropenias.
The drugs that can cause neutropenia are not commonly used medications. Routine testing for neutropenia would be done when those medications are used because the risk is known. That’s one reason why people with cancer treatments often have regular blood counts checked.
Vitamin B12, folate, and copper deficiencies are very uncommon in children, but can lead to abnormal blood counts.
Three levels of neutropenia:
The large majority of kids with neutropenia have only mild drops in their ANC and are not at significant risk of illness. In general the more severe the drop, the more significant the infection risk.
Mild neutropenia: The ANC ranges between 1000-1500/μL
Moderate neutropenia: The ANC ranges between 500-1000/μL
Severe neutropenia: The ANC is less than 500/μL
What do you do if there’s neutropenia?
Since most mild cases of neutropenia self-resolve, it is not usually anything for parents to worry about.
I used to recheck all of these, but found that many kids needed several rechecks because they always had a mild viral infection so the levels stayed suppressed (low). Despite the low ANC, they never got significantly sick.
Of course if there is another clinical reason, such as a significant illness or growth problems, following up even a mild lab abnormality is recommended. If kids start getting sick, their blood counts should be rechecked because of the clinical concern.
When kids are otherwise healthy, I find that we end up chasing abnormal levels if we try to recheck, so I’ve stopped rechecking automatically.
When a child is overall healthy and growing well, the level is only mildly low (above 1000) I do not recheck the level unless there is a clinical concern. If your doctor wants to recheck it (or if you want it rechecked), that is appropriate to do.
When the level is in the mid-range (500-1000) or if the child has had problems with recurrent infections or growth, a confirmation (repeat test) and possible further evaluation is more likely to be recommended.
If the level is in the severe range (less than 500), it should be rechecked and the child should be closely monitored due to high risk of severe bacterial infections.
Some physicians recommend repeating a blood count with any fever for a year in kids who have had any degree of neutropenia, so you’ll have to talk to your child’s doctor for a plan.
What symptoms might happen if the ANC is low?
Most children with a temporarily and mildly low ANC will have no symptoms and need no treatment.
Children with chronically low ANCs may have more infections that require antibiotics, such as pneumonia, skin infections (abscesses, cellulitis) and lymph node infections. They might also have chronic gum disease, mouth sores, or vaginal or rectal ulcers.
Common colds often contribute to the temporary dip in the ANC, but are not caused by the low ANC. A different type of white blood cell fights off viral infections, so the low neutrophil count is specific to bacterial infection risk.
Common symptoms seen with neutropenia:
Frequent significant infections (not just the chronic runny nose of a daycare kid)
Serious respiratory infections, including pneumonia or sinus infections
Skin infections (e.g. cellulitis, abscesses)
Multiple serious infections (e.g. meningitis, bone infections)
Lymph node infections
Vaginal, urethral, or rectal ulcers
When should you worry?
The level of ANC as well as the cause both determine the risk level.
Lower levels of neutrophils increase the risk of an overwhelming infection. An example would be when people are immune suppressed from chemotherapy they are at very high risk of bacterial infections.
On the other hand, an otherwise healthy person with a mildly low ANC is not more likely to get a bacterial infection than another person with a normal ANC.
If the child has any of the symptoms noted above or a very low ANC level, we start to worry more. Each case must be evaluated by the person who ordered the test and who has recently seen your child.
What treatment is done for a low ANC?
Most children do not need any specific treatment. They are monitored for recurrent infections, especially infections that require antibiotics. They are also monitored for growth, since if a body is chronically sick, it often doesn’t grow well.
Each infection that requires antibiotics is treated and blood counts might be checked to see how low they are at the time.
In children who have a chronically low ANC or a significant illness with a low ANC, a hematologist (blood specialist) is often consulted. They help evaluate why the ANC is low and if it requires a special treatment that stimulates the bone marrow to make more neutrophils.
Play is an important part of every child’s day. Recess should never be held for behavior modification. Chris Dendy shares important facts in this post.
I’m amazed at the number of parents who tell me that their child misses recess to finish homework or as a consequence for inappropriate behavior. It seems counterintuitive to restrict play when kids are unfocused or behaving out of line. We now have a lot of research on how kids with ADHD don’t respond to typical behavioral modifications. It’s not really a choice for them to do the behaviors they’re doing, so trying to offer recess as a reward just doesn’t work. With all this accumulated research, it’s surprising that some schools and teachers continue to support restricting recess.
Today’s blog is from Chris Dendy, an expert on ADHD. She is an acclaimed author and speaker. Chris has worked as a classroom teacher, school psychologist and mental health counselor. She’s worked as local and state level mental health administrator, has been a lobbyist and has served as executive director of a statewide mental health advocacy organization and as a national mental health consultant on children’s issues. Her Facebook post below shows the importance of recess.
I have edited her original post to make headlines more visible, but I did not change the content at all. See her original post linked at the bottom of this page.
BOTH AAP & CDC STRESS THE IMPORTANCE OF PLAY
EVERYONE SUFFERS WHEN YOU WITHHOLD RECESS:
When recess is withheld as a punishment for misbehavior or incomplete academic work, both teachers and children suffer. Teachers who know their research never withhold recess and here’s one key reason why:
“misbehavior is higher on days when children with ADHD don’t have recess.”
CHILDREN’S BRAINS WORK BETTER AFTER EXERCISE:
After exercising, students show improved attention, retention of information, working memory, mood and social skills. School officials also report a reduction in school suspensions. Students with better fitness levels earn higher scores on academic achievement tests.
EXERCISE GROWS NEW BRAIN CELLS:
Interestingly, John Ratey, M.D. a well-known psychiatrist, describes exercise as “Miracle-gro” for the brain because it actually builds new neurotransmitters and increases blood flow to the brain. The author of How the Brain Learns, Dr. David Sousa, explains that “down time” is needed to allow the brain to recharge and process new information. Recess provides this much needed recharging time.
IF A STUDENT IS CONSTANTLY MISSING RECESS, LOOK FOR UNIDENTIFIED LEARNING PROBLEMS:
One of the most common reasons for keeping students in during recess is to complete unfinished work. Instead of withholding this important activity, educators must determine the underlying reason for the failure to finish the classwork and implement a preventive strategy: utilize positive interventions instead of punishment!
For example, the culprit may be deficits in executive skills including inattention, difficulty getting started, or slow processing speed. Secondly, many students with ADHD have trouble getting started on their work and must be given an external prompt to start working. Finally, twenty-eight percent of children with ADD inattentive have slow processing speed. Children who struggle with this slow processing should be provided shorter assignments and/or extended time.
Unfortunately, researchers report that many of our children are on doses of medication that are too low for peak academic performance. Even though they are on medication, students with low medication doses will have problems paying attention and working efficiently. Teacher rating scales of classroom performance are available that reflect how well medication is working.
INCREASE MOVEMENT THROUGH “IN-HOUSE FIELD TRIPS:
Veteran teacher Jackie Minniti, suggests giving “in-house field trips” to allow increased movement and subsequent increased blood flow to the brain: for instance, give out supplies, close the door, take a note to the teacher across the hall that simply says, “Hi”, and then the student returns to his class. Doing jumping jacks or dancing to music in the classroom can be very helpful. Minniti’s positive incentives include rewarding timely work completion with five minutes extra recess time or giving stars on a chart toward a class pizza party.
FIND VOICE OF REASON AT SCHOOL OR ASK YOUR DOCTOR OR PSYCHOLOGIST TO WRITE A STATEMENT SAYING RECESS SHOULD NOT BE WITHHELD.
If you have a reasonable teacher, talk with her about trying these positive intervention strategies first instead of punishment. If you think the teacher will not be receptive to your suggestions, then consider getting a note from your physician stating that your child must have recess each day. The next step will be to ask that deficits in executive skills and the need for recess be addressed in an IEP or Section 504 plan. If the teacher fails to comply with these requirements in the IEP, you will have to approach the guidance counselor, special education coordinator, or principal for assistance.
THE CENTER FOR DISEASE CONTROL (CDC) STATES THAT RECESS SHOULD NOT BE WITHHELD AS PUNISHMENT:
Because of growing concerns about obesity and other chronic diseases, Congress passed the “Healthy, Hunger-Free Kids Act” in 2010 that resulted in the Centers for Disease Control in Atlanta developing guidelines in several areas including recess.
Each local school system that has a National School Lunch Program must develop a school wellness policy to address Congressional concerns. The CDC expressly states, “Schools should not use physical activity as punishment or withhold opportunities for physical activity as a form of punishment.” Exclusion from recess for bad behavior in a classroom (including incomplete academic work) “deprives students of physical activity experiences that benefit health and can contribute toward improved behavior in the classroom.”
AMERICAN ACADEMY OF PEDIATRICS (AAP) STATES UNSTRUCTURED FREE PLAY IS CRITICAL:
Here are highlights adapted from their policy statement.
1. Eliminating recess may be counterproductive to academic achievement. Recess promotes not only physical health and social development but also cognitive performance.
2. Creative supporting free play as a fundamental component of a child’s
normal growth and development.
3. Recess is a necessary break in the day for optimizing a child’s social,
emotional, physical, and cognitive development.
4. Recess may help provide the recommended 60 minutes of moderate to vigorous activity per day to fight against obesity.
5. Recess offers the opportunity to build lifelong skills required for communication, negotiation, cooperation, sharing, problem solving.
Updated from Dr. Dendy’s original article published in ADDitude magazine.