Bike safety starts before you even get on the bicycle.
Summer’s in full swing. I love to see neighborhood kids out playing. We don’t see that enough these days. I want kids to have fun outdoors for fresh air and exercise. Bike safety should be taught early on and encouraged every time people young and old are on bikes.
Twice already this summer kids have told me about friends who had ugly accidents due to wearing flip flops or sandals on a bike. My patients hear the message to cover their heads with a helmet and feet with proper shoes before bikes and scooters. These kids listened but not their friends.
My favorite bike safety tips are in this easy to read and share infographic.
Two measles vaccines are part of the standard vaccine schedule in the US. Do you know when outbreaks change the recommendations?
In my last post I discussed why we should worry about measles. Today I’ll talk about the measles vaccines available to prevent the disease.
What measles vaccines are available?
There are two types of measles vaccines in the United States: MMR and MMRV.
There is no longer a separate measles vaccine available in the US.
MMR
The MMR includes protection against measles, mumps, and rubella. This vaccine can be used in infants 6 months and older and is the only vaccine approved over 13 years of age for those who need to catch up on vaccines.
In addition to measles, mumps, and rubella, the MMRV has protection against varicella (chicken pox). The MMRV can be used from 12 months through 12 years of age (until the 13th birthday).
Using the MMRV vaccine has the benefit of one fewer injection, but there are some downsides.
It cannot be used as an early dose of measles protection prior to 12 months of age.
The MMRV should not be used in those 13 years and older.
The MMRV has a higher risk of fever within 42 days after vaccination compared to the MMR and Varicella vaccines being given in separate injections, even when they’re given on the same date in children 12-24 months of age. There is less data on children 24-47 months of age, but it is likely that they also have this increased risk.
The MMRV has a higher risk of febrile seizures from 5-12 days after vaccination compared to the MMR + Varicella being given in separate injections, even if given on the same date.
What is the typical age of vaccination?
One of the measles vaccines is recommended routinely at 12-15 months and then again at 4-6 years.
Either the MMR or the MMRV can be used at these standard times.
If the MMR is used, a separate varicella vaccine can be used at the same time or at a different time.
Can the 2nd dose be given early?
Yes. An early 2nd dose does count as the second dose as long as it is separated by at least 28 days from other live virus vaccines.
Early second doses do count toward the required two doses after the first birthday. There is no minimum age for the second dose, as long as both doses are after the 1st birthday and a month apart.
What does the booster dose do?
Contrary to common belief, the MMR/MMRV second dose is not a booster to increase the immunity of the first dose.
About 93% of people respond to their first measles vaccine and are protected against the measles. They are protected and wouldn’t need a booster, but we can’t easily tell if any individual person is immune after the first dose. It is also possible that a person is immune to some of the MMR/MMRV components but not to all of the components, so another dose is needed for protection to be more reliable.
The second vaccine helps more people convert to being immune. After the second dose, 97% of people are immune to measles.
There are some people (3%) who are not immune despite two doses, which is why we sometimes hear of a vaccinated person still getting the disease.
Herd immunity is one reason why it is important for everyone in a community who is eligible to get the vaccine to be immunized. By immunizing the community, we can protect those in the community who are not able to be vaccinated due to young age or medical condition and those who are vaccine non-responders.
High risk situations: outbreaks and travel
It is recommended to receive an MMR (or MMRV if age indicated) if there is a local outbreak and the health department recommends an early vaccine or if an infant 6-12 months of age will be traveling to an area of increased risk.
Infants and children in high risk areas can get the second dose as early as 4 weeks after the first.
Either of the measles vaccines can be used as long as they are indicated for the age of the person being vaccinated.
More about early doses
MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks.
It is not recommended for all babies to get an early vaccine at this point.
Local health departments help to advise whether or not local conditions warrant early vaccination.
International travelers should be vaccinated against measles after 6 months of age due to the higher risk of exposure during travel.
Why not give to babies under 6 months?
Under 6 months of age an infant is considered protected from his or her mother’s antibodies. These antibodies leave the baby between 6 and 12 months after birth.
The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday, when the antibodies have likely gone away.
Does an early dose count?
Any measles vaccine dose given before the first birthday does not count toward the two doses required after 12 months of age, but might help protect against exposure if the immunity from the mother is waning.
As mentioned above, an early 2nd dose does count as long as the first dose is after the 1st birthday and the second dose is at least 28 days later.
Is it safe to give the MMR before 12 months?
It is safe for a child to get extra doses of the vaccine if needed for increased risk of exposure between 6 and 12 months.
As discussed above, it is not because of safety that it is not routinely given earlier. It may not be effective at this age if the baby still has maternal immunity.
What’s the deal with live virus vaccines?
All live virus vaccines must be given either on the same date or a month apart. If they are given too close together on different dates they are less effective and the second one given does not count.
Other types of vaccines do not have this restriction, only live virus vaccines.
Examples of live virus vaccines include:
MMR
MMRV
Varicella
FluMist (only the nasal influenza vaccine, not the injectable flu vaccine)
Oral typhoid (not on the routine vaccine schedule, but recommended for international travel)
BCG (a vaccine against tuberculosis that is used in some countries, but not the US)
Oral polio (a vaccine no longer used in the US, but still in use in other countries)
Yellow fever (not on the routine vaccine schedule, but required prior to visiting some countries)
Zoster (a vaccine for older adults, not children)
For example…
If your child has FluMist (the nasal flu vaccine) on October 1st, if he or she gets the MMR or MMRV on October 15th, the MMR/MMRV won’t count.
This is becoming more difficult to track as pharmacies, work places, and other clinics offer vaccines. I can think of one instance where a parent had a child get a nasal flu vaccine a couple of weeks before the other parent brought the child in for kindergarten shots. The 2nd parent was not aware of the flu vaccine, so the live virus vaccines given at the routine well visit had to be repeated a month later. The child was not happy!
Always get documentation of the vaccines your child gets and be sure if it’s not done at your child’s primary care office that they get a copy! If you’re transferring to a new physician, request a transfer of records in writing before your first visit to your new medical home so they have what they need to best care for your family!
Tuberculosis testing with PPD
Although this is not a live virus vaccine, tuberculosis testing can also be affected by live virus vaccines.
A false negative skin test can occur if any live vaccine is given during the month BEFORE the TB skin test is done.
If MMR vaccine is given, you should wait at least 4 weeks before doing the TB skin test unless it is given on the same date.
All vaccines, live or inactivated, can be given on the same day or at any time AFTER a TB skin test is done.
What if someone who hasn’t been vaccinated is exposed to measles?
Unvaccinated people who are exposed to measles can be given post-exposure prophylaxis unless they have a vaccine contraindication.
If the MMR vaccine is given within 72 hours of initial measles exposure it may provide some protection or lead to a less severe infection.
Immunoglobulin (IG) can be given within 6 days of exposure to provide some protection.
If you think you’ve been exposed, contact your physician and/or the local health department.
Who shouldn’t be vaccinated?
The long list of medical contraindications to vaccines that some promote is not valid. There are very few contraindications to getting the MMR vaccine. These include:
Age less than 6 months of age
Anyone who has had a severe allergic reaction (anaphylaxis) after a previous dose or to a vaccine component or neomycin
Those with a known severe immunodeficiency (chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy, and some with human immunodeficiency virus [HIV] infection)
Pregnant women
Some conditions have precautions, but not true contraindications, to the MMR vaccine. The risks and benefits of vaccination should be discussed if a person has the following:
Moderate or severe acute illness
Tuberculosis testing (see separate section above)
Antibody-containing blood products within the previous 11 months
Those who have received a live virus vaccine in the previous 4 weeks
Seizure history
What about adults?
People born before 1957 are presumed to be immune to measles because they lived through several measles epidemics before the vaccine became available.
It is not considered necessary to check titers for these adults unless they are in a high risk group, such as healthcare providers. If their titers do not show immunity, they should be vaccinated according to current recommendations.
Adults born after 1957 should have documentation of two measles vaccines or the disease. Before 1980 it was only recommended to have one vaccine, so some adults may require another dose.
If documentation is not available, titers can be done to see if you’re immune or need a vaccine. Some may choose to simply get an MMR. Talk to your doctor.
Checking titers
Titers can show if people are at risk, but are not recommended routinely. Because of the overall high level of protection (97%), the cost-benefit ratio of testing titers routinely is not in favor of testing.
Certain persons, such as healthcare providers, may have to show immunity or get additional vaccine doses.
In summary
Two doses of one of the measles vaccines available is recommended for everyone after their first birthday. A dose can be given between 6 and 12 months if there is high risk but it does not count toward those two.
The MMR vaccine can be used in any person over 6 months of age if they are needing a measles vaccine, as long as they have not received another live virus vaccine in the previous 28 days.
The MMRV vaccine can be used between 12 months and 13 years of age. There is a higher risk of fever and febrile seizures with this vaccine compared to the MMR + Varicella vaccines given separately (even on the same date).
The first measles vaccine provides protection 93% of the time. The second dose increases the protection to 97% of people.
It is very important that where you are getting your vaccines has access to previous vaccines given, especially if you are getting any live virus vaccines. Keep a copy of all your family member’s vaccines available at all times.
If you are changing primary care physicians for any reason, have your records transferred prior to your first visit. This must be done in writing, but your doctor must provide these. The cost of these records will be determined by the hospital or clinic and state laws.
Always keep records of your family’s vaccine records easily available. You will need these for school entry, many camps, some volunteer or work positions, and more.
Getting one of the measles vaccines is not the only type of vaccine to get. We’re seeing outbreaks of measles currently, but any of the vaccine preventable diseases can make a come back if given the opportunity.
Why is everyone so worked up about the measles showing up all around the country? Is it really a big deal?
Measles is a big deal. If you understand that, you can stop reading right now. If you’re not sure why it’s so important that we vaccinate against this disease, read on. If you’re worried about the vaccine and haven’t protected your children with it, you need to learn about the disease.
Measles is highly contagious.
But it’s also preventable.
If all eligible persons are vaccinated, we can protect those who can’t be vaccinated due to young age or medical condition. This herd immunity is very important to our communities. Sadly, our herd is not protective at this point. Too many are not vaccinating due to unwarranted fears. This leaves too many vulnerable to disease, which allows infection to spread rapidly.
There are a very limited number of conditions that are true medical exemptions, but if herd immunity is high enough we can keep measles from spreading. Using false exemptions drops that herd immunity rate, leading to outbreaks like we’re seeing now.
We’ve been getting a lot of questions about the vaccine and the risks of the disease, so here’s a quick run down of the risks of a measles infection. I’ll cover the vaccines in the next post.
Why worry?
Measles is highly contagious and can be deadly.
Symptoms commonly include fever, rash, diarrhea, pneumonia, and ear infections.
Subacute sclerosing panencephalitis (SSPE) is a rare form of chronic progressive brain inflammation caused by measles virus. It can show up many years after someone is presumed to be healed from the disease, much like shingles can affect a person years after chicken pox disease.
For every 1,000 reported measles cases in the US, approximately 1 case of encephalitis (brain inflammation) and 2-3 deaths is found. The risk for death is greater for infants, young children, and adults than for older children and adolescents.
How contagious is measles?
Measles can be spread through the air of a room 2 hours after an infected person leaves. The rash doesn’t usually appear until approximately 14 days after exposure, 2 to 4 days after the fever begins.
A person is contagious 4 days before the rash starts, so can unknowingly spread the infection for days. They remain contagious for another 4 days after the rash starts.
Over 90% of susceptible people who are exposed will get sick.
Are you willing to put your kids at risk by delaying the vaccine knowing the risks of natural infection?
What vaccines are available?
There are two types of measles vaccines in the United States: MMR and MMRV.
There is no longer a separate measles vaccine.
We’ll go into these options next time. Stay tuned!
Drowning is one of the most common preventable causes of death in infants, kids, and teens. Learn how to protect against this tragedy!
Summer is on its way. We’ll soon be visiting lakes and pools to cool off from the heat. Unfortunately drowning is the leading cause of unintentional injury-related death in children between ages 1 and 4. It continues to be a top cause of unintentional death among other age groups through the early adult years. Fortunately there are many precautions we can take to help lower the risk.
I wrote about Sun and Water Safety last summer, and want to remind everyone about the risks of drowning. I also wrote about Dry Drowning previously, but it seems that it isn’t really a thing – see the addendum in that post.
About 1 in 5 people who die from drowning are children 14 and younger. Each year about 300-500 children under 5 years of age drown.
For every child who dies from drowning, another five receive emergency department care for nonfatal submersion injuries. Even though they’re not fatal, they have significant consequences.
Over half of drowning victims treated in emergency departments require hospitalization for further evaluation and treatment. These nonfatal drowning injuries can cause severe brain damage that may result in long term disabilities such as memory problems, learning disabilities, and a permanent loss of basic functioning.
What increases the risks?
Lack of Swimming Ability: Many adults and children report that they can’t swim. Swimming lessons can reduce the risk of drowning among children. See the link at the bottom for more on swim lessons.
Lack of Barriers: Barriers, such as pool fencing and alarm systems, prevent young children from gaining access to the pool area. A 4-sided fence reduces a child’s risk of drowning 83% compared to 3-sided fence with the house as the forth side. A great guide on barriers is from the US Consumer Protection Service.
Lack of Close Supervision: Drowning can happen quickly and quietly anywhere there is water. This includes bathtubs, swimming pools, pet water bowls, and buckets. This is why non-swimming times account for most drowning accidents.
Location: Most children 1-4 years of age drown in home swimming pools. More than half of the drownings among those 15 years and older occurred in natural water settings, such as lakes.
Failure to Wear Life Jackets: Most boating deaths are caused by drowning, with 88% of victims not wearing life jackets.
Alcohol Use: Among adolescents and adults alcohol use is involved in up to 70% of deaths associated with water recreation.
Seizure Disorders: For persons with seizure disorders, drowning is the most common cause of unintentional injury death, with the bathtub as the site of highest drowning risk.
How can you recognize drowning?
Movies show people splashing around and yelling for help as they drown.
Don’t let that fool you. Movies are not reality.
Signs of drowning:
Head low in the water, mouth at water level
Eyes glassy and empty, unable to focus
Head tilted back with mouth open
Eyes closed
Hair over forehead or eyes
Not using legs – Vertical
Hyperventilating or gasping
Trying to swim in a particular direction but not making headway
Appear to be climbing an invisible ladder
Trying to roll over on the back
Most drowning victims are silent. They don’t splash to get your attention. Watch this video from Inside Edition that captures several drowning victims:
Teach water safety
Learn how to swim and teach your children to swim as well. If your child(ren) are good swimmers, be sure to still have rules about pool use and limit pool access. Even strong swimmers can drown. See the link in the resources below for infomation on swim lessons.
No one should swim alone. If your children are not able to follow that rule, the pool should not be accessible to them. Gates and alarm systems can be used to limit access to home pools and hot tubs.
Not all teens are safe swimmers, but they don’t often fess up to their friends. They are also at risk of making impulsive decisions to drink alcohol near water, forego their life vest on a boat, jump off a cliff into water, or other things that could put them at risk. Talk to your teens about safety – in and out of the water! Encourage teens to learn CPR.
All pools should have a 4 foot fence around all sides. This includes below-ground pools as well as portable pools. It is much less safe to use the house as one of the borders, since young children can escape out the door and into the pool, but if you must use your home, take precautions. Install an alarm system to alert you if the door to the pool area is opened. Use a pool or spa cover when the pool or spa is not in use.
A short word on portable pools. They can include inexpensive blow up pools and larger pools. Portable pools present a real danger to young children because they are often not seen as a threat. Portable pools account for 10% of the total drowning deaths for children younger than 15 . They should be drained, covered, or fenced to protect children. Don’t leave them in the yard unattended.
Ask neighbors to put a proper barrier around their pools or hot tubs.
Ensure any pool or hot tub (spa) you use has anti-entrapment safety drain covers.
Have life saving equipment such as life rings, floats or a reaching pole available and easily accessible.
From https://downloads.aap.org/DOPA/Drowning-Prevention/pool_safety_english.pdf
It’s not just pools that are risks…
Bowls and buckets
Keep pet water bowls out of reach of young children.
Drain any buckets of water after they’re used.
Toilet dangers
Close bathroom doors and toilet lids to keep young ones from playing in the water.
Bath time
Monitor young kids and those with seizure risks in the bath the entire time. Do not leave the room even for a few moments.
Don’t read or check your phone when you’re watching kids in the tub, just like at the pool.
Drain the bath tub before young kids even get out. This not only helps your kids not climb back in (a common reason to need stitches when kids slip trying to climb in), but it also prevents them from drowning in left over water.
It’s not just Momo… Even if she started as a hoax, we DO need to protect our kids online.
The news is full of stories about Momo and other scary things our kids are exposed to online. Many stories say this is a hoax. YouTube has said this would be against their rules. It doesn’t really matter if this started as a hoax or if it’s against the rules. The fact is that our kids are exposed to things online.
Our kids do see inappropriate things
I recently saw a preschool aged child for a well visit. During the visit it came up that the child had been exposed to Momo online. When the mother learned that the child saw scary Momo videos, she came up with a great plan. They took images of Momo and transformed her into funny faces, much like what I did for the image above.
I think this mother’s idea is great. She took a character that was scary to her child and made it funny. She used the opportunity to talk to her child. It became a great teaching moment.
Our kids can never “un-see” what they’ve seen, but we can help them to not view it as so scary. If you are unable to do this alone, talk to your pediatrician or a therapist.
We know that traumas impact a child’s development. They can develop significant anxieties and suffer if things are not quickly and adequately addressed.
When things happen we need to find ways to help our kids process them. If your child’s mood or behavior suddenly changes, it is quite possible that they have experienced a traumatic event of some sort. If they won’t talk to you, seek professional help.
What can we do to prevent online exposures?
We can’t stop all exposures, but we can do many things to help protect our kids. This includes monitoring software, anti-virus software, and teaching our kids how to behave responsibly and safely.
Increasing responsibility
Our kids will be online, whether it’s at home or at school or at a friend’s house. They are growing up with the world at their fingertips through the internet, so we must teach them to use it wisely.
Like in other benefits and responsibilities of growing up, our kids should have fewer limits and less monitoring as they show maturity. We cannot expect them to be responsible online at 18 years of age if they never practice with supervision along the way.
Give your kids age-appropriate allowances for games, videos, and other online experiences. I love to use Common Sense Media to learn about movies, games, and other media.
Set up parental controls.
Research parental control software. It’s easy to search “parental control apps” or “parental control software reviews” to find the pros and cons to various brands.
Choosing the best for your family is not easy, but read several reviews to find what is best for your family’s needs.
Adult supervision and guidance
If our kids are playing outside, they will have close supervision when they’re young, less as they get older.
Online use should be no different.
Your 3-4 year old should not go to the park alone and they shouldn’t go online alone. If they are online, project the screen to the television so you can watch along or sit with them and play along with them. They should not be online when you are busy doing something else. It is not a safe babysitter.
As kids get older and can understand how to navigate the internet more safely, they can have less and less direct supervision. This does not mean they can have a free for all. Parents can still help them choose age-appropriate sites and have software to keep blocked sites from being accessible.
You can’t just avoid online use
Several parents over the years have tried to end the conversation when I bring up social media safety by saying, “we don’t allow any of that.”
It is not sufficient to simply not allow any social media. Our kids and teens will come across it, whether it’s their own account or a friends.
What things did you do as a teen that your parent didn’t know about? It’s even easier for kids to hide social media accounts than it is for them to do many of the things we used to do as kids.
As kids grow
Talk to older kids and teens about why pornography sites are harmful.
Have discussions about oversharing. Predators look for ways to identify where kids hang out. Kids shouldn’t give a team name or mention that their soccer game is tomorrow morning at 9. That innocent information can help a predator find them. Even photos with identifying information, like a school shirt or team jersey, can be risky if shared publicly.
Kids sometimes get tricked into sharing photos that are inappropriate. This includes pornographic images as well as snapshots identifying where to find them.
Talk about their digital footprint. Schools and employers will look at your child’s online history. It needs to be positive and what they post today will be there forever.
Teach kids basic right and wrong
We cannot protect our kids from everything, but we can teach them to be good decision makers.
Use real life examples and daily experiences to help your kids learn to make safe choices. Let them accept more responsibility and make more choices as they get older. Allow them to make the wrong choice sometimes. They’ll learn from these little mistakes much more than they would if you refuse to let them do that little mistake. This helps to prepare them to make the right choice with the riskier options as they grow.
For example, if your middle school child wants to stay up late to watch a movie but you know he has an early soccer game, discuss the situation with him. Let him make up his own mind in the end – without being judgmental. If he struggles getting out of bed and disappoints his teammates because he’s too tired, is that really the worst thing in the world? I bet the next week he won’t beg to stay up late so much. Just don’t play the “I told you so” game or give attitude about it. That will make him mad at you.
Let kids learn from their own mistakes without discussion or lecture. Kids learn from things like this if we let them. Trust me, there are lots of opportunities for them to learn to make safe, responsible choices as they grow.
In the end, if our kids want to find an inappropriate site or do something they’re not supposed to do, they will. If they use good judgement and make safe choices in other aspects of life, they are more likely to do so online too.
Be vigilant
It’s not just Momo… Even if she started as a hoax, we DO need to talk to our kids about risks online.
Follow your kids on their social sites. Talk about what sites they can and cannot use, but remember that it is easy for them to set up hidden accounts. That’s why it’s so important to talk to your kids and let them make their own choices as they grow. If you don’t allow options and never let them fail, they will not learn. The more you restrict them, the more they’ll hide from you.
Keep track of the time your child spends online. Go to your app store and search “time on phone tracker” or check out these popular apps that track time:
Moment (currently iOs only, but Android version coming)
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.
Use saline to irrigate the nose. They sell drops, sprays, and nasal wash systems to be used, depending on age and personal preference.
Hydrate
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.
Clean air
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.
Rest
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.
Dry 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.
Infection control
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.
Stay home!
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.
Wash
Before preparing food
After toileting or changing a diaper
When they’re obviously soiled
Before eating
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.
Vaccinate.
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.
What is developmental age?
Kids with ADHD have a delay in brain development that affects the ways they organize, process, and act upon information.
Chronologic age
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.
Developmental 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.
Setting expectations
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.
Recommended Video
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)
Fever
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)
If you’re wondering what type of cough your child has, check out The sounds of coughing.
Causes of bronchiolitis
Most cases of bronchiolitis are due to viruses.
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.
Prevention
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.
Testing
Virus testing
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.)
Oxygen levels
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.
Chest x-ray
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 work
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.
Treatments
The virus must run its course and symptoms can last several weeks, so what can you do to help ease symptoms?
Home treatments
Comfort measures
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!
Use saline
Saline can help thin out mucus and decrease the swelling of nasal tissues.
It can be used with or without sucking afterward. I talk a bit more about the benefits of saline in How to use nose sprays correctly.
Elevate the head
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.
Fluids
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.
Hospital treatments
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.
ADHD
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.
