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How To Use Nose Sprays Correctly

Nasal sprays are the preferred treatment for allergies based on guidelines, but I hear many reasons why people don’t use them. Some simply think they don’t work well. Others have gotten nosebleeds. Some simply don’t like the bad taste they get from using them. If used incorrectly you’ll taste medicine or feel a drip down the back of your throat. Nose sprays won’t work as well if used incorrectly and they might even traumatize the nose, leading to nosebleeds – and that traumatizes some kids and many of their parents. Using them correctly can help alleviate symptoms of allergies and allow kids to enjoy the great outdoors!

Start by using the right nose spray – or sprays

There are many nose sprays out there, and you need to be sure you’re using the correct product for your needs.

First you’ll need to know that allergy symptoms are caused by histamines. In a person who is sensitive to pollen, dust mites, or animal dander, histamine is released in response to exposure. The histamine can cause swelling of the nose or eyes, watery eyes, runny nose, and itch. Allergy treatments either focus on limiting allergen exposure, preventing the histamine release, or blocking the histamine response.

All of the nose sprays used for allergy management (except saline) are listed on the American Academy of Allergy Asthma & Immunology ALLERGY & ASTHMA MEDICATION GUIDE.

Saline

Saline is great for the nose. I actually prefer saline washes over saline sprays, but the sprays are good too. See the 2nd video below for why I love saline washes.

Saline helps to remove the pollen from the nose to limit the exposure time. It also helps to shrink swollen nasal tissues, which makes it easier to breathe, and loosens mucus to help get it out.

Saline is just salt water, so if you want something natural, this is it!

Many parents ask how often to use saline sprays, and it really can be used whenever it’s needed. For prevention of allergies, use it after going outside and before bed during pollen seasons. If you’re using it because of a stuffy nose, you can use it several times a day.

Saline can be used even in babies. If you use saline spray or saline drops they can be followed with blowing the nose (or using an aspirator).

I love to use saline first followed by a good blow (or suction) to clear out the nose. After the nose is cleared, if that’s not sufficient to last the whole day, the other sprays are more effective. Saline doesn’t have medicine to last several hours, but can be used before medicated sprays to help them be more effective.

Mast Cell Inhibitor

Cromolyn sodium is a mast cell inhibitor that can be used for allergies. It prevents the release of histamine, which causes allergic symptoms.

Cromolyn sodium must be started 1-2 weeks before pollen season and continued daily to prevent seasonal allergy symptoms. It doesn’t work as well as corticosteroid nasal sprays, so I generally don’t recommend cromolyn.

These sprays can be used in children as young as 2 years of age.

The biggest drawback is that it is recommended every 4 hours, up to 4 times a day. This is really hard to keep up every day during allergy season.

Antihistamine

If you don’t want the dry mouth or sleepiness associated with an oral antihistamine, you can try a nose spray antihistamine. Both oral and nasal antihistamines block the histamine from causing the typical allergy symptoms.

Antihistamine nasal sprays are approved for use down to 5 years of age.

Corticosteroid sprays tend to work better in the long run, but antihistamines are effective more quickly, so are good for rapid relief.

Antihistamine nose sprays are only needed once or twice a day, but since most kids like oral medicines better than nose sprays and you shouldn’t duplicate with both, I generally recommend that antihistamines be given orally.

Decongestant

Decongestant sprays are popular because they work quickly, but I rarely recommend them. The most common time I use them is to help get things stuck in the nose out.

Oxymetazoline hydrochloride (Afrin, Dristan, Sinex) and phenylephrine hydrochloride (Neo-Synephrine) are some examples of nasal spray decongestants. They are available over the counter.

Decongestant sprays shrink swollen blood vessels and tissues in your nose that cause congestion.

They can be used temporarily in kids over 6 years old, but if you use them longer than 3 days they actually cause more congestion.

Steroid

Corticosteroid nasal sprays can be used in kids over 2 years of age and are the preferred treatment in allergy guidelines because they work well.

These can be used once or twice a day year-round or just as needed for allergy relief. It’s best to start them 2-3 weeks before allergy season starts because it does take time for them to be most effective. If you forget to use them until symptoms start, it may take several days to feel benefit.

Corticosteroid nasal sprays are available over the counter. There are many brands, including less expensive store brands. They have various steroid active ingredients, but all work pretty well.

I generally recommend the non-fluticasone brands for kids. This is not because of the effectiveness of fluticasone. It works. But it smells flowery and many kids will resist it due to the smell.

Nasal steroids are approved for use to help allergies, but they also decrease the amount of mucus from other causes, such as the common cold.

If you’re worried about the side effects of steroids, know that the risk is very low with nasal corticosteroids. The dose is extremely small and nasal corticosteroids are considered to be safe for prolonged use, even in kids.

Because they work so effectively and are well tolerated, nasal steroids are my preferred allergy medicine. They can be used with antihistamines if needed.

Anticholinergic

Ipratropium is the ingredient in anticholinergic nasal sprays. It helps to decrease a runny nose by stopping the production of mucus. One downside to ipratropium is that it doesn’t help congestion or sneezing very well.

Ipratropium nasal spray can be used over 5 years of age for up to 3 weeks at a time for runny noses from allergies and colds.

It is available by prescription only and I’ve never personally prescribed it. I personally think it has too many limitations and few benefits.

Allergen blocker

I have to admit that I’ve never even heard of this before, but I saw it on the American Academy of Allergy and Immunology site referenced above.

Alzair produces a protective gel-like barrier that evenly coats the nasal membranes and acts to block inhaled allergens within the nasal cavity. It’s available by prescription and looks like it’s approved for kids 8 and over.

One downside is that it needs to be used every time you blow your nose, so I don’t see it useful for school aged kids who have to go to the nurse for all treatments.

If anyone has used it, I’d love to hear your comments below about how it works!

Using nose sprays – it’s all about technique

Most people use nose sprays incorrectly, even if they pick the right one.

It’s not intuitive how to use them correctly. We tend to aim towards the center of the nose (which leads to nosebleeds) and inhale too much (which leads to icky drip down the throat).

Getting ready

Blow your nose. Or even better, rinse it with saline!

Take off the cap. You’d be surprised how many people skip this step.

Shake the bottle before each use. Think of Italian salad dressing. If you don’t shake it, you won’t get the good stuff.

You will need to be sure the tube inside the bottle has the liquid in it if it’s a new bottle or hasn’t been used in awhile. Much like when you get a new pump soap, you need to pump a few times to get results. Once you see the mist come out, you know the medicine’s ready to spray out.

Positioning

Be sure to keep the bottle fairly upright during the spraying. See the 1st video below for why this is important.

Many people tilt their head back when using nose sprays. Don’t. You’ll get more drip down your throat and less effective spray onto the nasal tissues.

Look slightly down.

Put the tip of the spray bottle into the nose and aim toward the back of the eye on the same side of the head. Don’t ever aim toward the center of the nose. This causes nosebleeds. Use the right hand to spray the left nostril and the left hand to spray the right nostril to help get the proper positioning.

Spraying

When the tip of the spray bottle is in your nose properly, squeeze the bottle.

Take the bottle out of your nose before releasing the squeeze. If it’s still in your nose, it will suck up whatever’s in there… including germs that can grow in the bottle.

Don’t feel like you need to inhale the stuff to your brain. The medicine works in the nose. Sniffing too much will make the medicine bypass your nasal tissue and go to the back of your throat. This misses the opportunity for the medicine to work where it’s supposed to work and it’s an icky feeling in the throat.

Sniff only enough after the spray to keep it from dripping out.

Finishing up

Wipe the top of the bottle clean before putting the lid back on.

Store the bottle out of reach of children and keep it out of the direct sunlight.

For more

I’ve always said that one day I’d make videos of how to use nose sprays and nose wash systems correctly. I know this post is about nose sprays, but if your nose is plugged with mucus, the sprays just won’t work.

Nasopure has a number of videos on how to use nose washes that I frequently recommend. I don’t get paid at all from Nasopure — I just love the bottle and their website resources. And they’re even made in Kansas City!

Until now I haven’t found a great video on how to use nose sprays. Thanks to Dr. Mark Helm, I’ve finally found a great video for how to use nasal sprays.

I’m off the hook for making videos!

I like this video from AbrahamThePharmacist. He gives great information with a fun style.

I’ve shared the video below many times because it shows just how well a good nose wash can work. I warn parents that most kids don’t love it as much as this girl does. It usually involves a lot of crying and fighting in my experience, but it is so worth it! I don’t know where she got the tip for the syringe, but I’d recommend the Nasopure bottle as shown above.

And finally, for those who think their child is too young to do a nose wash, check out this cutie! She’s in several of the Nasopure videos but she shows perfect technique here!

Alphabet Soup of Meningitis Vaccines: A, C, W, Y, B… What does it mean?

In my previous post I discussed the many different types of meningitis and most of the vaccines used to prevent them. Meningococcal meningitis deserves its own post because there are different strains of meningococcus and different vaccines to cover those strains. We’re familiar with the recommended vaccine schedule, but one type of meningitis vaccine falls into a lesser known category, so it’s very confusing. Here I’ll discuss the two main types of meningitis vaccines that protect against meningococcal meningitis as well as the recommendations for their use.

Meningococcal meningitis can refer to any meningitis caused by the type of bacteria called Neisseria meningitidis, but there are many different types of N. meningitidis. We have vaccines to protect against types A, C, W, Y, and B.

Who gets N. meningitis?

Infants, teens, and young adults are most likely to get meningococcal meningitis. You can see from the graph that infants have the highest risk, followed by the elderly, but there is a bump in the adolescent years. Among the adolescents, 16-23 years of age is the highest risk.

Meningococcal disease incidence by age.
Source: CDC

People at increased risk

Like most infectious diseases, risk increases if there are a lot of people living in close quarters. This is why college outbreaks occur, but even teens and young adults not in college are at a higher risk.

People who have weak immune systems or a damaged or missing spleen are at higher risk.

Sub-Saharan Africa is called the meningitis belt. People who live or visit there are at risk.

Living in or visiting areas of a current or recent outbreak of course elevates the risk.

Working in a lab that handles N. meningitidis bacteria is considered high risk.

Anyone at higher risk should talk to their doctor about when they are eligible for meningitis vaccines. These recommendations differ from the standard vaccine recommendations.

Rates of meningitis are falling

Rates of meningococcal disease have been falling in the US since the 1990s, mostly due to the routine use of meningococcal vaccines. Among 11 through 19 year olds, the rate of meningococcal disease caused by serogroups C, W and Y has decreased 80% since tweens and teens were first recommended to get a meningococcal conjugate vaccine.

Interestingly, serogroup B meningococcal disease has declined even though vaccines were not available to help protect against it until the end of 2014.

It is difficult to measure the impact of these vaccines because the overall incidence of the disease is so low. It takes large numbers of vaccines over time to measure effectiveness because the disease is so rare. It’s easier to notice change when something is frequent. The less common something is, the harder it is to follow trends and measure incidence.

Vaccines to prevent meningococcal meningitis

In the United States there are two types of meningococcal vaccines, quadrivalent and serogroup B.

Quadrivalent Conjugate Vaccines (MCV4)

Menactra and Menveo are different brands of meningococcal conjugate vaccine. These protect against serogroups A, C, W, and Y. Because there are four serogroups, it is called quadrivalent, shortened MCV4 – meningococcal conjugate vaccine 4.

Between 80-90% of tweens and teens vaccinated with Menactra show immune protection one month after completing the series. This protection drops to 70-90% of adults vaccinated with Menactra.

Between 70-90% of tweens, teens, and adults vaccinated with Menveo show immune protection 1 month after completing the series of vaccine.

The immunity from the MCV4 vaccines seems to fall after about 5 years.

Side effects from the vaccines are generally mild and self resolve within a few days. These side effects include redness and pain in the area of the injection as well as fever. More serious reactions, such as an allergic response, are possible but rare.

Any vaccine (or use of a needle for a blood draw) can lead to fainting in tweens and teens. It is recommended that they sit for 15 minutes after all vaccines and blood draws. This can help to prevent a head injury if they fall when they faint.

Routine recommendations

MCV4 is usually first given when kids are 11 to 12 years of age, followed by a booster at age 16 years.

The vaccine’s protection falls over time, so two doses are necessary. For most US children, getting the vaccine at 11 years protects through the early period of increased risk and the booster at 16 years covers the late teen and young adult years.

High risk groups

Children between 2 months and 10 years who are considered high risk based on the risk categories above should be vaccinated earlier.

Adults should get the MCV4 vaccine if they have the risk factors noted above.

Serogroup B Vaccines

Bexsero and Trumenba are meningococcal vaccines that protect against serogroup B. These vaccines are commonly called Meningitis B vaccines, or MenB. These vaccines are significantly different from one another, so if the series of vaccines is started, it needs to be completed with the same brand. They are not interchangeable, as are most vaccine brands. There is no preference of one brand over another.

Bexsero is a 2 dose series. Doses should be 1 month apart. Between 60-90% of people show immune response 1 month after completing the 2 dose series.

Trumenba is a 3 dose series. It should be given at 0, 1-2, and 6 months. If the 2nd dose is delayed beyond 6 months, only 2 doses are required. Eighty percent of people show a protective immune response one month after completing the series.

Side effects to MenB vaccines are generally mild. They include soreness, redness and swelling of the injection area, fatigue, headache, muscle or joint pains, fever, nausea, and diarrhea. If these symptoms occur, they generally self resolve within a week. More serious reactions, such as an allergic reaction, are possible but rare.

Again, it is recommended that tweens and teens sit for 15 minutes after all vaccines and blood draws due to the risk of fainting.

High risk people

MenB vaccines are recommended for people at high risk between 10 and 25 years of age.

Healthy, low risk people

The tricky part is that Men B vaccine is only given permissive use for most 16-23 year olds.

The CDC’s Advisory Committee on Immunization Practices (ACIP) makes recommendations for vaccine use based on all the data that is collected. Members of the Committee felt that the data available did not support the routine use of MenB vaccines, so it is not on the list of recommended vaccines.

What is permissive use?

Permissive use means it is approved for use, but it isn’t one of the standardly recommended vaccines.

This category is given because the vaccine is felt to be safe, but there is not sufficient evidence to recommend that it be given routinely.

Is it ever required for healthy people?

Some colleges require it. This is often due to a recent local outbreak so they are considered high risk.

Does insurance cover it if it’s not recommended?

Most often insurance does cover the MenB vaccine, but this is one of the concerns raised by the groups who argued that it should be routinely recommended. They argued that some insurance companies might not cover it if it is not recommended.

If you plan to get the vaccine, you should check with your insurance carrier to see if it is covered.

Why isn’t it recommended for everyone?

The meningitis A,C,W,Y vaccine is recommended for everyone at 11 and 16 years of age, so why isn’t the meningitis B vaccine recommended for all?

MenB vaccines protect against the majority of currently circulating strains of meningococcal B, but not all. The MenB vaccine also gives only a short duration of protection.

It is expensive to vaccinate, and since there is a relatively low incidence of meningitis B disease, it would take a lot of money to prevent a single case. While no price can be put on the value of human life, the overall risk remains low to individuals, even when they are not vaccinated. All of these factors led to the committee’s decision.

Dr. Vincent Iannelli discusses the risks and benefits in more detail at Understanding the Recommendations to Get a Men B Vaccine if you want more details.

Where can you get MenB if you choose to get it?

Physician offices, student health care centers, pharmacies, and county health departments might offer the MenB vaccine. Since it is not on the standard schedule, they might opt to not carry it. If you desire it, you should ask if it’s available.

My office offered the MenB vaccine last summer, but we did not have enough patients want it after discussing the current recommendations. Much of our stock went unused and had to be wasted.

We did not feel that we could push it strongly despite the fact that we were losing money on unused stock.

I know this might surprise some who believe that doctors are just pharmaceutical shills. (Shills is a term used to imply that doctors offer vaccines only to make money despite knowing about their dangers.)

My partners and I didn’t push this vaccine because we didn’t believe strongly in it. We bought it to be able to offer it to patients who desired it, but since we couldn’t honestly say we recommended getting it, we had few want it.

In the end we decided to not re-order it. We no longer offer MenB vaccine.

We strongly believe in giving the vaccines that are recommended. Recommended vaccines have been shown to not only be safe, but also effective in preventing disease. They can make a big impact on our health as individuals and as a community.

Final MenB Vaccine Thoughts

Unfortunately, the MenB vaccine has failed to show sufficient effectiveness to support the cost of vaccinating everyone.

Putting value on one person’s life is not possible, so if my patients want this vaccine, I suggest they go to the health department, a pharmacy, or student health on their college campus.

I do not think it is wrong to get the vaccine. I simply can’t say that everyone should get it.

Some students must get it due to their school’s requirement. If a school requires it, that should not be argued. The schools with MCV4 requirements often have had a recent outbreak and are considered high risk. In that case, protect yourself!

Meningitis Basics: What you need to know.

Meningitis occurs when a virus or bacteria causes inflammation of our brain or spinal cord. We use several different vaccines to prevent a few types of meningitis, but it’s all very confusing. Recent commercials have raised questions about what these vaccines are and if they’re needed.

Today we’ll go over what meningitis is and what types of germs cause it. Next time I’ll discuss some of the new meningitis vaccines in more detail.

What is meningitis?

Symptoms of MeningitisBoth viruses and bacteria can cause meningitis, but not everyone with these germs gets meningitis. Most people have less severe symptoms when they get these infections.

Not everyone gets all the symptoms listed below when they have meningitis. Some of these symptoms are common to many less serious infections, but if your child has these symptoms and appears more sick than normal, he or she should be evaluated immediately.

Symptoms of meningitis include:
  • fever
  • stiff neck
  • body aches and pains
  • sensitivity to light
  • mental status changes
  • irritability
  • confusion
  • nausea
  • vomiting
  • seizures
  • rash
  • poor feeding

Viral meningitis

Viruses are the most common cause of meningitis. Thankfully viral meningitis tends to be less severe than bacterial meningitis.

Most people recover on their own from viral meningitis. As with many infections, young infants and people who have immune deficiencies are most at risk.

There are many types of viruses that can cause meningitis. It’s likely that you’ve had many of these or have been vaccinated against them.

Non-polio enterovirus

The most common virus to cause meningitis is one from the non-polio enterovirus family.

Fever, runny nose, cough, rash, and blisters in the mouth are all symptoms that kids can get from this type of virus.

Most kids are infected with this type of virus at some point. Adults are less susceptible, and can even have the virus without symptoms.

There is no routine vaccine given for non-polio virus strains.

MM(R)V

Measles, mumps and chicken pox viruses can cause meningitis.

We vaccinate against these typically at 12-15 months of age, so it is uncommon to see these diseases. The MMR and varicella vaccines can be given separately or as MMRV. (Rubella is the “R” and can lead to brain damage in a fetus, but does not cause meningitis.)

Influenza

Influenza can cause meningitis, which is one of the reasons we recommend vaccinating yearly against flu starting at 6 months of age.

Herpesviruses

Herpesviruses can cause meningitis. Despite the name, most of these are not sexually transmitted.

This family of viruses includes Epstein-Barr virus,which leads to mono most commonly. Cold sores from herpes simplex viruses are also in this group. Chicken pox (or varicella-zoster virus) is another of these blistering viruses.

Bacterial meningitis

Bacteria that lead to meningitis can quickly kill, so prompt treatment is important. If you’ve been exposed to bacterial meningitis, you may be treated as well, but remember that most people who get these bacteria do not get meningitis.

Most people who get bacterial meningitis recover, but some have lasting damage. Hearing loss, brain damage, learning disabilities, and loss of limbs can result from various types of meningitis.

Causes of bacterial meningitis vary by age group:

Newborns

Newborns can be infected during pregnancy and delivery as well as after birth. They tend to get really sick very quickly, so this is one age group we take any increased risk of infection very seriously.

Bacteria that tend to infect newborns include Group B Streptococcus, Streptococcus pneumoniae, Listeria monocytogenes, and Escherichia coli.

Mothers are routinely screened for Group B Strep during the last trimester of pregnancy. They are not treated until delivery because this bacteria does not cause the mother any problems and is so common that it could recur before delivery if it’s treated earlier. This could expose the baby at the time of delivery. If a mother does not get adequately treated with antibiotics before the baby is born, the baby may have tests run to look for signs of infection or might be monitored in the hospital a bit more closely.

Once the mother’s water breaks, we time how long it has been because this opens the womb up for germs to infect the baby. If the baby isn’t born during the safe timeframe, your delivering physician or midwife might suggest antibiotics. After delivery your baby might have tests done to look for signs of infection or might be monitored more closely in the nursery.

It is very important that sick people stay away from newborns as much as possible. Everyone should wash their hands well before handling a newborn.

Babies and children

As children leave the newborn period, their risks change. Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Hib) are the bacteria that cause disease in this age group.

Thankfully we have vaccines against many of these bacteria. Infants should be vaccinated against S. pneumoniae and H. influenzae starting at 2 months of age. (Note: H. influenzae is not related at all to the influenza virus.)

Vaccines against N. meningitidis are available, but are not routinely given to infants at this time. High risk children should receive the vaccine starting at 2 months of age, but it is generally given at 11 years of age in the US.

Teens and young adults

Neisseria meningitidis and Streptococcus pneumoniae are the risks in this age group.

Thankfully most teens in the US have gotten the S. pneumoniae vaccine as infants so that risk is lower than in years past.

Tweens and are routinely given a vaccine against A, C, W, and Y strains of N. meningitis. A vaccine against meningitis B is recommended for high risk people and can be given to lower risk teens. This will be discussed further in my next blog.

Older adults

Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), group B Streptococcus and Listeria monocytogenes affect the elderly. 

Talk to your parents to be sure they’re vaccinated and follow the vaccine recommendations for yourself too. Vaccines are not just for kids!

‘NI, Leptomeningitis purulenta cerebralis. Alfred Kast’ . Credit: Wellcome Collection. CC BY

 

Summer Penile Syndrome

Did you know there’s a name for the super swollen male parts from bug bites? Actually two names: Summer Penile Syndrome and Lion Mane’s Penis. Doctors might even call it seasonal acute hypersensitivity reaction. If you’ve ever seen it, you know it can be quite impressive.

What is summer penile syndrome?

Summer penile syndrome is a fairly common concern during the summer months. It’s usually due to a chigger bite on the sensitive skin of the penis or scrotum. You can often find a small bug bite near the center of the swelling.

They can itch like crazy, but usually don’t interfere with urinating.

Despite the significant swelling, there isn’t usually much pain, only itching. Unless there’s a secondary infection, there won’t be any fever.

What is a chigger?

Chiggers are a type of mite, which is an arachnid in the same family as spiders and ticks. They are also called harvest mites, harvest bugs, harvest lice, mower’s mites, or red bugs. Chiggers are so small they often go unnoticed until several hours after they attach to our skin. They can attach even under clothing, and the most common places that we notice chigger bites are in the areas of our pants.

Chiggers live in moist, grassy and wooded areas. They are commonly found in the warm summer months.

Adult chiggers don’t bite. It’s the larvae that cause itchy problems. The larvae are red, orange, yellow, or straw-colored, and no more than 0.3 millimeters long.

File-Chigger bite
Chigger. Source: https://commons.wikimedia.org/wiki/File:File-Chigger_bite.svg 
After crawling onto the skin, the larvae inject digestive enzymes into the skin that break down skin cells. They do not actually bite the host even though the bumps are called chigger bites. They form a hole in the skin called a stylostome. Their saliva goes into deep skin layers, which results in severe irritation and swelling.

People usually start to itch within a few hours and often scratch the feeding chiggers away. A hot shower with plenty of soap will kill chiggers and prevent them from finishing their meal, so showering after being in grassy or wooded areas can help prevent deeper reactions.

The good news is that in the US, chiggers are not known to carry diseases.

Prevention

Even though they don’t cause disease, chigger bites are something to avoid because they can cause significant itching for weeks.

Bug sprays with DEET will deter the chiggers. DEET is approved for use in children over 2 months of age.

Clothing can be treated with permethrin to avoid ticks and chiggers. Permethrin can be purchased at sporting goods stores to pre-treat your clothing. It should not be used directly on skin. Once dried into the clothing, permethrin will last for about six washings. You can also treat your shoes, which makes a lot of sense since chiggers are usually found in the grass and crawl up onto your skin.

Even untreated clothing can help a little if you don’t have time to pre-treat with permethrin. Wear long sleeves and long pants. Be sure to tuck the pant legs into your socks so they can’t enter from the bottom leg hole.

For more on bug sprays, including citronella, picaridin, oil of lemon eucalyptus and more, see the EPAs information on registered and unregistered products. You can even use this handy tool to find the right product for your needs.

How do you treat chigger bites?

Much like any bug bite, control of the itch is important. If kids scratch any itch, it can become secondarily infected from the break in the skin allowing germs in.

Antihistamines

Antihistamines are used for allergic reactions. We commonly use them for seasonal allergies, but they can help most allergy reactions.

Bug bites itch when our bodies react to the saliva injected into our skin with histamine. Histamine is our body’s allergic response and it itches. If you aren’t allergic to the bite, you won’t itch from it. This is the way we react to allergies, which is why we get itchy eyes and noses with allergies to pollen.

Diphenhydramine (Benadryl) is a short acting antihistamine that can help control allergic reactions, but tends to make kids tired or wired. It also only lasts a few hours, which can require frequent dosing.

I don’t like topical antihistamines, which are often sold to treat bug bites. I worry that kids will get too much of the medicine when it is applied to each bite. It’s a low risk, but still a risk. Just because they aren’t taking it by mouth doesn’t mean it isn’t absorbed. Children using a topical antihistamine for an extended time over large areas of the skin (especially areas with broken skin) may be at higher risk, especially if they also are using other diphenhydramine products taken by mouth or applied to the skin.

I am a fan of using an oral long-acting antihistamine, such as cetirizine or loratadine, to treat bug bites. Most kids with one bug bite have many. One dose of an oral antihistamine helps to control the overall histamine reaction, making each bite itch less.

Antibiotics

Despite the significant swelling, these usually do not require prescription antibiotics.

If your child has open areas from scratching the skin, you should keep the area clean and consider using a topical antibiotic ointment to help prevent infection.

Steroids

Over the counter topical hydrocortisone is a very low dose steroid. It can be used on insect bites to help stop the itch.

Stronger steroids that require prescriptions are occasionally used, but you will need to see your physician to discuss the risks and benefits of prescription steroids.

Oatmeal baths

Soaking in an oatmeal bath might help the itching. It works very well for dry skin conditions and sunburn relief as well.

You can buy commercially made oatmeal bath products or you can grind regular plain oats to make it fine enough that it dissolves in bath water. Test a small amount in a cup of water to see if it’s finely ground enough before putting 1 cup of oats into the bath water.

Some people have even made a paste of oats and applied it directly to the itchy skin for relief.

Baking soda

Another kitchen remedy for bug bite itch relief is baking soda. Mix a pinch of baking soda with a few drops of water to make a paste. Put this paste on the bites. Reapply as needed.

Ice or cool cloth

One more kitchen treatment is ice. Many kids won’t tolerate this one, but if they can’t tolerate an ice pack placed over clothing, you can try applying a cool wet washcloth directly to the skin.

When should you see your doctor?

If your child has any of the following symptoms, talk with your doctor.

  • Trouble urinating.
  • Pain or itch not controlled with the above measures.
  • Fever.
Fear has big eyes
By Robbie Grubbs from Houston (What????) [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

Suddenly my child’s peeing all the time… what’s up?

When children suddenly start peeing all the time, we need to consider the many potential causes. There are many reasons kids have frequent urination. Sometimes it’s as simple as they like to flush the toilet or splash in the sink. This is common in newly potty trained kids. But peeing all the time can also signify a medical problem that needs to be addressed. Learn the potential risks of why children run to the restroom frequently or start to have accidents. This can help parents decide if they need to rush to the ER.

Associated symptoms to identify

Frequent urination can be associated with other things that give us a clue as to what is going on. Sometimes they do not seem connected to the urine, so you might not associate the symptoms. Discuss the issues that apply to your child with your child’s physician.

Behavioral changes

Behavioral changes can be a clue. For instance, look for signs of anxiety. Remember that anxiety does not always look like fear. The frequent urination might be due to worrying about not making it to the bathroom in time and having an accident.

Pain

Pain while urinating might signify an infection. Infections often have other symptoms as well.

Pain might also be from skin irritation due to improper wiping in girls. In uncircumcised boys, pain can develop from improper cleaning under the foreskin. Staying in wet swimsuits too long also can lead to skin irritation and painful urination.

Pain in the abdomen, back or side can indicate problems with the kidneys or an infection. Sometimes this is due to constipation. It will require a physical exam and possibly testing to determine the cause. Schedule an appointment with your child’s primary care physician. If the pain is so severe that he or she cannot sleep, walk, or move easily, go to the ER.

Change in urine odor and color

A change in urine smell and color is important to note. Red, brown, cloudy or smelly urine can be signs of kidney damage, infection, bleeding problems, dehydration, and other serious conditions.

Some foods, such as asparagus and coffee, can change the smell of urine. Color changes can also happen as a result of foods, such as beets or berries turning urine red, or rhubarb or fava beans turning urine brown.

Many medications and vitamin supplements can change the color and odor of urine. It will be important to discuss your child’s recent foods, medicines, and supplements with his or her physician.

Other signs of illness

Other signs of illness can offer clues. Think about fevers, cough and cold symptoms, swelling of the eyes or legs, joint pains, and more.

One example to consider would be Rhinovirus. Rhinovirus typically causes upper respiratory tract infections with cough, runny nose, and pink eye. It can also sometimes cause vomiting and diarrhea or urinary tract infection symptoms.

Causes of frequent urination

Diabetes

Frequent urination can be a sign of diabetes. This is a potentially life threatening issue and needs to be addressed immediately.

Symptoms of diabetes will include being very thirsty and frequent urination. Kids might appear dehydrated despite the high urine volume. They can have weight loss, dry mouth, and low energy. Kids with untreated diabetes usually appear sick and tired.

When sugars reach a critical level, diabetics develop fruity breath. This is associated with a pattern of breathing called Kussmaul breathing. This is a medical emergency. Diabetes can be a rapidly developing problem. If you notice this breathing pattern, get to an ER immediately.

Testing for diabetes initially uses a sample of urine. Urine is tested for sugar. If there is sugar in the urine, blood will also be checked.

Children with newly diagnosed diabetes are referred to an endocrinologist. Endocrinologists are specialists in diabetes and other hormone issues. Newly diagnosed diabetics often spend a few days in the hospital for stabilization of medical issues and teaching of how to manage at home.

Urinary tract infection

Urinary tract infections (UTIs) commonly cause frequent urination. Other symptoms, such as fever, pain with urination, and urinary accidents, often occur. Bacteria and viruses can cause UTIs.

UTIs are more common in girls and in boys who are not circumcised.

A urine test can help to determine if there is a UTI. A quick urinalysis can suggest an infection, but a culture is needed for actual diagnosis. A urine culture takes up to 2 days to grow bacteria. Bacterial UTIs are treated with antibiotics. Viral UTIs self resolve after a few days.

Constipation

Many parents are surprised at all the things pediatricians blame on constipation. I can’t say how many parents deny that their child is constipated when they are. An x-ray often shows the abdomen is full of poop even when kids poop every day.

Note: I don’t always get an x-ray to diagnose constipation. Studies are only needed to help with diagnosis if the exam findings are not clear. Usually it’s obvious from the description of the stooling pattern and the look of the poop. Kids often cannot describe their poop accurately, so I use a Bristol Scale. You can use this at home to talk to your kids about their bowel movements.

Many children with constipation don’t initially seem to be constipated so a trial of Miralax is often recommended. This treats the constipation if it exists and is part of the diagnostic evaluation. Diet changes and changes to toileting habits are also important. These take longer to make a difference so I still recommend Miralax.

If treating the constipation helps, continue to treat until it is no longer needed.

Pollakiuria = increased frequency of childhood

Increased frequency of urination, also called pollakiuria, is common and not harmful. Other terms that have been used to describe this condition include extraordinary daytime urinary frequency and increased frequency of childhood.

The cause of this is unknown but often is triggered by a stressful event. Kids with this have a normal physical exam and urinalysis.

Pollakiuria involves frequent urination during the day. Kids will feel the need to urinate frequently, even though there’s really no physical reason.

Most children do not change their nighttime urinary pattern. If they previously wet the bed, they still will. If they previously stayed dry all night, they will continue to stay dry at night.

Pollakiuria is seen more often in boys, but also occurs in girls. It’s most common between 4 and 10 years.

Despite the frustrating symptoms, it’s not a serious illness and it self resolves. It generally lasts 1-6 months and can be quite problematic due to the frequent bathroom trips needed. Some kids pee as often as every 30-90 minutes.

To diagnose this, a child should be seen to discuss the symptoms and to do a physical exam. Often constipation aggravates this issue, so close attention to stool patterns and the abdominal exam are important. A urinalysis should be done to rule out diabetes or urinary tract infection. Pollakiuria is a diagnosis of exclusion. This means there is no test for it, but we rule out other potential causes of frequent urination.

This problem typically starts suddenly and ends suddenly. It can last for months.

What can you do to help if there’s no treatable cause?

If there is a treatable medical condition, treating that condition will usually help the frequent urination. While it seems like there’s nothing to do to help if there’s no cause found, don’t get discouraged! There are things to do that can help.

Contrary to what many intuitively think, drinking plenty of water is beneficial. Don’t limit water!

Don’t punish kids for needing to use the restroom or for having accidents. It may not be under their control at all. If it is a behavioral issue, the child needs support, not punishment. Punishment or belittlement will only make them feel bad. This worsens the situation. It can be hard to not get frustrated, but take a big breath and try to remain calm. Use words that are neutral and not judgmental.

Be sure the teacher knows what’s going on. If your child needs to go to the bathroom frequently, he needs to be allowed.

Remind your child that he or she is healthy. This can help to reduce the anxiety and stress in their minds. Stress can make this condition worse, so reassurance is very important!

Show your child that it’s possible to wait for a longer period of time to urinate. Explain that there will be no urine leakage because that fear increases anxiety about not going to the bathroom. The more confidence they develop, the better their bladder control. Practice waiting a little longer before going to the bathroom and celebrate small improvements.

Foods to avoid if your child has frequent urination:

The foods and drinks listed below may or may not increase frequent urination.

Avoid these for at least for 2 weeks. Slowly re-introduce one at a time to see if they lead to increased urination.

  • Highly acidic foods such as salsa, sodas, teas, coffee, cranberry juice and orange juice.
  • Caffeine acts as a diuretic and increases urine. It’s found in coffee, tea, chocolate, sometimes ice cream or other treats.
  • Spicy foods such as chili peppers, jalapeño peppers, horse radish, curry and salsa.
  • Artificial colors.
  • Carbonated beverages.

Most importantly…

The most important thing to remember is to first rule out medical causes that need to be treated.

Once those are ruled out, this is a lesson in patience. Don’t belittle your child or use harsh words when they need to use the bathroom again. And again. This will pass.

Work on having your child hold their urine for a few minutes longer with encouragement. Frequent urination usually stops as suddenly as it started.

New back to school recommendations for strep throat!

Many years ago I heard about research showing that throat cultures clear within 12 hours after the first dose of antibiotic for strep throat. I’ve been waiting since then for a change to our recommendation that kids must stay home from school for 24 hours after starting antibiotics. Guess what? The new Red Book (an infectious disease book from the American Academy of Pediatrics) is out and the back to school recommendations for strep throat have changed! This can help many parents get back to work when their kids can return to school and daycare earlier. But it doesn’t mean you should rush in to demand antibiotics for every sore throat!

Redbook return to school strep guidelines, 2018.
Redbook return to school strep guidelines, 2018.

I have summarized the Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America previously. These official guidelines have not been updated, but the Red Book represents the AAP official recommendations.

What is Strep throat?

Strep throat is not just any sore throat. Many viruses can cause sore throats but strep throat is caused by group A Streptococcus bacteria, also known as Streptococcus pyogenes.

Strep throat is not common in kids under 3 years. The incidence of strep throat peaks in young childhood and is less common in teens and adults.

A strep test is needed to diagnose strep throat in kids. Physicians and other healthcare providers can use Centor Criteria for adults, but a clinical diagnosis alone is not recommended in children.

Strep throat typically causes a sore throat, fever, swollen tonsils, and swollen lymph nodes (gland) under the jaw. Some kids will get a sandpapery rash on their trunk. When this happens, it is called scarlet fever. I also see a significant number of kids who get a stomach ache and vomiting with strep.

Strep throat sometimes causes white patches on the tonsils. This is called exudate. Exudate is found in other conditions, so you can't use it alone to diagnose Strep throat.
James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], from Wikimedia Commons
Red spots on the roof of the mouth is considered very specific for Strep throat.

Red spots on the roof of the mouth is considered very specific for strep throat.

Does strep throat need to be treated?

Most parents and kids want antibiotic treatment so that the miserable symptoms of strep go away faster, but do we need to treat strep?

You might be surprised, but antibiotics are not prescribed to treat strep throat symptoms. Antibiotics are used to prevent serious complications from the strep bacteria. Pain relievers, such as acetaminophen or ibuprofen, can be used to treat the fever and sore throat symptoms. School aged children, teens, and adults can also use throat lozenges for sore throats. (Do not use these in kids who are still at risk of choking.)

So the simple answer is we don’t always need to treat strep with antibiotics. In the days before antibiotics, most people got better. Even now there are some people who don’t go to a clinic when they’re sick, so they recover on their own.

Use antibiotics wisely

There are a lot of reasons to use antibiotics only when necessary.

One major reason is to help delay antibiotic resistance.

Some people have allergic reactions or side effects to antibiotics, so we should not use them lightly.

They also can increase total healthcare costs. Although penicillin and amoxicillin (which are recommended for strep throat) are inexpensive, treating strep throat does increase healthcare costs. The sheer number of illnesses that present to clinics for evaluation, the cost of testing, and the cost of the treatments can all add up. Of course, returning to work a day earlier can make an impact on our economy as well.

If your child has symptoms not characteristic for strep and is not otherwise high risk, you can monitor and treat for a few days at home.

But antibiotics make us feel better faster, right?

Antibiotics tend to shorten the symptoms by about 16 hours.

They have been shown to prevent serious consequences of strep infections, but those are rare, so the risk/benefit ratio may not support treating every case of strep. (Though I still do treat strep when I see it.)

Look at risk/benefit ratio for all treatments

If you want to read an example of the risks/benefits of treating strep throat, see this (slightly technical) case report.

Remember that this report simply highlights one case, it cannot be generalized to everyone with strep throat. It shows how doctors work through the risks and benefits with everything we treat. We don’t always state things like this out loud, but they go through our mind as we develop treatment plans.

It’s common in medicine to have case reviews such as this. Any one case does not change our treatment guidelines, but they can help us start to understand issues. They often serve to initiate further studies.

Are there risks to not treating?

Untreated Strep infections can lead to complications.

The character Beth in the classic book “Little Women” died of heart complications after scarlet fever.

(If nostalgia hits you, you can get the entire series of the March family on Kindle for less than a dollar!)

Complications from untreated strep can include tonsil abscesses, ear infections, sinus infections, arthritis, heart damage, and kidney damage. While some of these can be severe, thankfully the more severe complications are rare, even without treatment.

There is also a condition called PANDAS (pediatric autoimmune neuropsychiatric disorders) that some experts think is related to strep. This can involve the sudden onset or worsening of tic disorders, obsessive compulsive disorder, mood changes, and change in quality of school work. Throat swabs can be normal, but a blood test can help to identify a recent strep exposure. Testing is not recommended for everyone with tics or OCD, but talk to your pediatrician if symptoms start out of the blue and you’re concerned.

Don’t let the new recommendations make you rush in…

Strep throat is rarely an emergency. Don’t rush to the ER after business hours to have your child checked as soon as you notice symptoms. You can use pain relievers as well as cold drinks, smoothies and popsicles to manage the symptoms at home initially. Just because the back to school recommendations for strep throat allow return 12 hours after antibiotics start, coming in too soon might not help in the long run.

About the testing available:
Do not use telehealth to get your sore throat treated.

In children it is not recommended to diagnose strep throat without a throat swab test. This should be done in a medical clinic to avoid inaccurate testing.

Treating early in the course might diminish the opportunity for your body to fight strep off the next time it’s exposed. Yes, treating may allow a return to work, school or daycare in 12 hours, but if you can prevent the next occurrence (of course no guarantees…) wouldn’t you want to?

When should you not test or treat?

Kids under 3 years old

Strep throat is not common in kids under 3 , so it’s not recommended to test them.

I admit that if an older sibling or caregiver has strep and they have strep symptoms, I will test 2-3 year olds.  The recommendation is to not bother. Even if they have strep, treating does not tend to alter their course. Kids in this age group tend to not develop the severe consequences of strep like older kids, even when not treated.

Viral symptoms

Although both viruses and strep bacteria can cause fever and sore throat, there are clues that it is not strep. When strep carriers get sick, they can have a false positive throat culture. The strep that shows on testing is not the cause of their symptoms and leads to over treatment.

If there is a cough or runny nose, the sore throat is most likely a viral illness. A strep test is not recommended.

When there are blisters in the mouth or a characteristic hand, foot, mouth rash, they have a viral illness. A strep test is not recommended.

Recent strep

Because the rapid strep test looks at antigens the body makes in response to strep and not the bacteria itself, recent strep can affect rapid strep testing. The antigen can remain in the throat for a time after treatment, so a strep culture is recommended for several weeks after treatment of strep throat.

It is not recommended to do a throat culture after treatment unless a person is high risk for complications, such as rheumatic fever.

contacts of someone with strep

It isn’t recommended to test people who have been exposed to strep unless they have symptoms. If they do not have symptoms, a positive test is more likely to be a falsely positive (not true) test. It could lead to unnecessary antibiotics.

If a sibling over 3 years of age develops symptoms, it is recommended to test and not just treat.

Pets?

Pets do not get strep, so no need to swab your pet!

Why not just test every sore throat?

Studies show that 1 in 4 kids can have strep in their throat at any given time. They are simply carriers, but not truly infected with strep. Contrary to popular belief, strep carriers are not likely to spread strep infections.

If a strep carrier has a viral illness, they can have a positive test but the strep is not the cause of their illness. Antibiotics are not needed for this at all. A positive test leads to using antibiotics that are not needed, which can increase the risk of side effects and allergic reactions. They give a false sense of security of treatment, but if it’s a viral illness, antibiotics are not treating anything. Kids can be sent back to daycare or school while still contagious simply because they’re “being treated.”

“My child always has a negative rapid test but the culture is positive. Can’t we just treat?”

My back to school recommendations for strep throat:

If your child has some of the symptoms of strep (sore throat, fever, tender bumps in the neck, vomiting, or rash) consider strep throat.

Symptoms of typical viral illnesses make strep less likely. These might include runny nose, cough, red goopy eyes, or diarrhea. No testing is recommended.

It can be difficult to tell if a runny nose from allergies despite the strep throat or if the runny nose is part of the viral illness that includes a sore throat, so if in doubt, bring your child in for evaluation. The doctor can determine if testing should be done. Do not use telehealth for this. I recommend seeing your primary care physician during normal business hours.

If there is strep throat, penicillin or amoxicillin are the preferred treatments unless there is documented allergy.

Your child may return to school 12 hours after the first dose of antibiotic if they are otherwise well. (If they are not feeling great, they likely have something else going on!)

Thank you!

Thanks to Dr. Kathy Cain of Topeka Pediatrics for some helpful editing tips!

ASK to save a life!

June 21, the first day of summer, is National ASK (Asking Saves Kids) Day. The ASK Campaign encourages everyone to ask if there are unlocked guns in the homes where children play. The Asking Saves Kids (ASK) Campaign encourages parents to ask a very important question before playdates: “Is there an unlocked gun in your house?” It’s a simple question, but it has the power to save a child’s life.

1 in 3 homes with children in America have guns. Ask to save a life.
Click to enlarge. Source: http://askingsaveskids.org/

Keeping a gun in the home increases the risk of injury and death, yet 1 in 3 American homes with children have at least 1 gun.

Every year thousands of kids are killed or injured by guns. When parents think of asking about guns in a playdate’s home, they often can’t imagine how to enter into that conversation.

It doesn’t have to be awkward to ask before your child visits friends. I’ll show you how.

But first let’s review why this is so very important.

Guns are common in our communities. Ask if they are in the area your children will play, and if so, be sure they're stored safely! #ASKingSavesLives
Guns are common in our communities. Ask if they are in the area your children will play, and if so, be sure they’re stored safely! #ASKingSavesKids

Gun Safety

One question could save a child's life. Ask.
Click to enlarge. Source: http://askingsaveskids.org/

Many parents buy a gun to help protect their family, but a gun in the home increases the risk of a family member being hurt or killed by a gun more than preventing a crime.

Kids have natural curiosity and if they find a gun, they are likely to play with it, even when they are taught to not touch guns.

Toy guns and real guns are so similar, it can be difficult to tell them apart.

Several studies over the years show that gun education programs fail. Diane Sawyer’s Young Guns episode showed that even soon after gun safety education, kids will play with a gun and not follow the rules they just learned.

Regardless of the reason for or type of gun, there are guns in 1 in 3 homes with children in America. Too many of those guns are not locked. A gun in the home increases the risk of homicide, suicide, and accidental injuries.

Don’t mistakenly think that your gun is needed to keep your family safe. For every time a gun in the home was used for self-defense, there were 4 unintentional shootings, 7 criminal assaults or homicides, and 11 attempted or completed suicides.

Accidental shootings

Accidental shootings occur far too often, especially in young children.

See the table below that lists the numbers of leading causes of injury deaths by age. In children under 15, there were 73 unintentional firearm deaths in 2016. That number does not include homicides and suicides.

10 Leading Causes of Death by age in 2016
Click to enlarge. Source: https://www.cdc.gov/injury/wisqars/leadingcauses.html

Homicide

Sadly there have been too many kids who have been killed by intentional gunfire, both at home and in public areas. The higher the number of guns in a community, the more gun deaths there are.

Our kids must practice active shooter drills at school because school shootings are occurring with more frequency. Many of these shootings are kids who bring their parent’s gun to school.

Suicide

Suicide attempts with guns are usually fatal. Sadly too many people consider suicide as an option when they’re down.

Having a gun in the home when a teen is depressed increases the risk of death by suicide. Over 80% of teen suicide by firearm is done with a family member’s gun.

Keeping guns locked with the ammunition locked separately is important even when you don’t have young children. It can deter teens from accessing guns in a time of despair.

Hiding guns

Parental perception of what kids know about guns is lacking.
Child knowledge of handling of guns in the home. Source: https://www.bradycampaign.org/sites/default/files/Kids-and-Guns-Report%202016_final.pdf

Hiding guns is not a safe plan. Nearly 80% of kids know where the family gun is hidden. Parents usually don’t realize the kids know.

I’ve seen more than a couple surprised parents when they learn that their child knows where the family gun is stored in a drawer or closet. They presumed the child had no idea about the gun, but kids know things. It’s bad enough if they know your secret hiding place for birthday gifts, but if they know where the unlocked gun is, natural curiosities can take over.

It’s not political

I don’t care if you’re a Republican, Democrat, Liberal, or other political affiliation. This isn’t about politics. It’s about keeping kids safe.

This is not about the Second Amendment. Americans have a right to bear arms. But with rights comes responsibilities.

This is about the responsibilities that come with the right to bear arms. Adults have a responsibility to keep children safe.

When having the discussion, keep it about safety. Don’t make it about politics. That turns people off and gets them on the defensive. Don’t judge whether it’s okay to own a gun. Focus on the issue of making sure all guns are safely stored unloaded and locked.

Make it less awkward

Parents must have awkward conversations. Don't let that stop you from keeping kids safe.
Click to enlarge. Source: http://askingsaveskids.org/

As parents there are many awkward things we must deal with. Being awkward or difficult doesn’t make it okay to just ignore it if safety is involved.

By introducing safety concerns that are not judgement issues, it can be more natural to then talk about more sensitive topics.

Use these non-controversial openers to start the conversation before playdates.

Pets

Allowing a dog who is not friendly and patient around kids to be with the kids is a red flag. Ask if there are pets and how they respond to kids, especially kids they don’t know. If you’re not comfortable with that pet, ask if the parent can keep the kids and pet separate.

When kids are afraid of animals, the other parent needs to be aware.

If there are any pet concerns, see if they can keep the pet in another room while your child is there. If not, have their child to your home instead.

Allergies

If your child has allergies to animals or foods, the other parent needs to be aware. Talk about the allergy and what can be done to help your child not suffer.

When the parent is not able to keep your child safe from allergens in their home, ask if their child can come to yours instead.

Other safety risks

There are numerous other safety risks that could be used as introductory concerns. You can’t ask everything, but pick the things that are most important to you.

Will the kids be riding bikes or scooters? Are there enough helmets for everyone or should your child bring his own?

Is there a wooded area that will require bug sprays or tick checks after the play date?

If they play outside, how closely are they supervised? Do you need to send along sunscreen?

Does your child need to wear sneakers or will they be staying indoors and the flip flops are okay?

If a parent will be responsible for driving your child, do they have an appropriate car seat or booster seat?

Do they have a trampoline or pool? If so, what are their rules and safety measures?

Be first

Be the first to ask a child to your home. With the invitation, list everything you think another parent might be interested in knowing. Hopefully they will reciprocate by giving similar information when they invite your kids over, but if not, ask.

“We’d love to have Johnny over. We have a German Shepard, but he’s really good with kids. If Johnny needs him to be put in the master bedroom, just let me know. We also have a trampoline, but if the kids get on it, a parent is always outside. If that’s not okay, let me know. And we have a rifle, but it’s in the gun safe and the ammunition is locked separately. Is there anything we need to know about Johnny?”

Take the ASK Pledge

Pledge to ASK if there are unlocked guns where your child visits. Encourage friends and family to do the same!

Pledge to ASK if there are unlocked guns where your child visits: http://www.bradycampaign.org/take-action/pledge-to-ask
Pledge to ASK: http://www.bradycampaign.org/take-action/pledge-to-ask

Resources

The Truth About Kids and Guns from The Brady Campaign

CDC’s WISQARS™ (Web-based Injury Statistics Query and Reporting System)

WISQARS Interactive Visualization

jose-alonso-589704-unsplashphoto credit:Jose Alonso

Bumps, ridges, and soft spots on a baby’s head. When should you worry?

Parents often worry about lumps and bumps on a baby’s head. Babies normally have bumps, ridges and soft spots on their head. When should you worry?

Parents often worry about lumps and bumps on a baby’s head unnecessarily. Babies normally have ridges and soft spots on their head for a while after birth. Many have a type of swollen gland that parents can feel when rubbing the head. All of this is normal.

Skull anatomy

Let’s begin with a brief overview of a baby’s head. We are born with many bones in our skull. This allows the head to be squeezed out of the birth canal as the bony plates move together or even overlap one another.

Infant skull bones
Infant skull bones

Sometimes you don’t really notice much with these bones, but other times they overlap one another noticeably after birth. When a baby has a lot of head distortion due to overlapping of skull bones, we call it molding. It can make the head look pointed – which is often called cone head.  It can also make the head look flat on one side.

The good news? Even really odd looking heads are usually normal. Molding tends to resolve without intervention over the first few days of life.

Soft spots

There are 1-2 “soft spots” at birth. Usually the one on top to the head (the anterior fontanelle) remains open enough to feel for the first 18-24 months of life. The one towards the back of the head (the posterior fontanelle) is unable to be felt by about 2 months of age. It is often so small at birth that it’s not recognized.

Many parents fear that touching a soft spot will somehow damage the baby’s brain. Normal touching won’t hurt, even from a 2 year old sibling. There are several layers of skin and other tissues protecting the brain.

Doctors will feel the soft spots during routine check ups to be sure they are the right size for the growth of the baby’s head. There’s a lot of variation here, so if you question the size of your baby’s soft spot, discuss it at a visit with the doctor. He or she will need to not only feel the soft spot, but also will look at overall head growth, baby’s development, and the shape of the head.

Bruises and bleeding

Coming out of the birth canal can be traumatic for both mother and baby (and often for fathers too). Sometimes babies have a big soft or squishy bump on one side of the head, which usually is essentially a large bruise.

Bruises can cause yellow jaundice.

Any bruise can increase the risk of yellow jaundice in a newborn, so your doctor might watch your baby more carefully for this over the time that the blood is resorbed. This is because yellow jaundice is caused by breakdown of blood cells. Most babies show yellow color in their eyes and face. Even if it progresses to their chest and abdomen it can usually self-resolve with proper hydration, but it should be monitored. If the level gets too high it can be managed. Talk to your doctor if you’re concerned.

Cephalohematoma vs caput saccedaneum.

The two most common types of bruising are cephalohematoma and caput saccedaneum.

A cephalohematoma develops when there is bleeding between the skull and the bone lining called periosteum. Since it is outside the skull, it doesn’t affect the baby’s brain. It covers only one of the bones, and never crosses one of the suture lines.

Caput succedaneum is swelling of the scalp in a newborn. It develops from bleeding one layer above the periosteum in the skin. It can cross the bone areas since it’s not limited by the lining of the bone (periosteum). You will notice a soft, puffy swelling on the baby’s scalp, usually in the area that first came out during birth. Some will show bruising.

Both of these conditions can lead to increased risk of yellow jaundice due to breakdown of the blood collections, but usually self resolve without complications. If baby seems uncomfortable due to this area, discuss with your hospital nurse or doctor.

The picture below attempts to show the layers of bleeding described here and includes more uncommon (and more concerning) types of bleeding. Babies who have deeper bleeds need proper medical management. For information about subgaleal hematoma, see Seattle Children‘s website. Epidural hematomas are very rare in newborns.

Scalp hematomas

 

Flat spots

Flat spots are common, especially if babies prefer to always look to one side. This can cause the forehead to seem to bulge on one side or an ear to appear closer to the face than the other ear. This is usually due to baby laying one direction most of the time, allowing the brain to grow all directions but spot baby is laying on.

Babies always need to sleep on their back until they start to roll on their own, but this can encourage a flat head. It’s important to get baby to lay looking right sometimes, left other times. Supervised tummy time is helpful too. I recommend starting tummy time on day one. The earlier you start tummy time the less they seem to hate it!

When you hold and feed baby, alternate arms because they will look toward you and by simply holding in the right arm sometimes, left arm other times, they will turn their head. If your baby resists turning his head, check out this Torticollis information.

Lymph nodes

One of the most common head worries that brings parents to the office is a pea-sized (or bigger) movable bump on the back of baby’s (or even an older child’s) head. This is usually an occipital lymph node.

Lymph nodes of the head and neck
Lymph nodes of the head and neck

When I say it’s just a lymph node, some parents automatically worry about lymphoma.

Don’t go there.

Most of us remember having a swollen lymph node (AKA swollen gland) under our jaw or in our neck when we are sick. When they develop on the back of the head, it is usually from something irritating the scalp, like a scalp probe during labor, cradle cap, or bug bites in older kids. They can remain large for quite a while (often seeming to come and go when kids have scalp irritations), but unless they hurt to touch, enlarge rapidly, are red and hot, or a child looks sick otherwise, I don’t worry about them.

TL:DR

In short, most lumps and bumps on your baby’s head are normal. If you’re worried, bring your baby in to have your pediatrician look and feel.

Bumps, ridges, and soft spots on a baby's head is often normal - but when should you worry?
Bumps, ridges, and soft spots on a baby’s head is often normal – but when should you worry?

Should your child have an Athletic Heart Screen?

In recent years I’ve been getting more and more reports of athletic heart screenings. Local schools and sports clubs are offering to have athletes get a heart work up for a relatively small fee. Of course most are perfectly normal, which is a peace of mind to parents. Some have found minor things that aren’t of much consequence, but a few have found important heart issues. So why is there even a question of whether or not to do an athletic heart screen if it discovers important heart issues?

Why worry about healthy athlete hearts?

Sudden cardiac death in athletes has been in the news a lot over the years. We all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk.

Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator.

If you’ve not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow “A B C” so it is very different. CPR is recommended for all teens and adults.

Is the cost of a heart screen worth it?

Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation. It is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD).

Complex issues from the Statement linked above:
  1. the low prevalence of cardiovascular diseases responsible for SD in the young population
  2. the low risk of SD among those with these diseases
  3. the large sizes of the populations proposed for screening
  4. the imperfection of the 12-lead ECG as a diagnostic test in this venue

It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: 

To do an ECG screening on all athletes is not inherently unwarranted nor discouraged, but it isn’t recommended either.

What is recommended?

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is listed below.

Why isn’t an ECG (commonly called EKG) recommended?

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive and has not been proven to save lives.

If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time. One normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so.

The evidence does not support mass required screenings.

If your child has identified risks based on the questionnaire, a more thorough testing should be done.

What are the 14 points?

These 14 points are listed in Table 1 of the above linked statement: The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history*
Personal history 

1. Chest pain/discomfort/tightness/pressure related to exertion
2. Unexplained syncope/near-syncope†
3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from participation in sports
7. Prior testing for the heart, ordered by a physician

Family history

8. Premature death (sudden and unexpected, or otherwise) before 50 y
of age attributable to heart disease in ≥1 relative
9. Disability from heart disease in close relative <50 y of age
10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination

11. Heart murmur‡
12. Femoral pulses to exclude aortic coarctation
13. Physical stigmata of Marfan syndrome
14. Brachial artery blood pressure (sitting position)§

  • AHA indicates American Heart Association.
  • *Parental verification is recommended for high school and middle school athletes.
  • †Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
  • ‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
  • §Preferably taken in both arms.

What do I recommend?

I think that if you can afford the screen and any potential follow up recommended if it is abnormal, it is a great tool. It can be reassuring, though nothing can guarantee that no problem will develop.

In a perfect world cost wouldn’t matter, but I know it does, so if people can’t afford the screening, they should not feel like they are not doing the right thing if they skip it.

The 14 point question is all that is recommended to be done and can catch the majority of problems if done with a thorough physical exam.

A plug for an annual well visit in your medical home.

I think all kids and teens should have annual physicals in their medical home. The medical home is where their primary care physician is.

I know this is difficult due to the requirement of all athletes have a physical in a specified time frame before a season starts, but there are benefits to doing a physical in the medical home. At your usual physician’s office there should be record of growth over the years, a complete personal and family medical history, and previous vital sign measurements. Not to mention that your regular clinic should be able to update your vaccines if needed so there are no surprises when your school nurse looks at your record in the fall. Seeing your physician yearly also helps to build a relationship, so there is a better comfort level to talk if problems develop.

At this time insurance generally covers one well visit per year. Most physicians will fill out the sports physical form at this annual visit. When you go elsewhere, you usually must pay cash. You might as well get a comprehensive physical using your insurance. You pay a monthly fee for the privilege of having it – use it! Just be sure to schedule well in advance – everyone needs physicals at the same time due to state or club requirements, so slots fill up quickly.

Schedule your physical when you schedule a sport or camp.

When you sign your kids up for any new school, sport or camp, look to see what forms are needed. Call your doctor’s office at the same time you sign up for the sport or camp to schedule the annual physical. Just be sure the date you schedule is in the time frame that is needed  to get the forms completed.

Pay attention to your insurance rules for how often physicals can be done. Don’t necessarily schedule near your child’s birthday if it is outside the range that is needed to fulfill form requirements so you can avoid a second physical when only one per year is allowed.

If in doubt, call your pediatrician’s office and ask!

Should your child have an Athletic Heart Screen?
Should your child have an Athletic Heart Screen?

Is your teen driver a safe driver?

Summertime is a common time that teens learn to drive, but also the most dangerous time. Teens have more free time during the summer, so have more opportunity to drive than during the school year. Car crashes are the #1 cause of death in teens. We are now entering the “100 Deadliest Days,” the time between Memorial Day and Labor Day. This is when the average number of deadly teen driver crashes climbs 15% compared to the rest of the year. Make sure your teen is a safe driver before you let him or her hit the road alone.

Teens tend to be impulsive risk takers. Even cautious new drivers are inexperienced, so they are at risk of not knowing how to handle a situation. In addition to riding along with your teen as they learn the rules of the road, you should talk to them about expectations and safety. Continue the talks as they gain confidence because the risk of accident actually increases in the late teen years.

May is Global Youth Traffic Safety Month to educate about safe driving.

Driving Contract

After talking to your teen, get your thoughts down in writing. There are many driving contracts available online.

This contract from the CDC has areas to write in your specific details.

The idrivesafely contract allows you to enter details for each point covered.

The AAA Driving Agreement has a nice chart depicting privileges that vary based on circumstance.

NOYS Global Youth Traffic Safety Month
From https://noys.org/global-youth-traffic-safety-month/

Special Situations

Overconfidence of the teen driver

Research has shown that after the first few driving years, teens risk of having an accident actually increases. This may be due to teens gaining confidence and taking more risks.

According to the 2017 study, 75 percent of high school seniors “feel confident” in their driving abilities, and 71 percent use a phone behind the wheel. Driving while drowsy, speeding, having multiple passengers and browsing music become more prevalent as new drivers gain confidence.

Distraction

Distractions are a common cause of accidents. Younger drivers have the highest proportion of distraction related fatal crashes.

Over 70% of teens admit to using their cell phone while driving despite recognizing the dangers of this distraction.

Parents need to model safe behavior and stay off their phone while driving. Texts can wait. If it’s that important, pull over to check your phone. Have your teens agree to no cell phone use in a driving contract.

One of my favorite ads shows just how quickly accidents can happen.

Other passengers are another source of distraction. Teens easily distract one another. Limit the number of passengers your teen is allowed to chauffeur.

Even changing the radio station can be a significant distraction. Ask teens to set the station and leave it – or to make a soundtrack and play it for the road.

Speeding

Speeding is a contributing factor to many crashes. Speed limits are set for safety and going faster makes it harder to maintain control of the vehicle.

Talk to teens about the importance of not only following speed limits, but also about adjusting speeds to road and weather conditions.

It is better to arrive alive but late rather than to speed to attempt to get there faster. Talk to your teen about calling if they plan to be late rather than just trying to speed home to make curfew.

ADHD

The symptoms of ADHD, such as an inability to pay attention and impulsivity, can make driving even more dangerous than it is for a typical teen. There are more car accidents among teens with ADHD than the general population, but newer studies show ADHD drivers on medication are at a significantly lower risk than those not taking medicine. Talk to your teen about medication management if he or she has ADHD.

Safety tips for safe driving

  • Buckle up – it’s the law but even more important, it’s the safest way to travel. Make sure any passengers are properly buckled before you drive.
  • Avoid carpooling to reduce the distraction of others in the car. The more kids in the car, the higher the risk.
  • Avoid eating while driving.
  • Ignore your cell phone. (Parents be forgiving if your kids don’t answer your call or text right away.)
  • Know where you are going and how to get there before you get on the road. If you aren’t sure you’ll remember, set a GPS before hitting the road and turn the sound on to minimize the need to look at the screen.
  • Don’t drive when you’re tired. Drowsy driving is equated to drunk driving. If you have trouble staying in your lane or keeping your eyes open, you’re too tired to safely drive.
  • Adjust seats, mirrors and climate controls before driving.
  • Set your music for the road before you start driving.
  • Watch for pedestrians and bicyclists. Five percent of teen deaths in crashes are pedestrians and 10% are bicyclists.
  • Don’t drive under the influence of alcohol or any drug that affects your ability to focus behind the wheel. Car crashes are the leading cause of teen death and about 25% involve an underage drinking driver.

Follow the law and parental expectations

It goes without saying that teens must follow the law when driving. They must respect the rules of the road for their own safety and the safety of others.

In addition to the laws, household rules about passengers, nighttime driving and cell phone use can be individualized to your teen’s abilities and weaknesses. Even if a teen can legally drive alone, if he or she hasn’t demonstrated the ability to do it safely, parents should not allow it. More supervised hours can make a difference in their experience and if they in general do not show the ability to make safe choices, they should not have the ability to drive a vehicle unsupervised.