Supplements for ADHD: Do Vitamins, Herbs, and Fatty Acids Work?

Parents often ask if they can treat their child’s ADHD without prescription medication. There are many alternative treatments in addition to prescription medications – some of which are more effective than others.  I will cover ADHD treatment with supplements today.

Supplements for ADHD – general

If you’re giving your kids supplements for any reason, be sure to tell their physician and pharmacist to avoid any known complications or interactions with other treatments.

Supplement use in general is gaining popularity. All you have to do is visit a pharmacy or specialty store and you will see various products marketed to treat ADHD.

There are some studies that show people with ADHD have low levels of certain vitamins and minerals. More studies are being done to determine if supplementing helps symptoms. There is growing evidence for vitamin supplementation, but there are no standard recommendations yet.

Should you use high dose vitamins?

Clinical trials using various combinations of high dose vitamins such as vitamin C, pantothenic acid, and pyridoxine show no effect on ADHD.

I don’t recommend high dose vitamin supplements unless a specific deficiency is identified. I don’t routinely screen for deficiencies at this time because there are no standard recommendations for this. We still have a long way to go before we know enough to make recommendations.

For children without a known vitamin deficiency, a standard pediatric multivitamin can be used, but effectiveness is not proven. I have no problems with anyone taking a multivitamin daily. However, I cannot recommend any specific brand since none of them are regulated by the FDA and there are many reports that show the label often misrepresents levels of what is really in the bottle. There have been instances of higher or lower than listed amounts of ingredients as well as unlisted ingredients in supplements.

My advice is to buy a brand that allows independent lab testing of their products if you choose to buy any vitamin or supplement.

Vitamins & minerals

The following is adapted from the University of Maryland Medical Center with the help of ADDitude Magazine and Natural Medicines Comprehensive Database.

Magnesium

Symptoms of magnesium deficiency include irritability, decreased attention span, and mental confusion.

Some experts believe that children with ADHD may be showing the effects of mild magnesium deficiency. In one preliminary study of 75 magnesium-deficient children with ADHD, those who received magnesium supplements showed an improvement in behavior compared to those who did not receive the supplements.

Too much magnesium can be dangerous and magnesium can interfere with certain medications, including antibiotics and blood pressure medications.

Talk to your doctor before supplementing with magnesium.

Vitamin B6

Adequate levels of vitamin B6 are needed for the body to make and use brain chemicals called neurotransmitters. These include serotonin, dopamine, and norepinephrine, the chemicals affected in children with ADHD.

One preliminary study found that B6 pyridoxine was slightly more effective than Ritalin in improving behavior among hyperactive children – but other studies failed to show a benefit. The study that did show benefit used a high dose of B6, which could cause nerve damage, so more studies need to be done to confirm that it helps.

If B6 is found to help, we need to learn how to monitor levels and dose the vitamin before this can be used safely.

Because high doses can be dangerous, do not give your child B6 without your doctor’s supervision.

Vitamin C

Vitamin C can help modulate the dopamine levels in the brain. Dopamine is a neurotransmitter that helps control the reward and pleasure centers in the brain.

Vitamin C can affect the way your body absorbs medications (especially stimulants for ADHD) so it is suggested to avoid vitamin C supplements and citrus fruits that are high in vitamin C within the hour of taking medicines.

Preliminary evidence suggests that a low dose of vitamin C in combination with flaxseed oil twice per day might improve some measures of attention, impulsivity, restlessness, and self-control in some children with ADHD. More evidence is needed before this combination can be recommended.

Vitamin D

Vitamin D is the one vitamin that is recommended to take as a supplement by many experts.

As we have gotten smarter about sun exposure, our vitamin D levels have decreased. Vitamin D deficiency has been linked to many problems, including ADHD.

Zinc

Zinc regulates the activity of brain chemicals, fatty acids, and melatonin. All of these are related to behavior.

Several studies show that zinc may help improve behavior.

Higher doses of zinc can be dangerous, so talk to your doctor before giving zinc to a child or taking it yourself.

Iron

Iron deficiencies commonly occur in children due to inadequate dietary sources since kids are so picky. Other causes include blood loss or excessive milk intake.

Iron is needed for the synthesis of dopamine, norepinephrine, and serotonin- all neurotransmitters in the brain.

Low iron has been linked to learning and behavior problems.

Too much iron can be dangerous, so talk with your doctor if you want to start high dose supplements. (Regular multivitamins with iron should not cause overdose if used according to package directions.)

If you’re using high doses of iron, it is important to follow labs to be sure the iron dose is not too high.

Essential fatty acids

Fatty acids, such as those found in fish, fish oil, flax seed (omega-3 fatty acids) and evening primrose oil (omega-6 fatty acids) are “good fats” that play a key role in normal brain function.

In a large review, Omega-3/6 supplementation made no difference in ADHD symptoms, but there are other benefits to this supplement and it carries little risk.

If you want to try fish oil to see if it reduces ADHD symptoms, talk to your doctor about the best dose. Some experts recommend that young school aged kids take 1,000-1,500 mg a day, and kids over 8 years get 2,000-2,500 mg daily.

For ADHD symptom control it is often recommended to get twice the amount of EPA to DHA.

L-carnitine

L-carnitine is formed from an amino acid and helps cells in the body produce energy.

One study found that 54% of a group of boys with ADHD showed improvement in behavior when taking L-carnitine. More research is needed to confirm any benefit.

Because L-carnitine has not been studied for safety in children, talk to your doctor before giving a child L-carnitine.

L-carnitine may make symptoms of hypothyroid worse and may increase the risk of seizures in people who have had seizures before. It can also interact with some medications. L-carnitine should not be given until you talk to your child’s doctor.

 

Proteins

Proteins are great for maintaining a healthy blood sugar and for keeping the brain focused.

They are best eaten as foods: lean meats, eggs, dairy, nuts and seeds, legumes, and fish are high protein foods. Most people in our country eat more protein than is needed.

If your child does not eat these foods in good quantity, there are supplements available. Talk with your doctor to see if they are appropriate for your child. Many of the supplements are high in sugar and other additives. Some have too much protein for children to safely eat on a regular basis.

Herbs

There are some studies supporting nutritional supplements or herbal medicines for ADHD, but many reported treatments have not been found effective.

Pinus marinus (French maritime pine bark), and a Chinese herbal formula (Ningdong) showed some support.

Current data suggest that Ginkgo biloba (ginkgo) and Hypercium perforatum (St. John’s wort) are ineffective in treating ADHD.

Summary

In general I think we all should eat a healthy diet that is made up primarily of fruits, vegetables, lean proteins, and complex carbohydrates.

If children are on a restricted diet due to allergy or sensitivities to foods or additives (or extreme pickiness), discuss their diet with your doctor. Consider working with a nutritionist to be sure your child is getting all the nutrition needed for proper growth.

If supplements are being considered, they should be discussed with your doctor. Talking about risks and benefits can help decide which are right for your child.


Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


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Evaluation Process to Diagnose Learning & Behavioral Issues

I have talked about why kids should be evaluated if they have learning or behavioral issues and who is involved in this evaluation in the past few posts. Today I want to talk about what to expect during an evaluation. Not all kids need every test available. It depends on what their specific concerns are as to what will be tested, but a proper diagnosis can’t be made without standardized testing and a complete evaluation.

What types of things are evaluated?

Evaluation Process to Diagnose Learning & Behavioral IssuesThe evaluation includes several types of assessments because there are many things that can cause learning or behavioral issues.

There are no specific laboratory or imaging tests available to determine a diagnosis on a routine basis. It’s important to do a thorough standardized evaluation to get the right diagnosis.

Contributing issues include but are not limited to: ADHD, anemia, anxiety, bullying or abuse, chronic illness, depression, hearing or vision problems, learning disabilities, malnutrition, oppositional defiant disorder, sensory integration disorder, and sleep deprivation.

Symptom overlap

Having one diagnosis does not mean you can’t have a second. Actually many of these issues go hand-in-hand and co-exist.

ADHD, anxiety, neurodiversity, learning disorders
There is a lot of overlap of symptoms of many similar conditions.

Standardized questions

A big part of the diagnosis lays in the symptoms noted at home and school, so there are a lot of questions about how your child fares at each.

Both parents and teachers and any other significant adults should fill out standardized questionnaires as recommended by the clinician doing the evaluation for many behavioral issues. Older kids (and adults) can do self assessments.

It’s important to answer each question as honestly as possible to avoid misrepresentation of symptoms, which can lead to an improper diagnosis.

History

Reviewing the child’s story can give clues. This includes the current concerns of parents and teachers in addition to historical facts and events.

If there were developmental delays in motor skills or language development, further evaluation in those areas might be insightful.

It’s important to review the family history, since many of these issues run in families.

Sleep patterns are often insightful since sleep deprivation can decrease executive functioning and mimic many conditions.

Other issues, like a history of anemia or elevated lead levels should be discussed.

Exam findings

A physical exam should be done to help identify any physical symptoms that can contribute to learning or behavioral problems, such as large tonsils leading to sleep apnea.

Behavior evaluation

Some clinicians will go to your child’s classroom to observe behaviors. This is sometimes provided through the school district but might also involve a private therapist.

Neuropsychological testing

Neuropsychological testing might be recommended. It can assess learning disorders and attention issues, identify strengths and weaknesses, and help determine what interventions will work best for your student. Understood.org has information about neuropsychological testing.

Vision and Hearing

If your child has not had a vision and hearing screen done previously or there are concerns, it is recommended to do those screens. When a child cannot see the white board or hear the instructions, learning and behavior are both impacted.

Evaluation Process

As you can see, there are many things to consider when evaluating learning and behavioral concerns. A proper diagnosis usually takes more than one visit. More than one person should be involved in the screenings in many cases. Do not attempt to shortchange this process. Without a proper assessment, the wrong treatment might be advised, leading to poor outcome.

The next few blogs will discuss treatment options for ADHD, including dietary changes, supplements, alternative and additional treatments and medications.


Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


Share Quest for Health

 


 

Who’s Who In Learning & Behavior Evaluation & Management?

I tried to convey why it’s so important to get a proper diagnosis of learning and behavioral problems in my last blog, Labels – Why should my child be diagnosed? Today I’d like to explain what is done during the evaluation and who’s involved in testing and treatment. Primary care physicians are a great place to start with questions about how to evaluate and treat various concerns. After that where should you go?

Start with the pediatrician

learning and behavior evaluation and managementParents are sometimes surprised to learn that I treat ADHD, anxiety, and many other behavioral disorders. I see many kids every day with these issues. I enjoy watching as they learn to manage their behaviors and improve their executive functioning over the years. Even kids who really struggle in the early years can grow into confident and accomplished adults.

I often say that kids with ADHD are talented, smart and can do wonderful things. They have unique gifts.

There are some pediatricians who don’t treat these issues, but I find there’s a huge need. In many cases since I’ve followed a child for years, I know them well and can help better than a specialist who doesn’t have that history.

Despite plenty of experience, I do use specialists often.

Many learning and behavior problems have similar symptoms, so it might take several professionals to help evaluate the situation.

Of course the professionals at school are imperative to being part of the team. And there are times when the diagnosis isn’t clear or a child doesn’t respond to the treatment well, other specialists are very helpful to assess the issues.

Cautions…

There are of course many tests and treatments available that have not been proven to help. Future blogs will cover testing and treatments, but until then, just a few cautions.

There are tests available, such as EEG for ADHD, that are not shown to be beneficial and can increase cost without adding to the diagnostic evaluation.

There are many treatments that haven’t been shown to be effective but still advertise good results for a fee.

If it sounds too good to be true, it probably is. Discuss tests you are considering with your child’s doctor, especially if there is a large price tag attached.

 

Who’s who?

The alphabet soup of credentials confuses many parents. I’ve tried to compile a list of experts in various fields who might need to be involved in your child’s assessment and care as well as explain what types of things they can do to help in the process of evaluating and treating learning and behavior issues.

Parents

Parents (or primary caregivers) are critical to giving insight into how children learn and behave. They should be interviewed and fill out standardized questionnaires to help with the diagnosis. Their feedback on how each treatment is working is helpful in fine tuning treatment plans.

Teachers & Other School Professionals

Teachers are imperative in helping assess the issues and concerns since they can compare any one child to a room of their peers and they know how your child handles various situations and what their typical behaviors are.

Many schools will have a school counselor or psychologist evaluate and help treat students.

Teachers with advanced background in learning disabilities are used to help address specific concerns.

It’s recommended that each teacher fill out standardized questionnaires to help with the initial evaluation of focus and behavior disorders and again to assess responses to treatments.

Schools may put students on IEP or 504 Plans to help with their education. For more on these see IEP & 504 Plan. 

Therapists (not mental health)

Physical Therapists, Occupational Therapists, Audiologists, and Speech Therapists can be school based or private, but they are helpful in addressing specific motor skills, sensory issues, hearing issues, or speech/language concerns.

They do not prescribe medication, but work within their area to improve certain skills that affect learning and behavior.

Check with your insurance to see what is covered in your plan. Ask the school if they offer any of these services.

Mental health specialists

Psychologists (clinical psychologists, cognitive psychologists, educational psychologists and neuropsychologists) and clinical social workers offer testing as well as therapy for many disorders.

Some therapists specialize in testing, others in treating. Some do both. You will have to ask what their qualifications are and what role they play in diagnosis and management.

Clinical therapists can do parent training to help parents manage behaviors at home, especially for younger children.

Therapists cannot prescribe medications, but some people find that the therapy provides enough benefit that medication is not needed or that the therapy in addition to medicine helps better than either treatment alone.

Cognitive behavioral therapy is the preferred first line treatment for certain disorders, such as ADHD in young children and anxiety.

Therapists often provide social skills training, which is needed for many children with behavioral and learning issues who don’t learn social skills as easily as their peers.

You should check your insurance list of providers to see who is covered. It also might be worth pricing some who do not take your insurance but will give you a bill to submit yourself. If a person is out of network your cost might be about the same as a person who is harder to get in to see but on your plan.

I find the searchable database from Psychology Today to be helpful. You start with your zip code, then you can choose insurance, issues needed, male or female providers, and more to limit your list of suggested therapists.

Physicians

Physicians (pediatrician, family physician, developmental pediatrician, neurologist, and psychiatrist) can make a diagnosis and prescribe medications for treatment of certain diagnoses, such as ADHD or anxiety.

Not all have experience with each of these issues so you must ask what their experience is.

It can take quite a while to get into specialists and they can be expensive, so starting with your primary care physician often is easier and very helpful to rule out medical issues and to do the evaluation and treatment if they are comfortable.

Many psychiatrists do not accept insurance and they are typically difficult to get in to see.

Physicians (including psychiatrists) generally do not do therapy. They focus on the medication benefits and side effects. Therapy along with medication often improves outcome, so multiple specialists working together can be beneficial.

Physician-extenders

Nurse practitioners and physician assistants can work with physicians to diagnose disorders and prescribe medications to treat them. In some states they can work independently.

They do not offer psychotherapy, so it is often beneficial to work with more than one person to get the best outcome.

Benefits include that they are generally easier to get in to see and they are relatively inexpensive compared to physicians. Not all are comfortable with treating these issues. Ask about training and experience.

Working as a team

The types of professionals who work with any given child to assist in diagnosis and treatment vary depending on the issues at hand. The most important thing is that they work as a team and communicate with one another.

This communication is often done through parents and written reports. It’s important that all members of the team have access to what the others are doing.

Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

New in Fall 2018: ADHDKCTeen – a group just for teens with ADHD (and anxiety, learning difference, and anyone else who thinks it will help them).

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.

Share Quest for Health

 

Labels – Why should my child be diagnosed?

This is the first in a series of posts about learning and behavior I will do over the next several weeks. Parents are often afraid of labels when it comes to getting an appropriate assessment of learning  or behavior issues.

I see a lot of children with various behavioral and learning issues. Teachers and parents often first think of ADHD with any problem, but that isn’t always the problem, or at least the primary one. It’s simply one of the most common diagnoses. Since it’s so common, I will focus on this topic often, but it can mimic other problems and it often coexists with other issues.

I firmly believe that kids with learning and behavioral problems cannot just “work harder” to fix the problem.

We would never ask a child in a wheelchair to “just try harder” to walk up stairs. We shouldn’t expect someone who has trouble focusing to be able to “just try harder” either.

When I’m sleep deprived, I cannot focus as well. I cannot read and comprehend what would typically be easily understood and retained. I lose track of things. I lose my temper more easily or get upset about the little things that usually wouldn’t phase me. I must put extra effort into everything, which is even more exhausting.

I liken this to how some people feel most of the time.

How can we possibly expect them to just try harder without professional assessment and treatment?

What about labeling?
ADHD kid messing around
Kids with ADHD get distracted easily and have trouble staying on task.

One reason parents don’t want to have their child diagnosed with ADHD or any other learning or behavioral problem is that they fear a label.

What’s a label?

It’s not a diagnosis, but the way we’re perceived. Think about how many judgements and labels you make in a day.

I try really hard to not judge because it’s not my place, but those thoughts sneak into my mind all the time:

  • That person is rude.
  • That’s my shy (hyper, loud, smart, active, loving, etc) child.
  • That outfit is inappropriate.
  • That group of giggling girls is too loud and out of control.

I don’t say anything with these thoughts most of the time because it’s not my place.

I often mentally rebuke myself for having them, but I still have the thoughts.

The truth is that we all make judgements all the time. And when a child acts out a lot, he is judged and labeled.

If a child never seems to be organized, she is judged and labeled.

If a child falls behind academically, he is judged and labeled.

If a child bothers other kids in class with movements or talking, he is judged and labeled.

It happens with or without a diagnosis. The label is there.

With proper management, your child might lose the negative labels and be able to succeed!

Aren’t behaviors and focus problems from bad parenting?

Probably in part due to this stigma, parents worry about how the diagnosis will reflect on the child and family. If a child has an infectious disease or  a chronic condition such as asthma, there is much less hesitation to assess, diagnose, and treat the illness.

If this is just due to bad parenting, how does medicine help?

Diagnosing isn’t always easy.

One of the problems with diagnosing many learning and behavioral disorders is they’re difficult to test for since there is a continuum of symptoms of normal and atypical and there are so many variables (such as sleep) that can affect both learning and behavior.

There are diagnostic tools that should be used to assess the issues at hand. Your child shouldn’t be diagnosed without a standardized assessment. There are many available, depending on the concerns (ADHD, anxiety, dyslexia) and the age of the child, and sometimes kids need more than one type of assessment. Some of these can be done at your physician’s office. Others can be done with a professional who offers that type of assessment.

There is no proof that electroencephalography (EEG) or neuroimaging is helpful to establish the diagnosis of ADHD.

So many excuses to wait…

There are many reasons for parents to be hesitant to begin an evaluation when their kids are showing signs of a learning or behavioral problem.

  • Some think it’s just a phase.
  • Many wonder if another few months of maturity will help the child.
  • Some think the child is just misbehaving and stricter rules or harsher punishments will help.
  • Others think the child is just looking for attention and giving more praise will help.
  • Some parents think it is because of the other children around — you know, “Little Johnny is always messing around in class so my Angel Baby gets in trouble talking to him.”
  • We should try something else. (Linked blog is from a parent who shares her story.)
Why not wait?

While I’m all for looking for things on your own that can help a child’s behavior and optimize their learning (to be covered in a future post), I also think that avoiding the issue too long can lead to secondary problems:

  • academic failures
  • poor self-esteem
  • depression
  • drug/alcohol abuse
  • accidental injuries due to impulsivity and hyperactivity
  • strain on family life
  • social issues with peers

Working with the school and seeking professional help outside of school can help your child succeed.

If a parent is not wanting to start medication, there are other things that can be done that might help the child succeed once the specific issues are identified.

Not treating ADHD and learning differences has consequences.

The children suffer from poor self-esteem because they constantly are reminded that their behavior is bad or they fail to perform at their academic potential.

They have a harder time doing tasks at school because they lose focus. They get distracted and miss important information.

Children get in trouble for talking inappropriately, acting out or for invading other’s personal space.

Social skills lag behind those of peers and they often have a hard time interpreting how others react to their behaviors.

Their impulsivity can get them into dangerous situations, causing more injuries.

Older kids might suffer from depression and anxiety from years of “failures”.

Teens often try to self-medicate with drugs or alcohol.

Why are you hesitant?

If you still worry about labeling your child with a diagnosis, think about what the root of your worry really is.

Remember that the diagnosis is only a word. It doesn’t define the best treatments for your child, but it opens the doors to allow investigation of treatments that might help your child. In the end most parents want healthy, happy kids who will become productive members of society.

How can you best help them get there?

Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


Share Quest for Health

All About Ear Infections – Prevention

Ear infections are all too common and cause a lot of distress for kids and their families. What can we do to help prevent them from happening?

This is part 3 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

What can be done to prevent ear infections?

Avoid all smoke exposure.

Tobacco smoke is known to predispose children to ear infections, upper respiratory infections and wheezing.

Do not bottle prop.

Keeping a baby’s head elevated a bit while bottle feeding can help prevent ear infections.

Breastfeed.

Breast milk is protective against many types of infection, including ear infections.

General infection prevention.

Avoid taking your infant to places where there are a lot of people during sick season.

Wash hands often. Teach kids to really wash their hands. Because they don’t do a great job much of the time.

Attempt to limit sharing of toys that young children mouth, and wash them between children.

If your child attends daycare, try to find one where there are fewer children per room.

Vaccinate.

One of the biggest causes of bacterial ear infections is pneumococcus. Your child will be vaccinated against this as part of the standard vaccine schedule.

Saline.

If you know me, you know I often recommend saline to the nose.

Saline drops for babies followed by suctioning.

Nasal saline rinses for kids over 2 years of age. (Nasopure has a great library to teach proper use and even videos to get kids used to the idea.)

Saline is a great way to clear the mucus from our nose, which can help prevent cough, sinus infections, and ear infections.

Keep the pacifier in the crib.

When kids play, they often drop their pacifier, which can encourage germs to accumulate on it before they put it back in their mouth.

Xylitol.

There are several studies that suggest chewing gum with xylitol as its sweetener helps prevent ear infections in children who can chew gum. For younger infants, there are nose sprays with xylitol. Xylitol is a naturally occurring substance that is used as a sweetener is many products, many of which are reviewed here. I do not endorse any of these, but do find this a helpful resource.

Treat acid reflux.

This can include dietary changes, positional changes, or medications. Talk to your doctor to see which is right for your child.

Treat allergies.

Treating allergies can help decrease mucus production and improve drainage.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines
Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age

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All About Ear Infections – Treatments

Yesterday I wrote about what ear infections are, what they’re not, and what causes them. Many parents don’t care so much about the what’s and why’s – they want treatment. Now. Because ear infections hurt, and no one wants to watch their baby suffer. Today I’ll discuss treatments.

This is part 2 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

Treatments for Ear Infections

First manage the pain

Regardless of the cause of the earache or what the ultimate fix will be, you will want to first manage pain. It does not matter if it’s a real infection or if it’s even the ears that are causing problems, if your child is in pain, treat the pain.

Oral pain relievers

Ear pain can be managed with pain relievers, whether it’s a true infection or simply pain from the congestion that comes with a cold. You can begin pain relief at home whether or not the ear infection is confirmed with standard doses of either acetaminophen or ibuprofen.

Ear drops

Ear drops for pain work fast but the relief doesn’t last long, so I recommend also giving acetaminophen or ibuprofen per standard dosing recommendations in combination with drops. Ear drops can include both over the counter options and prescription options as long as the eardrum doesn’t have a hole or tube in it.

Do not put anything in the ear if you suspect a hole or know your child has a tube unless your doctor recommends it.

Olive oil works pretty well and most of us have that in our kitchen. Saturate a cotton ball with oil (not hot oil) and squeeze the cotton over the ear canal, putting 2-4 drops in the canal.

There are many over the counter ear drops for pain, but I find that the oil you already own is not only cheaper, but works just as well.

Prescription numbing drops are an option if your doctor thinks they are appropriate. These have been difficult to find in recent years for many factors. Be sure you’re using an approved product if you use prescription pain drops.

Positioning

If you’ve had an ear infection as an adult or watched your child refuse to sleep, you’ll know that ear infections can hurt more when lying down. Safely elevating the head can help the pain associated with the increased pressure lying down.

For young infants, elevate the head of the bed by putting risers under the legs of the bed or by wedging something under the mattress. Be sure it is stable, whichever you do. Never put an infant under 1 year of age on a pillow or other soft bedding.

For older children, propping up on several pillows is often helpful. Many toddlers and young children will not stay on pillows, so this is less effective.

Treat associated issues

When kids have ear pain, they often have a runny nose, cough, fever, and other symptoms. Each of these should be managed as discussed on previous blogs: fevergreen snotcoughgenerally sick. How long symptoms will last are discussed here.

treatment varies by age of the child and severity of the infection:

  • Pain relief for anyone with an ear infection is the first treatment. See above.
  • Monitor for the first 2-3 days without antibiotics in many instances, since most ear infections will self-resolve.
  • Antibiotics can be used if symptoms persist more than 2-3 days ~ earlier for children under 6 months of age, those with significant illness, those who had another ear infection within the past 30 days, or for those who have an increased risk of ear infection (such as immune deficiency or an atypical facial structure or chromosomal defect known to affect hearing or immune function).
  • If a child has tubes and develops an ear infection, pus will drain out of the tube. Antibiotic ear drops are the first choice for this type of infection. Antibiotics by mouth are not typically needed.
  • Prevent the next ear infection. See Part 3 tomorrow!

Why not use antibiotics for every ear infection?

Antibiotics don’t treat viruses

The large majority of ear infections are caused by a virus, for which antibiotics are ineffective. About 80% of ear infections self resolve without antibiotics.

Antibiotics can cause problems

Not only are antibiotics not needed, but they also carry risks. About 15% of kids who take antibiotics develop diarrhea or vomiting. Nearly 5% of children have an allergic reaction to antibiotics — this can be life threatening. So when you look at the benefits vs risks, you can see that most of the time antibiotics should not be used as a first treatment.

Superbugs

When bacteria are exposed to an antibiotic but don’t get completely killed, they learn to avoid not being killed the next time they see that same antibiotic. This is called bacterial resistance, also known as “superbugs”.

Superbugs can be shared from one child to another, which explains why some children who have never had antibiotics before have an infection that is not easily taken care of with the first (or second) round of antibiotics and why if a child needed several different antibiotics to clear an ear infection might get better with generic amoxicillin with the next.

It’s the bacteria in the ear that become resistant, not the child. The more we use antibiotics, the more resistance builds up and the less likely antibiotics will work for serious infections.

What are tubes and how do they work?

Tympanostomy tubes are small plastic tubes that are placed in a surgically made hole in the eardrum (tympanic membrane). They keep the hole in the eardrum open so that if pus develops in the middle ear it can drain out through the tube. This helps prevent the pain caused by the pus filling the middle ear area and pushing out on the eardrum. It also helps prevent the hearing loss that happens when the eardrum can’t move due to pus behind it.

photo from USAToday (Rosenfeld RM. A Parent’s Guide to Ear Tubes. Hamilton: BC Decker Inc., 2005)

Pus behind the eardrum causes many symptoms, which may include balance problems, poor school performance, hearing difficulties, behavioral problems, ear discomfort, sleep disturbance, and/or decreased appetite with poor weight gain. The benefits of tube placement for these children must be compared to the cost and risks of anesthesia and having an opening in the eardrum.

The majority of ear infections resolve completely without complication. The longer the pus remains behind the eardrum the less likely it will go away. If the pus is there longer than 3 months, it’s less likely to resolve without treatment.


When are tubes recommended?

Since placing tubes does involve risks, they are not recommended for everyone.
Guidelines recommend the following evaluation for tubes:
  • If pus or fluid has been in the middle ear for over 3 months (OME or OM that never clears), a hearing test should be done.
  • If the hearing test is failed, tubes should be considered.
  • If fluid has been there longer than 3 months but hearing is normal, recheck the hearing every 3-6 months until the fluid clears. If the hearing test is failed on rechecks, then tubes are warranted. (I know plenty of families who opt for tubes despite normal hearing due to quality of life despite this recommendation.)
  • Children with higher risk of speech issues or hearing loss may be considered for tubes earlier. This would include children with abnormal facial structures, such as cleft palate, or certain genetic conditions that predispose to developmental delays, hearing concerns, or immune problems.
 Dr. Deborah Burton is an Ear, Nose, and Throat (ENT) surgeon who answers common ear tube questions and discusses common tube complications in just a couple of her fantastic collection of blogs. She also gives tips on how to avoid ear infections to prevent the need for surgery!

What about recurrent ear infections?

I know parents get frustrated with recurrent ear infections, and I’ve seen many families who are happy that they got tubes for their child after recurrent ear infections, but studies show they aren’t really necessary. If each ear infection clears, that shows that the eustachian tube (the tube that drains the middle ear into the throat) can do its job. As long as the pus is there less than 3 months with each infection, the risk of tubes does not usually outweigh the benefits according to studies.
Again, quality of life can factor in here and I think that’s hard to measure in a study. If kids are missing out on sleep and not eating well due to ear pain, tubes might really help. Discuss this with your child’s doctor.

Are there kids who should be considered tube candidates earlier?

Some kids are more sensitive to the problems associated with OME. These kids might have sensory, physical, cognitive, or behavioral issues that increase his or her risk of speech, language, or learning problems from pus in the middle ear. Children with known craniofacial abnormalities or chromosomal abnormalities who are at higher risk for speech and hearing impairment will also be considered for tubes more liberally. These kids might benefit from tubes even if they don’t have pus for 3 months in the middle ear or hearing loss.

What are complications and risks of tubes?

Tube placement requires anesthesia, which is overall safe, but not without risk.
Tubes keep a hole in the eardrum, which can allow water and bacteria to get into the middle ear, leading to infection. This leads to pus draining out of the ear canal, called otorrhea. This pus can be treated with antibiotic ear drops initially, and oral antibiotics if it last more than a month.

Some ENTs recommend earplugs when kids with tubes swim, but studies do not show that they are needed in most cases. If kids get recurrent otorrhea, they might be candidates for earplugs when swimming. Kids who swim in lake water or do deep water diving might also benefit from earplugs.

NEXT UP: Prevention

So now that you know what ear infections are and how to treat them, check in tomorrow for Part 3: how to prevent them.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines

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The flu shot doesn’t work

I’ve seen a few kids this season who have influenza despite the fact that they had the vaccine. When the family hears that the flu test is positive (or that symptoms are consistent with influenza and testing isn’t done), they often say they won’t do the flu shot again because it didn’t work.

How do they know it isn’t working?

Influenza can be deadly.

Most of the kids I’ve seen with flu who have had the shot aren’t that sick. Yes, they have a fever and cough. They aren’t well.

But they’re not in the hospital.

They’re not dying.

They tend to get better faster than those who have unvaccinated influenza.

Some kids still get very sick with influenza despite the vaccine.

That’s why there’s surveillance to see how it’s working.

When FluMist was determined to not be effective, it was removed from the market.

Studies are underway to make a new type of flu vaccine that should be more effective.

We know the shot isn’t perfect, but it’s better than nothing.

Maybe if you weren’t vaccinated you’d be a lot sicker.

Maybe you were exposed to another strain of flu and didn’t get sick at all.

I think it’s still worth it to get vaccinated each year (until they come up with a vaccine that lasts several seasons).

If everyone who’s eligible gets vaccinated against the flu, herd immunity kicks in and it doesn’t spread as easily. Historically only around 40% of people are vaccinated each year against influenza. We know that to get herd immunity we need much higher numbers.

Shot fears…

If your kids are scared of shots, check out Vaccines Don’t Have to Hurt As Much As Some Fear.

Don’t rely on Tamiflu to treat flu symptoms once you’ve gotten sick.

Tamiflu really isn’t that great of a treatment. It hasn’t been shown to decrease hospitalization or complication rates. It shortens the course by about a day. It has side effects and can be expensive. During flu outbreaks it can be hard to find.

Prevention’s the best medicine.

Learn 12 TIMELY TIPS FOR COLD AND FLU VIRUS PREVENTION.

Get your flu vaccine. #fluvaccine #vaccineswork
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Tamiflu: The not-so-great influenza treatment

Over the years I’ve written a lot about Tamiflu because I have strong feelings about its use. Here I’ll summarize what I’ve learned over the years because during flu season I get many requests for Tamiflu (oseltamivir). Understandably parents fear the flu once they see how miserable their kids are when it hits their house, but I don’t like to use Tamiflu because I just don’t think it works well and it has quite a few side effects.

The pressure’s on…

In recent years I’ve felt coerced into writing more prescriptions for Tamiflu due to the powers of the guidelines recommending it. It’s more common in my experience to hear negative feedback about side effects than it is to see patients get better faster. (Note: this is a very biased view, since those who are better would not call, but since so many call with side effects it seems fair to say I don’t like the drug.)

I am not alone in my dislike of Tamiflu. I follow a listserv of pediatricians around the country and many share my views. In a discussion of influenza and antivirals, one doctor suggested watching a TED Talk by Dr. Ben Goldacre: What doctor’s don’t know about the drugs they prescribe.  Dr. Goldacre starts talking about Tamiflu specifically about 10:10, but the entire lecture is done in an entertaining and informative manner if you have the time.

I feel deceived.

When I practice medicine, I follow standard recommendations and guidelines that are based on peer reviewed articles and data. The question is, what important data is left out? There is a movement to solve this problem of unpublished studies. You can see updates at the Tamiflu Campaign of the British Medical Journal.

The WHO has downgraded Tamiflu’s status, but I haven’t seen the CDC or AAP comment on that.

Back to influenza treatment…

First, current influenza treatment guidelines regarding the use of antivirals:

From the CDC’s recommendations for antiviral use for influenza
Summary of Influenza Antiviral Treatment Recommendations
  • Clinical trials and observational data show that early antiviral treatment can shorten the duration of fever and illness symptoms, and may reduce the risk of complications from influenza (e.g., otitis media in young children, pneumonia, and respiratory failure).
  • Early treatment of hospitalized adult influenza patients has been reported to reduce death.
  • In hospitalized children, early antiviral treatment has been reported to shorten the duration of hospitalization.
  • Clinical benefit is greatest when antiviral treatment is administered early, especially within 48 hours of influenza illness onset.
  • Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who:
    • is hospitalized;
    • has severe, complicated, or progressive illness; or
    • is at higher risk for influenza complications.
  • Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk with confirmed or suspected influenza on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset.
That last statement is what really gets me confused.

I know that influenza can be deadly.

And that we should try to do everything in our power to help prevent severe illness and death.

But to treat any healthy person with suspected flu with a medicine that hasn’t been shown to be very effective and has side effects seems unreasonable to me.

Because it’s a guideline, if a physician chooses not to give antiviral treatment and there is a bad outcome, they could be held liable.

Despite the research.

I think this option also encourages people to not get the vaccine because they think they can just treat it if they get the disease. It’s not that easy…

look at what a search for “unpublished tamiflu trials” shows.

For those of you unfamiliar with the Cochrane group: They are a well respected group that reviews all the studies within certain parameters on one topic to evaluate the overall findings of several independent studies.

From the Cochrane Group:

A review of unpublished regulatory information from trials of neuraminidase inhibitors (Tamiflu – oseltamivir and Relenza – zanamivir) for influenza.

These results are from a review of published and unpublished studies that they could find.

From the abstract:

“The authors have been unable to obtain the full set of clinical study reports or obtain verification of data from the manufacturer of oseltamivir (Roche) despite five requests between June 2010 and February 2011. No substantial comments were made by Roche on the protocol of our Cochrane Review which has been publicly available since December 2010.”

They found several problems with Tamiflu from the studies they were able to review:
  • Drug manufacturers sponsored the trials, leading to publication and reporting biases. One of the authors reported that 60% of the data was never published. This is over half of the research, and I suspect it didn’t support use of the medicine (remember the company that benefits from selling the medicine was doing the trials…)
  • There was no decrease in hospitalization rate for influenza in people treated with Tamiflu.
  • There was not enough evidence of prevention of complications from influenza. Design of the trials (again by the people who make the drug) did not report the prevention of complications from influenza, such as secondary infections.
  • There is not evidence in the trials to support that Tamiflu reduces spread of the virus. One of the main reasons people request the medication is after exposure to prevent illness! (Note: this might have changed because the indications on the package insert now say it can be used to prevent illness in those over 1 year of age and they were previously not allowed to mention prophylaxis.)
  • Tamiflu reduced symptoms by 21 hours. Yep. Less than one day of fewer symptoms. For the cost of the drug and the potential side effects, is feeling sick for 1 day less really worth it?
  • There was a decreased rate of being diagnosed with influenza in those randomized to get Tamiflu, probably due to an altered antibody response. The authors suspect a body becomes less able to make its own antibodies against influenza when taking Tamiflu.
  • Side effects were not well documented. A review study done in children exclusively (Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: systematic review and meta-analysis of randomised controlled trials) focused on treatment of disease and prevention of illness after exposure.
Findings included:
  1. Symptom duration decreased between 0.5 and 1.5 days, but only significantly reduced symptoms in 2 of 4 trials. That means in 2 of 4 trials there was no significant reduction in symptoms.
  2. Prophylaxis after exposure decreased incidence by 8% of symptomatic influenza. This means for every 13 people given Tamiflu to prevent disease, one case will be prevented. Not great odds.
  3. Treatment was not associated with an overall decrease in antibiotic use, suggesting it did not alter the complication of bacterial secondary infections.
  4. Tamiflu was associated with in increased risk of vomiting. About 1 in 20 children treated with Tamiflu had an increased risk of vomiting over the baseline vomiting due to influenza.
  5. There was little effect on the number of asthma exacerbations or ear infections by treating influenza with Tamiflu.
Investigators have documented their discussions with the maker of Tamiflu on Tamiflu correspondence with Roche.

 

Recent studies have tried to compile all that is known about how oseltamivir works:

Results from this study include:
  • In the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.7 hours, 29 hours in children.
  • There was no difference in rates of admission to hospital between treatment groups in both adults and children.
  • Oseltamivir relieves symptoms in otherwise healthy children but has no effect on children with asthma who have influenza-like illness.
  • Using oseltamivir had no significant effect on admissions to the hospital.
  • Oseltamivir causes gastrointestinal disturbances in both prophylaxis and treatment roles. In prophylaxis, it caused headaches, renal events (especially decreased creatinine clearance), and psychiatric effects.

So what do I recommend during the cold and flu season?

    1. Get vaccinated! The influenza vaccines have been shown to help prevent influenza and are very well tolerated with few side effects. If you or your children are due for other vaccines, be sure to get caught up. Even if they aren’t a perfect match, some protection is better than none, and if more people get the vaccine herd immunity helps!
    2. If you get sick, stay home until you’re fever free without the use of a fever reducer for at least 24 hours! Don’t spread the illness to others by going to work or school. The influenza virus is spread for several days, starting the day before your symptoms start until 5-7 days after symptoms start– kids may be contagious for even longer. You are most contagious the days you have a fever.
    3. Wash hands well and frequently. If you can’t use soap and water, use hand sanitizer.
    4. Cover your cough and sneeze with your elbow or a tissue.
    5. Avoid close contact with people who are sick. But remember that people spread the virus before they feel the first symptoms, so anyone is a potential culprit!
    6. Don’t share food, drinks, or towels (such as after brushing teeth to wipe your mouth) with others.
    7. Don’t touch your eyes, nose, and mouth — these are the portals for germs to get into your body.
    8. Keep infants away from large crowds during the sick season.
    9. Frequently clean objects that get a lot of touches, such as keyboards, phones, doorknobs, refrigerator handle, etc.
    10. Avoid smoke. It irritates the airway and makes it easier to get sick.
    11. Remember that many germs make us sick during the flu season. Just because you’ve been sick once doesn’t mean you won’t catch the next bug that comes around. Use precautions all year long!
    12. Did I mention that you should get vaccinated?

Because the guidelines recommend Tamiflu as above, I will probably be forced to prescribe it by worried parents who hope that their kids will feel better. (You’ve heard of defensive medicine, right?)

Key Point:

Influenza is a miserable illness. The key is prevention.

I’ve had my vaccine, how about you?

If you’re worried about the injection, check out Vaccines Don’t Have to Hurt As Much as Some Fear.

A physician’s story of his sister dying of influenza despite being overall healthy and getting good medical care: Even With All Our Modern Medicine, I Watched My Sister Die From Flu

Added 1/14/18: I just saw this story about a girl with very scary hallucinations from Tamiflu. I’ve heard these stories before. It’s not as uncommon as the story might lead you to believe.

Further Reading:

Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children: A link is available to the full text of the study by T Jefferson, MA Jones, P Doshi, CB Del Mar, CJ Heneghan, R Hama, and MJ Thompson.

 

A new home: Quest for Health KC

I’ve finally made the move after years of contemplating this endeavor. My previous blog, https://pediatricpartners.blogspot.com/ has served me well for nearly 5 years, but I wanted to update the look and features. The name, Quest for Health KC, was chosen because it’s similar to the old blog name, but adds the KC location to differentiate it.

I blog about all things related to pediatrics: child health and wellness, insurance issues, safety, parenting, and more. Feel free to comment on posts and request specific topics!

Quest for Health KC

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Dry Drowning – What Parents Need to Know

I thought about calling this one “We’re drowning in dry drowning phone calls” because we are getting many worried calls about dry drowning, but that’s overly dramatic and I hate headlines that make things seem like the sky is falling…

I had never heard of dry drowning until social media picked it up a couple of summers ago. Maybe I did as a resident, but since I’ve never seen it, I’d forgotten the term. Either way, it isn’t very common at all.

Several articles have emerged since the original writing of this post that clearly indicate there is no such thing as dry drowning.

One of the reasons I think so many parents are worried is that it is common for kids to go under water: in the tub and in the pool. Many get water in their mouth or complain that it went up their nose. Few actually get any into their lungs, which is where it can cause problems. How can you know when you need to worry?

Most of us recall a time we coughed briefly after inhaling liquid, and we were fine. So when is it worrisome? It’s when the water that gets into the lungs causes inflammation within the next day or two. This inflammation makes it hard for the lungs to work – the air tubes are swollen, so air can’t get through. Treatment is giving oxygen, sometimes with a ventilator (breathing tube and machine) until the inflammation goes down.

Symptoms you need to recognize and act upon by taking your child to an ER:
  • Cough: If your child has coughing for a minute or more after being in water, he’s at risk. This indicates that the child is trying to clear the airways. If water got down there and they cough most up, some can remain behind and lead to inflammation over time. Watching your child carefully for the next 3-4 days is important. This can be hard to recognize initially, so a complete evaluation is important if any other symptoms develop.
  • Difficulty breathing: Anyone who is struggling to breathe needs further evaluation. Signs can be rapid breathing, sucking in the ribs or the stomach, difficulty talking, or even a look of fear from difficult breathing.
  • Near drowning: If your child had to be pulled out of the water, he should be evaluated in an ER. Even if he seems fine afterwards. The reaction is delayed, so they can seem to be 100% better and then go downhill.
  • Behavior changes or confusion: If a child is confused, lethargic** or has a change in ability to recognize people, he should go to the ER. Serious illnesses can present with a change in mental status, including significant infections, concussion, heat exhaustion, brain tumors, and drowning. The ER doctor will ask what else has been going on to help identify the cause of confusion.  **Many people misuse the term lethargic. Lethargic isn’t the same thing as being tired after a long day. The medical definition is “Relatively mild impairment of consciousness resulting in reduced alertness and awareness; this condition has many causes but is ultimately due to generalized brain dysfunction.”
  • Vomiting: Vomiting after a day at the pool can be due to infection (from swallowing contaminated pool water), food poisoning (from food left in the heat too long) or dry drowning. It’s best to check it out in the ER.
What will happen in the ER?

Many parents don’t want to go to the ER because of high co-pays. We try to keep kids out of the ER as much as possible. But some issues are better taken care of in an ER. Most offices don’t have the equipment or staff to manage these issues well. Dry drowning can be life threatening, and the evaluation and treatment should start in the ER. I cannot say exactly what the doctor will do, since that will depend on your child’s symptoms and exam. There is no specific treatment for this, only supporting your child’s airway and breathing as the swelling goes down.

  • If the doctor thinks your child may have swelling of the airways, he might order a chest x-ray to look for pulmonary edema (lung tissue swelling).
  • An iv might be started to be able to give adequate fluids, since your child might not be up to drinking well.
  • Oxygen levels will be monitored and extra oxygen might be given.
  • Since the swelling worsens before it gets better, if there is a strong suspicion of dry drowning your child will be admitted for further observation.
  • Some kids need help breathing and are put on a ventilator (breathing machine) until the swelling goes down.
Prevention is important!

swimming
Watch your kids when around water!

As with many things, we should do all we can to be sure our kids are safe around water. This includes the bathtub and toilet as well as swimming pools, lakes, and ponds.

  • Childproof your home when you have little ones who might play in a pet water bowl or the toilet.
  • Teach your kids water safety. Swimming lessons can help them learn skills. Tell them to never try to dunk each other. They shouldn’t pretend they’re drowning because it might distract a lifeguard from a true emergency.
  • Learn infant and child CPR.
  • If you have a pool or pond at home, be sure there is a fence limiting access from your house.
  • Watch your kids closely and keep them within reach when they’re in water until they are strong swimmers. When they are strong swimmers you can let them swim outside your reach as long as lifeguards are present.
  • Learn what distress in the water looks like. The movie depiction of drowning with a lot of yelling and thrashing around is not what usually happens. If someone can verbalize that they’re okay, they probably are. Drowning victims can’t ask for help. There is a video linked to this page of what to look for with drowning that shows an actual rescue.
From this site, signs of drowning:
  • Head low in the water, mouth at water level
  • Head tilted back with mouth open
  • Eyes glassy and empty, unable to focus
  • 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
  • Trying to roll over on the back

Addendum:

    • I just read a post that gives references regarding drowning definitions. It appears I didn’t forget learning about dry drowning in medical school.

It isn’t really a thing.

The symptoms listed above that I recommend getting evaluated are still concerning symptoms, but they might be from another cause.

Check these out:

On “Dry Drowning”

Drowning in a Sea of Misinformation: Dry Drowning and Secondary Drowning

Drowning is never dry: Two ER doctors explain the real swimming danger kids face