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.


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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

Itchy, sneezy, puffy… what can you do about allergies?

It’s allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors. This is an update to a previous blog I wrote on the subject, since there are many more medicines now available over the counter.

Symptoms of Allergies: 

allergies

Allergies are more than just sneezing.

They can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes.

Some kids get a crease across their nose from wiping.

Others get purple circles under their eyes called allergic shiners.

These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

Treatments: 

It is best to treat before the symptoms get bad. It is easy to monitor pollen counts online to know what’s out there and start treatment before symptoms make you (or your child) miserable. Treatments include medicines and limiting exposure.

Medications:

I don’t want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help.

Antihistamines

Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others.

In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits.

You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help.

Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. Insurance companies rarely cover the cost of antihistamines these days.

Antihistamine and decongestant combinations

Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn’t needed.

If you need a decongestant initially, you can use one with your usual antihistamine. Most decongestants on the market are ineffective. If you ask the pharmacist for pseudoephedrine, it is available behind the counter. It was replaced by phenylephrine years ago due to concerns of methamphetamine production, but works a little better than phenylephrine.

Decongestants do NOT fix a cold, they only dry up some of the mucus. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age.

Nasal Spray steroid and antihistamine

Nasal spray steroids and antihistamines are available over the counter or as a prescription. An office visit to discuss the value of these for your child and proper use is recommended.

Nasal steroids are often the preferred treatment based on effectiveness and tolerability.

Eye drops

Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better.

Most insurance companies don’t cover prescription allergy eye drops well, so you might want to check your formulary before asking for a prescription. This is usually available on your insurance website after you log in.

Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye.

Montelukast

Montelukast (commonly known as Singulair) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. Once a person has been on montelukast for a couple of weeks, they usually don’t need an antihistamine any longer. It is available only by prescription, so make an appointment to discuss this if your child might benefit.

Steroids

Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  

The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

Wash off pollen

Wash hair, eyelashes, and nose after exposures — especially before sleep. They all trap allergens and increase the time your body reacts to them.

I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses.

keep pollen out of the house

Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.

Wash towels and sheets weekly in hot water.

Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting.

Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them.

There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners.

Keep the windows closed. Sorry to those who love the “fresh air” in the house. For those who suffer from allergies, this is just too much exposure!

Think about pets

Keep pets out of bedrooms. If you know a family member is allergic to an animal, don’t get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal.

Contact lens wearers

If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts.

Smoke is an added irritant

Keep smoke away. Smoke is an airway irritant and can exacerbate allergy symptoms. Remember that the smoke dust remaining on hair, clothing, upholstery, and other surfaces can cause problems too, so kids can be affected even if you don’t smoke near them.

What if all of the above isn’t helping?

Maybe it’s really not allergies.

Allergies to things other than foods are rare before 2 years of age.

Viruses can cause very similar symptoms to allergies.

Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don’t find it very helpful for environmental allergens because you can’t avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn’t take long to see patterns. Testing is important if allergy shots are being considered.

Need help tracking allergy symptoms?

There’s an app for that! Here’s one review I found of allergy apps. I don’t have any personal experience of any, so please put your favorite in the comments below to help others!

Wrong medicine or wrong dose.

Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.

Some kids outgrow a dose and simply need a higher dose of medicine as they grow.

Is Nothing working?

Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment with your pediatrician to discuss if this is an option for your allergy sufferer.

 

Traveling Around the World

Spring Break is around the corner, which means many of my patients will be traveling to various areas of the world for vacation or mission trips. Many of these areas require vaccines prior to travel, so plan ahead and schedule a travel appointment with your doctor (if they do them) or at a travel clinic. Many insurance companies do not cover the cost of travel medicine visits, medications, or vaccines, but they are important and are a small cost in comparison to getting sick when on your trip.

Vaccinate when you can!

Immunization records will need to be reviewed, so if you are going to a travel clinic outside your medical home (doctor’s office) be sure to bring the records with you.

Vaccines work best when they are given in advance, so do not schedule the pre-travel visit the week you leave! Some vaccines that are recommended are easily available at your primary medical office but others are not commonly given so might require a trip to a local health department, large medical center, or travel clinic.

Check with your insurance company to see if the cost of the vaccine will be covered or not so you can include your cost in your travel budget if needed.

Watch the food and drinks

Many diseases are spread through eating and drinking contaminated foods. If in doubt: do not eat! Cooked foods are generally safer. Any fresh fruits or vegetables should be washed in clean water before eating. Be sure all dairy products are pasteurized. Avoid street vendors, undercooked foods (especially eggs, meats, and fish), salads and salsas made from fresh ingredients, unpeeled fruits, and wild game. Drink bottled water or water that has been boiled, filtered or treated in a way that is known to be reliable. Use the same water to brush teeth. Do not use ice unless you know it is from safe water because freezing does not kill the germs that cause illness.

As always, wash hands often, use sanitizer as needed when washing is not available, and avoid touching the “T” zone of your face (eyes, nose, and mouth). Do not share utensils or foods. Avoid people who are obviously ill.

Medicines for travelers Diarrhea

  • Many companies that schedule international travel recommend bringing antibiotics for prevention or treatment of diarrhea.
  • This is not recommended by many experts due to the rise of “superbugs” with the use of unnecessary antibiotics.
  • In general, the use of antibiotic prophylaxis is recommended only for high-risk travelers, and then only for short periods.
  • The average duration of illness when untreated will be 4 to 5 days, with the worst of the symptoms usually lasting less than a day.
  • Antibiotics might lead to yeast infections, allergic reactions, or even a chronic carrier state (colonization) or irritable bowel syndrome.
  • Antibiotics should be reserved for the treatment of more serious illnesses that include fever and significant associated symptoms such as severe abdominal pain, bloody stools, cramping, and vomiting.
  • Bismuth subsalicylate is available over the counter for adults and can reduce traveler’s diarrhea rates by approximately 65% if taken four times daily. Risks of bismuth products are that it can turn the tongue and stool black and they contain salicylate. Salicylate carries a theoretical risk of Reye syndrome in children, so should be avoided in children.
  • Probiotics and prebiotics have been shown to help prevent and treat diarrheal illnesses safely in most people with intact immune systems.

Mosquitos…

Many diseases are spread by mosquitos. Contact with mosquitoes can be reduced by using mosquito netting and screens (preferably insecticide-treated nets), using an effective insecticide spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body. Everyone at risk for mosquito bites should apply mosquito repellant. See below for prevention medication options.

Non-Infectious Risks

Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page.
  • Learn local laws prior to travelling.
  • Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.
  • Remind everyone to stay in groups and to not venture out alone.
  • Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.
  • Wear sunscreen! It doesn’t matter if you’re on the beach or on the slopes, you need to wear sunscreen every time you’re outside. Don’t ruin a vacation with a sunburn.
  • For more safety tips, see this helpful brochure.

Keep records

It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.

Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.

  • your name, address, and phone number
  • emergency contact name(s) and phone number(s)
  • immunization record
  • your doctor’s name, address, and office and emergency phone numbers
  • the name, address, and phone number of your health insurance carrier, including your policy number
  • a list of any known health problems or recent illnesses
  • a list of current medications and supplements you are taking and pharmacy name and phone number
  • a list of allergies to medications, food, insects, and animals
  • a prescription for glasses or contact lenses

Specific Diseases to Prevent

Risks of illness vary depending on where you will be travelling and what time of year it will be. I refer to the CDC’s travel pages and the Yellow Book for information on recommendations. Some of the most common issues to address are discussed below in alphabetical order.

Dengue Fever

Dengue is a mosquito-borne viral illness. It is seen in parts of the Caribbean, Central and South America, Western Pacific Islands, Australia, Southeast Asia, and Africa. There is no vaccine or specific treatment. Mosquito bite prevention measures are important.

Hepatitis

Infants should begin vaccinations against Hepatitis B starting at birth and against Hepatitis A starting at a year of age. Be sure these vaccines are up to date. Hepatitis A is spread through food and water, so be sure to follow the above precautions even if vaccinated.

Malaria

Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.

Prevention medications might be recommended, depending on when and where you will be travelling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication.

  • Atovaquone-proguanil should begin 1–2 days before travel, daily during travel, and 7 days after leaving the areas. Atovaquone-proguanil is well tolerated, and side effects are rare but include abdominal pain, nausea, vomiting, and headache. Atovaquone-proguanil is not recommended for prophylaxis in children weighing <5 kg (11 lb).
  • Mefloquine prophylaxis should begin at least 2 weeks before travel. It should be continued once a week, on the same day of the week, during travel and for 4 weeks upon return. Mefloquine has been associated with rare but serious adverse reactions (such as psychoses or seizures) at prophylactic doses but are more frequent with the higher doses used for treatment. It should be used with caution in people with psychiatric disturbances or a history of depression.
  • Primaquine should be taken 1–2 days before travel, daily during travel, and daily for 7 days after leaving the areas. The most common side effect is gastrointestinal upset if primaquine is taken on an empty stomach. This problem is minimized if primaquine is taken with food. In G6PD-deficient people, primaquine can cause hemolysis that can be fatal. Before primaquine is used, G6PD deficiency MUST be ruled out by laboratory testing.
  • Doxycycline prophylaxis should begin 1–2 days before travel to malarious areas. It should be continued once a day, at the same time each day, during travel in malarious areas and daily for 4 weeks after the traveler leaves such areas. Doxycycline can cause photosensitivity so sun protection is required.  It also is associated with an increased frequency of vaginal yeast infections. Gastrointestinal side effects (nausea or vomiting) may be minimized by taking the drug with a meal and it should be swallowed with a large amount of fluid and should not be taken before bed. Doxycycline is not used in children under 8 years. Vaccination with the oral typhoid vaccine should be delayed for 24 hours after taking a dose of doxycycline.
  • Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present. Prophylaxis should begin 1–2 weeks before travel to malarious areas. It should be continued by taking the drug once a week during travel and for 4 weeks after a traveler leaves these areas. Side effects include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and itching, but generally these effects do not require that the drug be discontinued.

Measles

We routinely give the first vaccine against measles (MMR or MMRV) at 12-15 months of age, but the MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks. Under 6 months of age, an infant is considered protected from his mother’s antibodies. These antibodies leave the baby between 6 and 12 months. The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday.

Any vaccine dose given before the first birthday does not count toward the two doses required after the first birthday, but might help protect against exposure if the immunity from the mother is waning. It is safe for a child to get extra doses of the vaccine if needed for travel between 6 and 12 months.

Meningitis

  • Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States. In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but can be given as young as 9 months of age. MenACWY-CRM is newly approved for children 2 months and older.
  • There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel.
  • Meningitis vaccines should be given at least 7-10 days prior to potential exposure.
  • Travellers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. The vaccine is available for children 9 months and older in my office and a newer vaccine is approved for 2 months and up. Boosters for people travelling to these areas are recommended every 5 years.

Tuberculosis

Tuberculosis (TB) occurs worldwide, but travelers who go to areas of sub-Saharan Africa, Asia, and parts of Central and South America are at greatest risk. Travelers should avoid exposure to TB in crowded and enclosed environments and avoid eating or drinking unpasteurized dairy products. The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States.

Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure.

It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body’s immune system is compromised, as with old age or another illness.

Appropriately treating the TB before it causes active disease is beneficial for the long term.

 

Typhoid

Typhoid fever is caused by a bacteria found in contaminated food and water. It is common in most parts of the world except in industrialized regions (United States, Canada, western Europe, Australia, and Japan) so travelers to the developing world should consider taking precautions. There are two vaccines to prevent typhoid.

  • Children over 2 years of age can be vaccinated with the injectable form. It must be given at least 2 weeks prior to travel and lasts 2 years.
  • The oral vaccine for children over 5 years and adults is given in 4 doses over a week’s time and should be completed at least a week prior to travel. The oral vaccine lasts 5 years.
  • Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.

Yellow Fever

Yellow fever is another mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.

Zika Virus

At this time it is advised that pregnant women and women who might become pregnant avoid areas in which the zika virus is found. For up to date travel advisories due to this virus, see the CDC’s Zika page.