Posts Tagged ‘toddlers’

Wheezing in infants and toddlers: we still don’t know what’s best to do

November 13, 2010  |  General  |  No Comments

The winter virus season is fast approaching, bringing with it the old dilemma of what to do about infants and toddlers who wheeze. Last year I noted that we had no specific treatment that worked.

A few months after my post, investigators in Canada published a large study that compared two of the standard treatments traditionally used for wheezing infants and toddlers: oral steroids and nebulized (inhaled) epinephrine (or albuterol). The randomized, placebo-controlled study compared children who came to the emergency department for breathing difficulties. They received either, both, or none of those therapies. The endpoint the researchers studied was how many of those children progressed to get sick enough to need admission to the hospital during the subsequent week.

The results showed that maybe — maybe — there was a slight beneficial effect of both treatments together in keeping kids out of the hospital, but neither treatment alone helped. An accompanying editorial in the same issue pointed out the problem here: when infants and toddlers come with their first episode (or episodes) of wheezing, we don’t know if they are going to continue to have problems in the future (such as progressing to asthma) or not. These treatments clearly help asthma. So if we give them to all comers with wheezing symptoms there will be some, those who are destined to have asthma later, who will benefit. But that’s not at all the same thing as saying that these treatments (which are not risk-free) will help kids with bronchiolitis, by far the most common cause of wheezing in this age group.

Over the past year the authors of the study, probably a bit stung by the pooh-poohing of their findings, have churned through their data from a different angle. This sort of data-mining in search of positive findings is common, especially if the original findings were not earth-shaking (or even useful). After all, people’s careers in academic medicine may be at stake. Anyway, they’ve just published an article on the cost-effectiveness of of using the combination of inhaled epinephrine and oral steroids. They conclude that these therapies, which medically don’t help much, still save a little money — to society, not necessarily to the family. I don’t find that argument convincing, either.

So what do most of us do with wheezing infants and toddlers, especially those who have bronchiolitis? I think most of us give a trial of the inhaled medicine to see if it helps. If it does, we continue it; if it doesn’t, we don’t. If there is dramatic improvement with the inhaled medicine, we consider giving the steroids. The presumption is that kids who respond dramatically to the inhaled medicine are more likely to become asthmatic, so what we are really doing is treating early asthma, not bronchiolitis.

As a parent, what this controversy means to you is that the correct answer is still unknown, although the preponderance of expert opinion is that bronchiolitis — wheezing in small children — requires supportive care, such as help with feeding, clearance of respiratory mucous, and sometimes oxygen, but there are no good data showing the benefit of anything else.

Adoption of smoke-free legislation reduces childhood asthma

October 8, 2010  |  General  |  2 Comments

We’ve known for a long time that tobacco smoke causes asthma exacerbations in children. And it doesn’t have to be the actual smoke; for children with asthma, simple exposure to rooms where people have smoked, or even to the clothing of smokers, can trigger breathing problems. A principal argument for banning smoking in public places is that these environments can be downright toxic for asthmatics. Do these anti-smoking regulations actually work? The bottom line question would be this: after these laws are passed, is there any change in the number and severity of asthma attacks? An important recent report in the New England Journal of Medicine gives us an answer. Yes — these regulations help children breathe better.

The research was done in Scotland, where all smoking at enclosed public places was banned in 2006. The premise of the study was simple: look at how many children were hospitalized for asthma before the ban and afterward. The results were striking: throughout Scotland, there was a reduction of asthma admissions in children of 15%. That may not seem like much, but the ban had only been in effect for 3 years when the data were collected. The direction of the trend line strongly indicates that there will be further reductions.

It’s important to understand that correlation doesn’t imply causation. That is, there’s no way to know if the drop in asthma attacks was really caused by the ban. But the authors did a large number of adjustments and corrections to the data set to rule out confounding variables (such as rural/urban, socioeconomic status, age, severity of previous asthma attacks). The reduction occurred in children of all ages — toddlers up through school-age.

The link above is only to the abstract of the article (you need a subscription to get the full text), but the key figures are there in the abstract. If anyone wants the complete article and can’t get it, let me know.

What causes diarrhea in children?

July 10, 2010  |  General  |  1 Comment

Here’s another excerpt from my new book, How Your Child Heals. It’s from the chapter on symptoms, and it’s about what causes diarrhea.

Diarrhea, the frequent passage of watery stools, is something with which most parents of small children are well acquainted. It is a common symptom because its most common causes, intestinal viruses, are all around us. There are many of these for a child’s immune system to meet as it matures. Each new encounter usually causes illness, but subsequent exposures often cause few or no problems. These viruses are highly infectious, so they spread easily wherever toddlers gather to share toys and cookies. The result is what doctors call gastroenteritis, a fancy term for an inflamed stomach and intestines.

Other things besides viruses can cause diarrhea, but most of these cause it in the same way intestinal viruses do — injuring the cells lining the intestines so they cannot do their job of absorbing the nutrients passing by them. A wide variety of food intolerances can also lead to diarrhea, often because the absorbing cells, though present in the intestine, are in some individuals unable to deal with a particular food properly. Common examples of this include a deficiency of the absorbing cells that process lactose, a type of sugar in dairy products, or a sensitivity to the proteins present in cow’s milk. Whatever the cause of the poor functioning of the absorbing cell lining, the result is often diarrhea. If there is significant stretching and squeezing going on in the intestine the child will often have cramping pain, too.

When the intestinal lining is injured, it cannot do its job of absorbing food. If a large amount of unabsorbed food makes it to the lower reaches of the small intestine, it draws water out of the intestinal wall. It also becomes excellent food for all the bacteria living there, and the action of the germs gorging themselves on this sudden feast produces even more substances that draw water into the intestine. When this mixture is dumped into the large intestine, the enormous mass of bacteria normally living there magnifies the effect. The large intestine can absorb quite a bit of water, but it can become overwhelmed by the volume of what it is being asked to take in. Plus, its lining cells may themselves be injured by the infection and be less able to do their job.

These things makes the stools watery. Diarrhea also means more frequent stools. The simple increase in the amount of material the intestines must deal with is one cause of the more frequent stools. Another is that most causes of diarrhea also speed up the transit time, the length of time it takes what a child swallows to pass all the way through.

There is another kind of diarrhea, one less common in children. This disorder is of the large intestine, the colon, and is called colitis because that word means an inflamed colon. It is typically caused by one of several varieties of infectious bacteria. Since the colon can become quite irritated and inflamed, the diarrhea of colitis often has blood in it from oozing off the intestinal wall. It is usually a more serious illness than simple gastroenteritis of the upper reaches of the intestine. This is why seeing blood in your child’s stools is a reason to visit or call the doctor, especially if your child has fever as well.

We have several ways to deal with diarrhea, the first of which is to do nothing other than make sure your child is getting enough fluid to replace that lost in the stools. This is how doctors usually handle the situation, because typical gastroenteritis is quite self-limited and will pass soon. When it does, the damaged absorbing cells very rapidly replace themselves on the villi and all is well. If it persists for many days, that is a reason to suspect something else is causing it.

Simple common sense teaches us we should not challenge the intestines of a child with diarrhea with large meals full of complex, difficult to absorb foods, because the poorer the absorption, the worse the diarrhea potential. Parents have known this for generations. This is the rationale for using smaller, more frequent meals of simple starches like rice and bread, or even of eliminating all solids for a day or so. There are several ways of approaching this issue, but many parents find out by trial and error which dietary manipulations work for their children and which ones do not.

We do have several drugs to treat diarrhea, most of which work by slowing down the transit time through the intestines. Lomotil is the brand-name of a commonly used one. These drugs affect the intestinal nerves that control how fast the intestines squeeze the food along, slowing down the process. They work well in adults, although you can easily see how it is possible to overshoot and end up with constipation. However, doctors rarely recommend these drugs for small children because, as with the nausea and vomiting medicines, the potential side effects outweigh any benefit of using them for a condition that usually quickly passes without treatment.

What causes fever?

June 11, 2010  |  General  |  No Comments

Here is another excerpt from my upcoming book, How Your Child Heals. It’s about fever, from the chapter about symptoms and signs.

Fever means an abnormal elevation of body temperature. But what is abnormal? Most of us have heard or read that “normal” is 98.6 degrees Fahrenheit, which is 37 degrees centigrade. In fact, normal temperature varies throughout the day. It is as much as one degree lower in the morning than in the afternoon, and exertion of any kind raises it. Where you measure it also matters. Internal temperature, such as taken on a child with a rectal thermometer, is usually a degree or so higher than a simultaneous measurement taken in the mouth or under the arm pit.

There is also a range of what is normal for each individual — not all people are the same. So what is a fever in me may not be a fever in you. As a practical matter, most doctors stay clear of this controversy by choosing a number to label as fever that is high enough so this individual variability does not matter. Most choose a value of 100.4 degrees Fahrenheit, or 38 degrees centigrade, as the definition of fever. It is not a perfect answer, but it is a number that has stood the test of time in practice.

We maintain our normal body temperature in several ways. Chief among them is our blood circulation. Heat radiates from our body surface, so by directing blood toward or away from our skin we can unload or conserve heat. We can also control body temperature by sweating — evaporation of sweat cools us down. We know how important a mechanism this is because the rare person who cannot sweat, or who is taking a medicine that interferes with sweating, has trouble keeping his body temperature regulated when he gets sick. If a swing in blood flow inwards to raise temperature happens very fast, we respond by shivering. This is also why we shiver if we go outside without a coat in the winter; our bodies are redirecting blood flow from our skin to our core in order to maintain temperature.

All parents know that a common cause of fever in children is infection. A more precise way to think about it is that a common cause of fever is actually inflammation. Since in children infection is the most common cause of inflammation, we generally assume a child with a fever has an infection somewhere in her body unless we can prove otherwise.

Our brains have a kind of thermostat built into them. Like the thermostat in a house, it senses the temperature of the blood passing by it and uses a series of controlling valves in the blood circulation to fine-tune the temperature. Also like your house thermostat, it continues to sense the temperature, and adjust it as necessary, until it has reached the value for which the thermostat is set. Fever happens when the thermostat is reset, just as happens when you twist the dial on the wall for your furnace — the body reacts to bring itself to the new setting. What twists the knob on the brain’s thermostat to cause fever are substances in the blood.

These fever-inducing substances belong to a family of inflammatory molecules that are released from body cells. Mostly they come from a cell called a macrophage, but germs themselves can also release things that have the same effect. The sudden rises and falls a parent often sees in their child’s temperature when they have an infection reflect the usually brief time these substances are in the blood. Sustained fever for many hours can happen if these materials are steadily present.

Opinions vary among doctors about when fever needs treatment. Fever itself virtually never causes harm on its own. The only times it can do harm is when it gets very, very high — 106 degrees or more — for a sustained period. That only happens in highly unusual situations; ordinary childhood infections never get it that high. It is true fever can make a child uncomfortable, although children generally tolerate it much better than adults. For that reason alone many doctors advise treatment.

There is another reason to treat fever. Toddlers may experience brief convulsions – seizures — when their body temperature rises very fast. These so-called febrile seizures cause no harm to the brain itself, and often run in families, but fever treatment makes good sense for a child who has had them in the past.

We have two effective drugs to treat fever — acetaminophen (Tylenol) and ibuprofen (Motrin). Both work the same way: they reset the brain thermostat back down to a lower lever. Both only last a few of hours or so in their effect, which is why you will see your child’s fever go back up again when they wear off if there are still any of those fever-causing substances from the inflamed site still in the circulation.

Children and toxic plant poisoning

April 30, 2010  |  General  |  No Comments

As I’ve written about before, we commonly see children in the PICU as a result of some toxic ingestion or other. Toddlers take medicines they shouldn’t, but don’t know any better; teenagers also take medicines they shouldn’t, but usually should know better.

Toddlers also put anything in their mouths, including plants, and some of these are potentially toxic. In fact, between 5 and 10% of calls to poison control centers involve a plant ingestion. Yet hospitalizations of children for plant poisoning or toxicity are extremely rare. Thus, although such exposures are common, serious consequences are rare. Still, it is good for parents to be aware of some of the common plants around the house and garden than can cause problems.

Philodendron leaves, for example, can be quite irritating to the mouth and tongue but don’t cause any systemic effects. At holiday time, the berries of both holly and mistletoe, particularly the latter, can be quite toxic, so it’s important to keep them out of reach of toddlers. Here and here are lists of common indoor and outdoor plants that can cause problems.

What should you do if your child has eaten some plant material that worries you? The answer is to call your local Poison Control Center, the number for which is in the front of most telephone books.

It’s respiratory syncytial virus (RSV) time again

January 25, 2010  |  General  |  No Comments

I’ve written before (here and here) about the reliable winter time arrival of RSV. This virus is the most common cause of pneumonia and bronchiolitis in children under six months of age. To scientists, RSV is a fascinating virus with several unique properties.

One of these is its behavior in the population. During its annual visitation, RSV is everywhere. Then it suddenly vanishes. There are exceptions to everything in medicine — I have seen sporadic cases during the off-months — but generally RSV arrives with a bang in mid-winter and then leaves suddenly in the spring. It is the only virus that consistently and reliably causes an epidemic every single year. Not even influenza does that. However, RSV epidemics may still have some regional variability. For example, often one city will have a much more severe epidemic than do others in other regions of the country.

Another aspect of RSV that interests medical scientists is how poor a job our immune systems do in fighting it off. Virtually all children are infected with RSV during the first year of life. Not only that, all of us are reinfected multiple times during our lives. Attempts at devising a vaccine for RSV have all been unsuccessful. In fact, early versions of an experimental vaccine seemed to make the disease worse in some infants, raising the possibility that some aspect of our immune response to the virus actually contributes to the symptoms.

RSV has a high attack rate — the term scientists use for the chances that a susceptible person will get the infection if exposed to it. That, plus our generally poor defenses against it, explain the frequent epidemics.

RSV is generally not a serious illness, but for some children it can be life-threatening. These children are very small infants, especially those born prematurely, and those with underlying problems with their lungs or their hearts. For those infants we have a monthly shot that helps reduce the severity of RSV when they get it, and may even prevent a few cases, but this is not ideal.

Since RSV cannot be prevented, the best thing a parent can do is try to postpone it. That is, if you have a newborn infant in the height of RSV season, try to minimize exposure of your child to people with cold symptoms, especially toddlers. And for those who do handle your infant, have them wash their hands first.

It's respiratory syncytial virus (RSV) time again

January 25, 2010  |  General  |  No Comments

I’ve written before (here and here) about the reliable winter time arrival of RSV. This virus is the most common cause of pneumonia and bronchiolitis in children under six months of age. To scientists, RSV is a fascinating virus with several unique properties.

One of these is its behavior in the population. During its annual visitation, RSV is everywhere. Then it suddenly vanishes. There are exceptions to everything in medicine — I have seen sporadic cases during the off-months — but generally RSV arrives with a bang in mid-winter and then leaves suddenly in the spring. It is the only virus that consistently and reliably causes an epidemic every single year. Not even influenza does that. However, RSV epidemics may still have some regional variability. For example, often one city will have a much more severe epidemic than do others in other regions of the country.

Another aspect of RSV that interests medical scientists is how poor a job our immune systems do in fighting it off. Virtually all children are infected with RSV during the first year of life. Not only that, all of us are reinfected multiple times during our lives. Attempts at devising a vaccine for RSV have all been unsuccessful. In fact, early versions of an experimental vaccine seemed to make the disease worse in some infants, raising the possibility that some aspect of our immune response to the virus actually contributes to the symptoms.

RSV has a high attack rate — the term scientists use for the chances that a susceptible person will get the infection if exposed to it. That, plus our generally poor defenses against it, explain the frequent epidemics.

RSV is generally not a serious illness, but for some children it can be life-threatening. These children are very small infants, especially those born prematurely, and those with underlying problems with their lungs or their hearts. For those infants we have a monthly shot that helps reduce the severity of RSV when they get it, and may even prevent a few cases, but this is not ideal.

Since RSV cannot be prevented, the best thing a parent can do is try to postpone it. That is, if you have a newborn infant in the height of RSV season, try to minimize exposure of your child to people with cold symptoms, especially toddlers. And for those who do handle your infant, have them wash their hands first.

The ear drum game — on ear infections

December 14, 2009  |  General  |  No Comments

Here is a recent article of mine published by Smartman Daily.

Most dads with a toddler have experienced the ear drum game. For the minority who haven’t, it goes something like this. Your child has a cold for a few days, but otherwise seems fine. Suddenly she spikes a high fever and clearly hurts somewhere. You take her to the doctor. He takes a very quick look–only seconds, it seems–at her ears and pronounces that she has an ear infection. By the age of three, eighty percent of all children will have had one, and half will have had more than one. Here are answers to six important questions about this common condition.

#1: How can a doctor be sure your child has one?
Here’s a trade secret–frequently we aren’t. If you ask five pediatricians to look in a child’s ear, you may well get five different opinions. This is why medical students call it the ear drum game–it seems whatever they say about a child’s ear, their instructor will say the opposite. Sometimes the diagnosis is obvious. The ear drum is inflamed and bulges outward from the pressure behind it. That pressure comes from infected fluid clogging up the normally air-filled middle ear cavity. Those are the easy ones. The tougher ones are ear drums that are somewhat red, a bit distorted in their shape, perhaps a little less mobile than usual. In those children doctors are often swayed by other things–fever, if the child seems to be pulling at her ears, if she has had past ear infections. These cases are judgment calls, but doctors often follow our old saying that “common things are common,” so we tend toward diagnosing ear infection if it is a borderline case.

#2: Where do ear infections come from?
The middle ear, the place where sound waves bouncing off the ear drum get passed along to the brain so a child can hear, is normally free of germs. There is a tube connecting the middle ear to the back of the nose, there to let air in and out. You can feel this happening when your ears pop going up and down in an airplane. The nose is normally thick with germs. The connecting tube has ways of keeping the germs out of the middle ear, but when those defenses break down the germs pounce on the opportunity, crawl up the tube, and cause an ear infection. The most common cause of tube malfunction is a viral respiratory infection, which is why an ear infection so frequently follows a cold. The tendency for the tube to malfunction also runs in families, which is why frequent ear infections do the same.

#3: Why do we treat ear infections with antibiotics?
An ear infection means germs in the middle ear, but often a child’s body can handle the germs without help. After all, children have been getting ear infections for eons and antibiotics have only been around for a half-century or so. Sometimes these germs aren’t even bacteria, so antibiotics would be of no use anyway. The practice among most American physicians over the past decades has been to treat all ear infections with antibiotics. The reason was to reduce the chances of a child getting one of the uncommon complications that can happen, and the number of these complications has dropped significantly in the antibiotic era.

#4: Okay, but do ear infections always need antibiotics?
For children over six months, the answer is no. The antibiotics-for-all approach has always been questioned by some doctors, especially for children older than two. These doctors reserve antibiotics for children whose symptoms last more than a day or so. This is a decision that should involve parents. Most want antibiotics, and there is nothing wrong with that–it is standard practice. But if you don’t want them, at least right away, another acceptable approach is to get a prescription for the antibiotic, but not fill it unless your child’s symptoms persist. More and more physicians and families are opting for this. Antibiotics are not risk-free. Either way, it’s a good idea to treat the ear pain and fever with medicines like ibuprofen (Motrin) or acetaminophen (Tylenol).

#5: What about prevention?
We know some things are associated with ear infections, and they share the property of contributing to malfunction of the tube between the middle ear and the nose. Exposure to tobacco smoke is one, because it irritates the lining of the nose. Another is putting a child to bed with a bottle, because every time a child swallows the tube opens wider. If the child is lying on her back, the nose bacteria have an easier time of reaching the middle ear.
Sometimes doctors prescribe a low dose of a daily antibiotic for a child who has had many infections. The more controversial kind of prevention is placing a plastic tube through the ear drum to connect the middle ear directly with the outside world. These so-called pressure equalization tubes work by helping keep the middle ear free of the fluid that gives bacteria a hospitable place to grow. If your child has a lot of ear infections, your doctor may recommend these. Besides talking to your doctor, you can learn more about the generally accepted reasons for placing tubes at several authoritative sites, such as here.

#6: Why do ear infections generally go away when a child gets older?
By the time a child gets to school-age, ear infections are uncommon. This is because, as the skull grows, the connecting tube gets longer and less straight, putting a useful mechanical obstacle in the way of germs trying to get up the tube to reach the ear. Additionally, older children get fewer colds than toddlers. So, if your child has a lot of ear troubles, take heart in the fact things will certainly get better over time.

Wheezing in infants and toddlers — what to do?

June 22, 2009  |  General

Wheezing is common in small children — around a third of all children will have an episode of wheezing before they are three years old. Although it’s common, we still don’t quite know the best thing to do about it. The problem is that wheezing, like fever, is a symptom of a disease, not a disease itself. It’s not one thing. Every physician who treats small children in the office, the emergency department, or the pediatric intensive care unit is often faced by the dilemma of what to do with a wheezing small child.

In such children wheezing is often triggered by a viral illness. When it happens in infants it is often caused by a virus we call RSV (short for respiratory syncytial virus) and causes a disorder called bronchiolitis. For those children, we know that not much of anything helps the symptoms — all we can do is provide supportive care and wait for the illness to run its course. What about wheezing children who don’t have bronchiolitis? Can anything help them?

The problem facing the doctor is that all the treatments we’ve tried over the years for small children who wheeze are taken from how we handle older children who have chronic, frequent wheezing — what we call asthma. These treatments work for asthma, yet they often don’t for wheezing that isn’t. A certain number of children who have their first spell of wheezing will go on, over years, to develop true asthma. But most wheezing toddlers won’t progress to asthma — they will have an episode or two (or three) of wheezing and then “grow out of it.” If you bring your infant or toddler to the doctor for a first (or second) episode of wheezing, the doctor has no way of knowing which of these two things will happen. There are a few clues, such as a family history of asthma, which will increase the chances of future asthma, but there’s no good way to tell.

How do most doctors handle this problem? Most will try a dose or two of asthma medications (inhaled albuterol and/or budesonide, or oral prednisolone are commonly used) just to see if it helps. If the child gets better, they can be continued.

My point is that you should understand that for this problem — wheezing in an infant or toddler — your doctor is handicapped by not being able to predict the future. Only time will tell. It’s a frustrating, but common medical scenario.

More teenagers with preventable brain injuries

May 10, 2009  |  General  |  No Comments

I’ve written before about traumatic brain injuries in children. These sorts of injuries are frustratingly common — I’ve just seen several new ones. Although we’ll never eliminate them, there are many ways to reduce both their number and the severity of those that do occur. These ways are well known and extremely low-tech. Since car accidents are the leading cause of them in children, that is where we can really have an effect.

A small child who is unrestrained by a car seat is particularly likely to have a severe brain injury if involved in an accident, and that accident need not be at highway speeds. These days more and more parents know how to use car seats for their infants and toddlers, and over the past decade I’ve seen fewer and fewer injuries to unrestrained small children.

What I continue to see, however, are teenagers who are out by themselves, away from their parents, and don’t use a seat belt. The result is they are ejected from the car after impact, and this raises enormously the risk of severe brain injury. I’ve just seen yet another such case.

The most severe injuries come from what we call diffuse axonal injury, or shear injury. This injury results from the brain being jarred suddenly inside the skull, often with a bit of rotational effect. We call it shear injury because the force of impact shears apart the delicate wiring bundles that connect the nerve cells to one another. Most children recover to some extent, but some degree of permanent damage is common.

If you are interested in learning more about traumatic brain injury, the Brain Trauma Foundation is an excellent place to start.