Carsickness

My little grandson, Otto, struggles with carsickness, so this topic has been on my mind of late.

Carsickness, of course, is a sensation of dizziness, fatigue, restlessness, confusion, nausea or actual vomiting associated with car rides or other movements.  The actual mechanism is a dissociation of visual from spatial sensory input.  In other words, the eyes misperceive where the inner ear says the body is going (or vice versa). It can occur 1-18 years of age but is most common in 4-13 years, peaking age 6-9,  usually dissipating thereafter. Perhaps 30% of children have some symptoms, 5% have severe/prolonged/frequent symptoms.  10% even report problems on swings and slides.

What can we do? Some suggestions:

  1. Proper seat positioning–front facing is better than rear (but only if its safe–children should be rear facing until AT LEAST age 2, and sit in the back until > 90lb)
  2. Plenty of fluids before/during the drive. Adequate hydration will mitigate symptoms.
  3. Keep window down when feasible–fresh air also relieves some of the problem.
  4. If possible, warm the car up during cold months so the child can sit in their seat without heavy outer clothing, increasing comfort and easing symptoms during the ride.
  5. Distractions– as with seasickness better to look to the horizon, its best to focus out of the car.  ‘I spy” games are good; pointing out interesting sites like mountains, buildings, even road signs.  Anything requiring close looking is bad–movies/videos; video games are the worst(no surprise!). Nontechnical interactive games (“Madlibs”) can be a fun way to shift the child’s focus. Audio pass times, like singalongs, listening to music, audio books are another good strategy.
  6. Snacks before or during the ride. Light, “neutral” foods like crackers, ice pops, non-acidic fruits are good; heavy, fatty, greasy foods, or very salty, spicy fair with strong odors–not so much.
  7. Be aware of your child’s symptoms.  Poor color, change in demeanor, evidence of anxiety, and, of course, if your verbal child complains of symptoms–consider stop and take a brief walk for some fresh air.
  8. Patience and humor–car sickness certainly has a clear psychological component. An easygoing, approach to your child’s difficulties–to limit anxiety or negative feelings on their part–is essential.  Junior vomited in the car? Gross, but relax: wash it out and the odor is gone, tomorrow you will forget it and in a few years it’ll be a humorous family anecdote!
  9. If all else fails, try some anti-histamines. Dramimine for > age 2, benadryl can be used for younger kids.  These medicines may cause drowsiness which can be of benefit, if the child sleeps through some of the symptoms.  However, be aware of a “paradoxical reaction“–some children experience agitation, irritability, confusion, even transient hyperactivity from antihistamines which can be unpleasant or even worsen the underlying problem. So (as always!)  try everything else before considering drugs.

If your child struggles from car/motion sickness, please give me a call and let’s discuss it.  Thanks for following.

Kudos to the NY Times Parenting blog for some of the inspiration for this blog post.

Maternal Immunization

As we enter flu season , let’s review some important immunization information. Young parents, and in particular expectant mothers are an important population of citizens who should keep their immunization status current.  This involves in particular 2 shots–TdaP and, in this season, flu shots.  Children under 6 months old are ineligible to receive flu vaccine so their only protection comes from immunizing their contacts.  Under 2 months they also have not received whooping cough vaccine yet, so, again, prevention by keeping that infection out of their environment is essential to protect them.

But that protection goes even further.  Both vaccines provide antibodies that cross the placenta and provide good immunity to the baby from even before actual birth. As 80% of whooping cough infections occur before 2 months of age–before they have even received their first shot–and 70% of infant deaths occur in that age group, this early maternal conveyed immunity can be life saving.  In a typical year 20 infants < 2 months of age will die from pertussis. Studies demonstrate that hospitalization for pertussis in this age group is decreased 90% when mother’s receive prenatal TdaP. Therefore, it is recommended that women receive TdaP with each pregnancy between week 27-36.

Also note that infants <6 months of age are at greater risk for hospitalization from flu compared to older children, as well as many serious complications from that infection–pneumonia, secondary bacterial sepsis, or encephalopathy(brain swelling). If the baby has other health problems like prematurity, genetic or chromosome abnormalities like Down Syndrome, or heart disease, that merely ups the ante for this risk. Maternal prenatal immunization lowers infant hospitalization rates for influenza by 77.7%.

Influenza, of course, poses substantial risk for pregnant women themselves.  While approximately 9% of women age 15-44 are pregnant during flu season, 23-44% of women in that age group who require hospitalization are pregnant. Of additional concern is that influenza is an important risk factor for the pregnancy and is a frequent cause of complications like premature birth.  Studies indicate that maternal prenatal flu immunization lowers that risk by 40%.

Only 59% of pregnant women get flu shots and 55% get TdaP; only 35% get both. Both vaccines are recommended for all pregnant women (flu in season).  They are both safe and effective. The leading reason for not immunizing is not knowing the recommendation.

So I’m telling you now. Expectant Mom’s (and Dads!)–talk to your primary care physician (mothers to OB) about flu and TdaP vaccine.  Call me and let’s talk about it. It may very well save your baby’s life.

Thanks for following. Image credit from communications.wellsfargoadvisors.com.

Nightmares and Night Terrors

Every parent hates the experience of their young child waking suddenly with a bad dream. The child is terrified and everyone’s sleep gets disrupted. What’s going on? We just finished Halloween so time to “un-frighten” this issue.

Nightmares, of course, are scary, unsettling dreams that we all experience from time to time.  In young children, they tend to occur in early morning hours during rapid eye movement (“REM”) sleep. The child will wake up frightened and tell you their scary experience. It is not uncommon for the same scary dream to recur.  With night terrors , the child will begin terrible screaming, often with eyes wide open but not really awake, and will have no recollection of the dream or the experience upon awakening.  With the memory of the bad dream it may be difficult for the child to return to sleep but given that there is no such memory with night terrors, returning to sleep is usually less of a problem there.

Both conditions are common in toddlers and young children.  Unless they occur frequently there is no cause for alarm. Night terrors appear to occur in families.

The best treatment is prevention: a  good bedtime routine; avoid overstimulation–reading stories is better than vigorous physical activity; limit video entertainment–stop video games > 1/2 hour before retiring; avoid large snacks, especially high sugar snacks–a small cup of water or milk is better.

To help your child after a nightmare, keep it simple–hugs, reassurance that you are there and that dreams are not real.  Talk about pleasurable incidents from the previous day or anticipated ones in the days to come. Distract the child with whatever toys or happy objects are at hand.

Please note that if you take your child to bed to sleep with you after a nightmare  you likely will set yourself up for difficulty getting them back to their own room on subsequent nights. If you must, better to have your child sleep next to you on the floor with a pillow and blanket–no mattress, to encourage them to return to their own room when things calm down.

With night terrors, things are a bit different.  Gently wake the child up from the sleeping, shrieking fit.  Quickly reassure them that everything is fine; a quick trip to the bathroom or diaper change (as applicable), half a cup of water to drink, and back to bed.  In both situations, keep it short and sweet–dragging it out only disrupts sleep patterns further.

As stated above, if these episodes begin to occur on a more regular basis there MAY be some underlying issue–in health, lifestyle, or social situation– that must be uncovered and addressed. Give me  a call in that situation and let’s try and figure it out together.

Thanks for following.

Athletic Training guidelines

I have blogged on this subject previously so please forgive any redundancy.  However, the National Athletic Trainers Association (NATA) recently published guidelines for healthy sports training and participation and I wanted to share them with you.  They are:

  1. Delay specialization as long as possible
  2. Train 1 sport max 8 mo/year
  3. Only 1 competitive team per season
  4. 2 days off from training each week
  5. Age (years) = hours/week training maximum
  6. Time away from sport (min 2-4 weeks) in between competitive seasons

I cannot overemphasize how important I think the above is.  Sports participation is great–I think it is an essential element in the upbringing of almost all healthy children. However, we must ALWAYS focus on the real reasons: fitness, socialization and fun, cultivate positive personality traits like dedication, team work, fair play.

Remember that world class athleticism is so unique.  Those in possession of that rare attribute do need to work hard if they hope to realize it’s potential.  But if your child is not one of those singularly gifted individuals (few are) then you cannot create it in them by making them work more and harder, you are far more likely to cause injury, anxiety, and/or hard feelings between you and your child in that stubborn effort.  And if you are the only one who seems to recognize your child’s great potential then it’s probably time for a reality check, Mom and Dad.

Also, as I’ve pointed out, it’s a fool’s errand to chase college scholarships earlier than high school years, and at any rate the only sports that offer full scholarships are football and men’s/women’s basketball–the “revenue generating sports” in college. All others mostly offer partial scholarships as best. So if one’s goal is to finance your child’s college education it’s much better to invest in stocks/mutual funds/529 plans as opposed to extra sports training.  I’m not at all saying that paid training camps and private coaching is worthless, but rather that it’s purpose must be to improve your child’s performance to increase their enjoyment of the sport experience as opposed to being an investment in a scholarship to help pay for college. A good rule of thumb is if you have to talk your child into the extra training, if its your idea and not their’s, then it’s probably not such a good idea after all.

Please keep the above NATA guidelines in mind and call me with any questions regarding your child’s sports participation.  Thanks for following.

 

Cold Medicines

I have previously discussed appropriate non-medicine treatments for common cold symptoms.  The data–or lack thereof– regarding so called cough and cold preparations (“C/C”) continues to grow.  Let’s review it here.

In a recent edition of the journal Infectious Diseases in Children, Edward Bell, PharmD offered an excellent summary of the subject. His most important summary is direct–“evidence supporting the efficacy of commonly available orally administered C/C product ingredients (e.g. cough suppressants, mucolytics, anti-histamines, decongestants) in children does not exist.” This statement is based on research from 2002-15 involving > 3 BILLION pediatric visits and 95 million C/C prescriptions.  Randomized, controlled trials conducted in 1991 and 1997 compared drugs like diphenhydramine (benadryl) and dextromethorphan (the “DM” in most cough medicine) to placebo for treatment of nocturnal cough and found no difference between the 2 treatments (“fake” medicine did just as much).  A 2015 comprehensive review of > 4000 subjects(212 kids) evaluated anti-histamines for common cold symptoms demonstrated similar results–no difference, and Congressional testimony from respected university educators and researchers concurred that there is no scientific evidence  for efficacy of anti-histamines for treatment of common cold symptoms.

It is also important to note the evidence of no benefit with the well documented list of common and sometimes serious side effects of these drugs.  Besides sedation, they can cause dry mouth, urinary retention, increased heart rate and appetite.  Please note that these occurrences are NOT rare.  Perhaps of even greater concern are the secondary effects from the well known problem with drowsiness–cognitive impairment with adverse effects on learning(school) and DRIVING (teens!), even hallucinations.

In 2017 the Food and Drug Administration labelled codeine as of no use for cough suppression in children under age 12 and then followed that up with warnings against its use up through age 18 as well.  Side effects here also include even more serious problems with drowsiness along with constipation, abdominal pain, agitation, sometimes even respiratory compromise and /or drug dependency.

Claims regarding so called “second generation” antihistamines, like loratidine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra) being “non-sedating” are at least somewhat disputed by considerable published literature.  Those studies suggest that mostly the above problems still occur with these more recently developed products, only to a lesser degree than the older stuff.

So, please, parents, I urge you to stay away from this CRAP and concentrate on what works–fluids, vaporizer, nasal saline, OTC analgesics. And try and be patient: George Harrison of the Beatles sang “All Things Must Pass” (couldn’t resist the reference) and mostly nature will run its course and in a bit of time all will be well again.  Too often, trying to rush things along like with the above does little of benefit and can cause harm. (A lesson in life, perhaps?)

Certainly for more severe episodes with significant fever, pain, sleep or activity disruption, or prolonged disruptive symptoms more thorough evaluation and often treatments may be indicated.  Give me a call to discuss it, and thanks for following.

Nursery School Absences

A fair number of patient encounters for any pediatrician involves toddlers excluded from nursery school/day care for medical problems these places determine are a potential hazard to the other classmates and/or require some treatment for safe return.  Truthfully, it is a fair source of business for us.  Now, while it is impossible to totally ignore the economic realities of maintaining one’s business, it has always been my practice (and, in my experience, for all of my colleague pediatricians that I personally know) to look to the medicine side of things and, as for the other, if not “run itself”, merely let good business flow from good care.

So many of those daycare mandated encounters are simply less than necessary from a treatment or safety standpoint for anyone in that particular center.  As most of these establishments have their exclusion protocols, in reality they are usually drawn up by teachers, administrators, or the business proprietors themselves–in other words, people without formal medical expertise.  They mostly are not based on research or scientific data.

For example, most require antibiotic drops for conjunctivitis with drainage and allow return after 24 hours of treatment.  However, virtually all medical studies indicate that drops have little effect on infection course and do not end contagiousness within 24 hours. >50% of centers require antibiotics to treat diarrhea; as these drugs frequently CAUSE diarrhea that is too often exactly the WRONG approach.

It turns out that the American Academy of Pediatrics, in conjunction with several other medical professional societies, has published a detailed manual for policies and procedures for these childcare facilities.  At almost 600 pages, it covers virtually every non-business/financial issue of those establishments’ daily working routine.  Summarizing , our guidelines do not recommend exclusion for (you intrepid readers can reference page 132 in the link):

  • Common colds irrespective of any nasal discharge
  • cough without fever
  • Pink eye regardless of discharge, unless 2 unrelated students have it at the same time
  • Fever<102 if unaccompanied by any other symptoms of illness
  • Rash without fever or behavior change, including molluscum contagiosum,                ringworm thrush, “Fifth disease” or even MRSA.
  • Lice or nits–only excluded at the end of the day

Recommendations for exclusion include cases where the child is too ill to participate in daily routines; requires care that would be beyond the ability of staff to administer without potentially compromising other children; diarrhea 2x/d greater frequency than the child’s normal stooling pattern or that is not contained in the diaper with blood or mucous, or a demonstrated bacterial cause of that infection; vomiting > 2/24 hours, abdominal pain with fever or > 2 hours; rash with behavior change or fever, mouth sores in drooling child.  Certain diagnosed infections (impetigo, varicella, TB, measles) have recommendations specific to that illness.

I believe it’s a fair question how any childcare center can exceed our scientifically determined recommendations, exclude a child based on their arbitrary decision, AND be justified to keep all of the money for that day’s care.

For what it’s worth, any parent making that point to their daycare facility has my support, even though it likely means fewer office visits for me.  That seems only fair in my mind.  Send along questions and comments, and thanks for following

Immunization update

Let’s review some recent data reported on the unfortunate and ongoing attempts to create controversy regarding immunizations.

Firstly, Danish researchers have summarized 2 large studies. One followed > 530,000 children from 1991-98. Approximately 440,000 were immunized with measles, the rest were not. 738 were diagnosed with either autism or autism spectrum disorder(ASD).  No difference in the incidence of those conditions were discovered between immunized vs  non immunized children either short or long term. Subsequently a second study did the same thing 1999-2010 with > 650,000 children; again, no difference in autism or ASD in children immunized vs those not, despite sorting the data by age, sex, birth cohort, family history of autism, or other immunizations.  Let us note that these 2 studies take place over almost 2 decades and observed over a million people without identifying any association of measles to autism .  I hope all concerned parents will consider that enormous amount of data very carefully.

Another report reviewed injury claims filed and paid by the National Vaccine Compensation Program. The NVCP was developed as a “no fault” system to compensate people for vaccine related injury claims in an effort to help people AND protect the source of life saving vaccine production from destructive litigation.  It is “user friendly”–its default position is that the vaccine is “guilty unless proven innocent” to enable people to receive needed compensation for serious problems (whether there is proof of association or not) and it goes so far as to pay claimants costs for legal representation and witness time irrespective of whether a claim is ultimately paid or not. About 70% of claims received compensation from 2006-17. 3.4 billion vaccine doses were given in that time, and the claim rate was 2/million doses.  A large portion of the claims were localized shoulder injuries when the vaccine was inadvertently injected into joint space causing arthritic changes as opposed to any systemic medical reaction.  For all the heat generated by claims of vaccine risk in the lay press and social media, one must wonder, where are all the actual injury claims?

As of this past Tuesday, New York City has declared the local measles outbreak is over.  Keeping the above in mind, let’s assess the damage: 654 people were diagnosed; 52 hospitalized and 16 required ICU care.  The City spent an additional $6 million to send 500 health workers out to identify and vaccinate recalcitrant citizens.

Unfortunately, here in New Jersey, the infection marches on.  In fact, the Asbury Park Press reports a 53% increase in “religious exemption” claims in schools for measles since 2013-14 (1641 to 2516).  In Ocean County, the absolute number of exemptions has jumped from 145 to 363 students–an increase of 1.8-4.2% of students enrolled. This may sound like small potatoes, but public health studies indicate that we need 95% immunization coverage to achieve “herd immunity.” Less than that and vulnerable people–the old, young, and chronically ill–are at much greater risk of exposure to measles, a disease that historically hospitalizes 25% of its sufferers and kills 2 of every 1,000 who become infected. How is that right, smart, or fair?

Send along questions or comments, and thanks for following.