Otitis media

We pediatricians see so much otitis media that I imagine we oftentimes sound like the proverbial broken record –“your child has an earache” over and over.  Perhaps it would be helpful if we just tattoo the diagnosis on our foreheads?  Long articles or even books have been written about otitis media; let me summarize a few important points.

Not every acute otitis media (AOM) requires immediate treatment with antibiotics.  As with so many acute conditions, after a few days of watchful waiting spontaneous resolution is likely.  So, for otherwise healthy young children, pain management with OTC analgesics, pain drops, and fluids is often all that is required.  Prompt initiation of antibiotics are indicated for:

  1. < 2 years of age
  2. Fever > 101
  3. Severe pain
  4. Pain >48 hours
  5. Bilateral pain
  6. Underlying chronic illness like asthma

Amoxicillin is still the mainstay as first line for non-allergic children but current recommendations are for 7 days of therapy at markedly higher dosages–80mg/kg/day.  This means that a typical 45 lb 5 year old should get 500 mg 3x daily–previously considered “adult” dosing.

A special note about otitis media with effusion (OME).  This is a common complication of AOM although it also can occur on its own.  Negative pressure in the middle ear (typically from inflammation from infection) causes fluid being “sucked” into the space from surrounding tissue which can result in hearing loss or feeling of “fullness” in the ear.  The fluid is typically very thick so the condition is sometimes called “glue ear.”  All kinds of interventions have been tried without success: antibiotics, antihistamines and decongestants, oral steroids.  Nasal steroids do seem to offer some small benefit.

Again, here, watchful waiting will most commonly result in resolution.  I recommend that the child blow his nose regularly or blow up balloons (but be careful).  Recent information shows that nasal balloons are quite effective and probably safer.  More definitive treatment is placement of pressure equalizing tubes by an otolaryngologist (ENT).  They stay in for 9-12 months and usually correct the problem.  However this apporach must be considered carefully: 1/6 children will require multiple sets of tubes, particularly if the first set is placed in children < 3 years old.

Generally, tubes are reserved for children who:

  1. Have documented hearing loss > 40 dB (decibels)
  2. Hearing loss > 20dB > 3 mo
  3. >3 mo duraiton with evidence of speech delay, behavior problems, poor school performance, or balance problems (assuming those problems are likely caused by the OME)

One final point.  While (or perhaps because) these conditions are so common, I believe there is likely some element of “overdiagnosis” here–particularly by practitioners who are unfamiliar with your child.  So consider carefully ER visits for those otherwise routine URI/febrile illnesses.  As always, please don’t hesitate to call me with questions about this; and thanks for following.

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Caffeine and kids

In so many instances as I advise people on healthy lifestyles for their families I will think to myself: “you hypocrite, you’re no one to talk!” One area where I am on 100% safe ground is caffeine consumption.  Caffeine is the most commonly used drug in the world–more than alcohol or tobacco, consumed by at least 90% of adults; the average American drinks about 280mg/day.  I rarely partake.  So here I can pompously look down from my perch of near perfect abstinence and lecture you sinners.

More seriously, though, please consider these effects of caffeine on your body:

  1. CNS–increased alertness.  Too much can cause headache, irritability, even seizures.  It’s a common cause of sleep problems in kids
  2. Cardiovascular–increases heartrate and blood pressure
  3. Gastrointestinal–increases stomach acidity.  It can exacerbate reflux disease and esophagitis and even lead to ulcers.
  4. Metabolic–increases urine output.  Note the not uncommon practice among some teens to consume “energy drinks” before training or working out.  These products can have 2-3x the caffeine content of coffee and can increase your child’s risk of dangerous dehydration during practice/games.

A few fallacies about caffeine–it does not stunt your child’s growth; while it does slightly decrease calcium absorption it is probably not enough to have any adverse effect on bone mineralization.  On the other hand, while it is sometimes used as a perceived milder alternative treatment for ADHD, most evidence is that this is largely ineffectual.

Here’s a list of caffeine content in common items in a child’s diet (from “KidsHealth” by Nemours):

Item Amount of Item Amount of Caffeine
Jolt soft drink 12 ounces 71.2 mg
Mountain Dew 12 ounces 55.0 mg
Coca-Cola 12 ounces 34.0 mg
Diet Coke 12 ounces 45.0 mg
Pepsi 12 ounces 38.0 mg
7-Up 12 ounces 0 mg
brewed coffee (drip method) 5 ounces 115 mg*
iced tea 12 ounces 70 mg*
dark chocolate 1 ounce 20 mg*
milk chocolate 1 ounce 6 mg*
cocoa beverage 5 ounces 4 mg*
chocolate milk beverage 8 ounces 5 mg*
cold relief medication 1 table 30

Again, note that “energy drinks” can commonly have 200-300 mg of caffeine/serving.

Generally, safe levels of caffeine consumption/day are:

  • Adults–300-400 mg
  • Teens–100 mg
  • 10-12–85 mg
  • 7-9–60 mg
  • <7–45 mg

So please keep the above in mind for your child’s diet/routine/activity.

One final thought: another not uncommon practice among some teens is to combine caffeine and alcohol consumption; the idea being that the caffeine mitigates alcohol’s effects.  Not true.  First of all, drinking both gives you double the diuretic effect and risk of dehydration.  More importantly, please note that caffeine makes the consumer more alert but no more sober.  Consumiing caffeine adds zero benefit or safety factor to the dangerous practice of drinking and driving.  Make sure your teens are aware of this important fact.

Send along questions and comments; thanks for following.

Bullying

School will be starting soon.  With it many annual traditions will start anew. Most are good. Here’s a bad one: bullying.  One study found approximately 160,000 lost school days due to bullying. Bullying has many forms: teasing and name calling, physical intimidation to outright assault, cyber bullying via social media. Boys bullyng tends to be more physical and directed at individuals outside of the group while among girls it tends to be of an emotional nature directed at unfavored members within the group. But that’s not universal–there is lots of overlap.

What not to do:

  1. Don’t force her into anything unless a real crime may have been committed ( assault, sexual violence). The child already feels a loss of control. That only exarcerbates it.
  2. Do not directly confront the bully yourself. You could be charged with crimes against a minor.
  3. It is most unlikely to be helpful to confront the bully’s parents. Besides being so unpleasant, you could find yourself accused of violations like harrassment or even physical assault, given how these things can degenerate into a physical exchange.
  4. Do not push your child into some physical confrontation. If your child is the initiator of the violence then he will face the consequences which can be significant–school discipline or even juvenile criminal charges. Moreover it’s not necessarily  true that the best way to get a bully to back down is to hit back. Too often, the bully is older, bigger, and stronger. You may well be pushing your kid into a situation where he would just get beat even harder.

Good things to do:

  1. Listen. Almost always helpful. Relating stories about bullying in your own past-witnessed or experienced-can be supportive and reassuring. A good way to initiate a conversation is to ask your child generally if they see any bullying in their school (sport team , etc ).
  2. Coach a verbal response. A practiced answer, delivered promptly and calmly (“never let them see you sweat”) can be disarming and helpful. I say always try and take the “high road” – a response like “we’re friends, we’ve known each other a long time, I know you don’t mean that” or” or “you’ve never been a mean person like that”-you get the idea. A sharp, witty, sarcastic, and insulting reply may be effective if the former is not.  But one must be very careful here–it could lead to physicality which is almost definitely not in your child’s best interest.
  3. Save any evidence-videos, texts, social media posts.
  4. With your child’s concurrence you may involve the school. I will add that in my 30 years as a pediatrician I’ve seen school districts’ and administrators’ responses run the gamut–from effective and supportive to apathetic and incompetent to downright destructive(eg, trying to “protect the school’s reputation” or shield a favored star athlete).  So one must be careful here.
  5. if there are concerns for your child’s physical, emotional, or mental health don’t hesitate to call me.

This is a large topic that we can return to again in the future.  Please send along questions or comments and, as always, thanks for following.

GER/crying II

Last week I posted thoughts on babies with reflux,  indications and mostly pitfalls of medications there.  Frequently those babies are also colicky; let’s finish this up with a few words about that.

Colic is defined as an otherwise healthy infant who cries for >3 hours/day for > 3 days/week.  It is said to occur in approximately 25% of babies but I think that most babies have at least some periods at some point early on that can be characterized as “colic.” < 5% have some definable cause and most of those are things like constipation, milk allergy, reflux as above, or sensitivity to breastfeeding mother’s diet.  There is no good evidence that it is caused by “gas” but I doubt that we pediatricians will ever convince Grandma of that!

So, generally, these kids are still very healthy.  Mostly, if your baby is eating and eliminating well it is unlikely to be more serious.   I tell parents that after 30 years of practice I have more concern about babies who are listless and seem uninterested in eating for extended periods than for kids who scream unless you feed them and never seem satisfied.  However, if your instincts suggest that something may be wrong its always best to take a look.  We can check many things; a few of note:

  1. Adequate weight gain.  Changing formulas works < 5% of the time.
  2. Fingers, toes, groin–rarely more subtle, serious problems can develop here.
  3. Neurologically normal?  Muscle tone and reflex abnormalities are very difficult to see.
  4. Nursing mother’s diet.  If we eliminate all foods “associated with” colic in nursing moms, I tell them, they would be plants–consuming only water and sunlight.  Nursing mothers should follow Aristotle’s “Golden Mean–moderation in all things.”  A balanced, varied diet without too much of any one thing.  Avoid caffeine, alcohol (one drink/day is allowed) and take only necessaary medications
  5. Even mother’s state of mind–colic may be the baby’s reaction to post partum depression.

Mostly what works best are the low tech, tried and true methods.  Hold your baby, gentle slow movements and speak softly and gently to her.  Avoid loud noise, bright lights, vigorous stimulation.  The warmth of your body, a heating pad, or hot water bottle; even a warm bath.  Pacifiers of course and do not overfeed.  Sometimes it helps even to take the baby for a drive.

A few medicines used commonly: simethicone(“mylicon”) an emulsifier that breaks up gas bubbles; Soothe drops(Gerber)–a probiotic that increases healthy gut bacteria; Gripe water–an herbal product, there are several brands.  I do not endorse any products specifically.  They are mostly safe and some people swear by them.  If you have been following me you know that my advise is usually the less medicine, the better.  Lastly, a Sleep Tight--the white noise and vibrations simulate a car ride.  Again, no endorsement, but long ago it did help a young Luke Geneslaw, recent college grad!

Send along questions and comments, and thanks for following.

GER/colic

Here’s a brief summary of a good medical article on the treatment of colic/reflux/fussy babies:

http://www.ncbi.nlm.nih.gov/pubmed/25556017

You can link to the full text if you are more computer savvy than me, but its a medical journal full of specific technical jargon that may be unfamiliar to the average person who lacks medical training.

My children are grown now but I can sure remember their colicky infant stage.  And not so fondly–trying to cope with uncontrollable crying and a baby who spits up so much can be frustrating and even scary to young parents.

What’s going on?  Well, the jury is still kind of out on exactly what it is and the pendulum still swings back and forth on what to do.  For a long time now, many in the medical community have settled on gastroesophageal reflux (GER, “reflux”) as a big contributor, even though we cannot know for sure.  But there are good reasons–most of these kids spit up a lot, arch their backs when they cry suggesting heartburn, and have at least some vague temporal association with feeding.   So a lot of medications have been used to try and alleviate those symptoms.  Frankly, as the above article references, none have gotten the job done.  To the extent that there are any studies they mostly demonstrate no real efficacy compared to placebo in the large majority of infants.  And they are not free of risks in their own right.  Cisapride (propulsid) was used to improve esophageal musle tone until they found that lots of babies developed cardiac arrythmias from that drug.  For years now they have tried various acid neutralizing medicines–so called “H2” blockers like ranitidine(zantac), protein pump inhibitors(PPI’s) like omeprazole(prilosec) or lansoprazole(prevacid).  But as we can see from above, still–no good.  And use of these drugs have been shown to increase the risk of more serious lower respiratory tract infections like bronchitis and pneumonia (the acid environment of the stomach is effective in killing most microbes that we swallow before they can infect us; neutralize that acid and you neutralize that natural defense).

So, once again, we come back to what I say so often: let’s not rush to use a drug on your kid unless we have good reasons and some solid, scientific evidence that that approach is effective AND safe.  As the article suggests, most babies are going to gradually improve over the course of 6-9 months anyway, so a conservative approach is usually best and all that’s necessary.

There are special considerations for infants who:

  1. Were severely premature
  2. Serious congential abnormalities or infections
  3. Serious neuromuscular disorders
  4. Projectile vomit (shoots out of their mouth) frequently
  5. Vomit blood, black, or green material
  6. Frequent nasal vomiting with choking, cyanotic (blue) spells
  7. Very fussy with disruptive coughing and wheezing
  8. Colicky and not gaining weight

These infants require further evaluation; medications may be indicated.

Next time let’s try and review some things that may be effective for “everyone else.”  Thanks for following.