Talking about Corona with your Kids

All of us are living through an unprecedented experience. We must keep aware of how this is affecting children; they are witnessing these events through the outlook of youth. What should you say to your child and how should you say it? A recent article in my journal Pediatric News interviewed child psychiatrist David Fassler, MD of University of Vermont. Please  allow me to summarize his recommendations, adding a few of my own.

First, be available.  Encourage your children to speak up about their concerns.  Ask them questions–what have they heard, what do they think, what are their friends saying? Don’t push them to discuss subjects if they seem reluctant to do so. Be sure to say only what you know–if you don’t have the answer, say so. You can then look up information together. While you are doing that, remember to share with them that not everything posted on the internet is true or accurate (of course, that applies generally–good opportunity to remind them of that FACT).  Take that opportunity to screen information for them; don’t shrink from gently steering your child away from a site or information that seems too technical, confusing, and in particular that which seems alarming or inaccurate. This is a great time to remind you all that one area to definitely avoid when seeking answers is social media sites which are generally riddled with misinformation.

Talk with your children about this in a calm, balanced, matter of fact way.  Your tone, facial expressions, and body language are all important. If in discussion with other adults, be aware that children may be listening from the side. Endeavor to keep more troubling exchanges out of their earshot. Do acknowledge their fears; its ok to  calmly share your own qualms as well to your child in terms at their intellectual/developmental level. It’s best, wherever possible, to deflect specific questions about family finances in the face of the myriad shutdowns in the community. Regarding that topic, gentle and general reassurance is best. Don’t promise too much, and, again, don’t make untrue statements. Examples: “We are fine right now”; “we are going to pull together and we will take care of each other as we always do.”

Make sure your children maintain their regular healthy lifestyle habits: regular bedtimes and awakenings(in particular with teens); 3 square meals (now that so many are home a lot more, avoid excess snacking); do homework assignments promptly and regularly; read for pleasure.

Finally, and old adage says that “every challenge is an opportunity.” Your children are unable to attend school and many parents are stuck at home idled from work as well.  A great chance for  family time! Read, watch movies together; play games (for the love of Gd, board or card games some instead of just video games!!); take family walks, bike rides, play sports–have a catch, shoot baskets, hit tennis balls together (maintaining appropriate “social distance”).  At least this is happening in springtime–enjoy it.

I quoted George Harrison in my last post–“All Things Must Pass.”  With my aches and pains, I have benefited from the gaining of a bit of wisdom from aging.  I certainly don’t know when, but, eventually, we will get through this.  We just need to remain calm, patient, and–most important– supportive of each other.  ESPECIALLY OUR CHILDREN!!

Thanks for following.

Coronavirus (what else?)

OK, to call these recent events “unprecedented” is just obvious.  I have been in practice for 35 years and have never seen  anything remotely like this. My job as a pediatrician has 2 basic roles:

  • Well care–providing immunizations and expectant evaluations like measuring growth for early identification to prevent problems; as well as discussion and “anticipatory guidance” to preview and prepare young families for what comes next in a child’s life.
  • Diagnose and treat illness and disease–everything from colds, injuries, rashes,  to mental health problems.

And here we are now facing  a worldwide health risk phenomenon. I will not address how or why we got to this point.  We are here now and have to deal with it. That requires some modification in office procedure and practice style. Most of the functions above will continue apace–well check ups and the large majority of acute complaints can be addressed as they always have been.  However, it is obvious that a large percentage of appointments are for cough/fever/ache type illnesses–the very symptoms of COV-19, the “corona” virus. So my office will have to make these adjustments:

  1. We suggest that most children with cough/fever simply stay home, rest, manage symptoms for comfort.  As we all know, most of these sicknesses are caused by viruses (corona included), are “self limited” and will pass on their own.  No specific treatment is necessary or, in fact, useful to shorten the course. Supportive care is all that we need or have.
  2. As always, I encourage my patients to call me for advise.  During this situation I will essentially be screening all sick appointments personally. I will help my staff and parents to decide the best approach for each child’s problem on a case by case basis. Absent fever some can be scheduled in the office. Likely we will ask you to notify us of your arrival, wait in your car and our staff will call your cell to bring you up so you can then be promptly ushered into an exam room.
  3. Along the above, we are going to limit appointment scheduling, seeing fewer patients per hour.  Our goal is to limit any waiting room time as much as possible.  You arrive and go right into a room.  If feasible check in may take place while you sit in the exam room.  Limit exposure for everyone as much as possible.
  4. I urge you not to rush to the ER or urgent care center.  Great way to expose your family to all kinds of nasty critters(we’re talking pathogens here, not other patients!) I will try and help you decide if you need to go, and will call ahead for you–again. minimize wait time and exposure where possible.
  5. In the coming days Coastal Healthcare will have telemedicine capability.  Let me state up front: I am old school.  Treating over the phone or video is, at best, suboptimal. However, under the present circumstances we simply have to make the best of it.  So, again on a case by case basis, and with parents’ agreement, I may opt to treat/prescribe for your child using those electronic encounters only.

Keep in mind: our goal is to help to stop the spread of this dangerous infection. But the good news is evidence from around the world indicates that the vast majority of children are spared serious complications from COV-19.  Unlike the flu, corona causes serious problems mostly for older people.

I appreciate everyone’s patience while we make these (presumably) temporary adjustments. Nothing is forever. George Harrison–typically–sang it so wisely and beautifully:

All Things Must Pass

Be safe, friends.

Common Limb Complaints

Two common and annoying orthopedic problems that we see regularly are growing pains and transient synovitis of the hip.  Both can cause considerable pain and distress but fortunately are otherwise self limited and apparently without any long term implications.

Transient Synovitis of the hip (TS) results from inflammation of the tissue covering the joint (synovium).  It actually can involve any large joint–in particular of the leg–but the large majority of cases involve the hip.  No one knows exactly what causes TS, but as it typically follows URI/viral infections by a few weeks the consensus is that it probably involves some mild, self limited auto-immune issue.  It occurs most typically in children aged 3-8 years with peak at 4-5 years. Children will develop pain and limp fairly abruptly over a day or 2.  The pain may be located in the hip, groin, or buttock and may extend to the knee.  It is very unusual for both sides to be involved.  There may be a mild fever but mostly the children are well appearing. Some children may complain of so much pain that they may at least temporarily be unable to walk.

Lab tests and x-rays are usually normal although on occasion there may be a  small amount of fluid in the joint (effusion) which will invariably resolve on its own.

The only treatment recommended is rest and analgesics like ibuprofen. Infrequently the pain may last for weeks; if so, physical therapy to reduce pain and preserve joint flexibility can be of benefit.

Growing pains are a well defined phenomenon of otherwise vague leg pains.  Nobody knows for sure what causes them either, although my personal guess is that it represents a response to overexertion, with muscle cramps/”Charlie horses.”  Children–or teens–will complain of leg aches and pains at night–NEVER during the day with growing pains.  The pain involves the thighs and calves–NEVER the joints themselves.  These children also are otherwise well appearing–no fevers, rashes , headaches or neck pains, swelling or discoloration of the involved limb.  Growing pains may be an ongoing complaint for some children throughout their early years. As with TS, rest and analgesics are all I recommend; massaging the painful limb often provides good relief as well.  Keep a close eye on activity levels to avoid overexertion. Growing pains ALWAYS resolve by the next morning.

Children with systemic symptoms like high fevers, weakness or fatigue, headaches or neck pains, rashes, multiple joint complaints or ongoing morning stiffness are less likely to have either TS or growing pains. Please call me in these situations so together we can figure out what may be wrong and relieve your child’s discomfort.

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Tattoos and Piercings

I grew up in an age when tattoos were the stuff of drunken sailors and Marx Brothers movies.  Now, of course, they are nearly everywhere–among the kids and, not infrequently, the parents. I admit, I still don’t get it, but on the other hand, who cares about the style opinions of a crotchedy old geezer like me? So I’d like to discuss some safety issues with tattoos and piercings.  A recent article in my journal Pediatric News reviewed an excellent  presentation by Dr. Cora Breuner of Seattle Children’s Hospital which I will summarize.

Tattoos have been around for >4,000 years, body piercings since at least 700 AD. As above, the style has really taken off in popularity.  38% of 18-29 year olds have them (72% of tattoos are on non-visible body areas) and 23% have body piercings.  Tattoo recipients have increased by 20% from 2012-16 alone, it’s now a $1.65 billion industry. Most people (86%) like their choice–it makes them feel happy, attractive, sexy, rebellious, unique–even athletic or spiritual.  Who am I to argue?

The main risk of tattoos is skin infection. Given the nature of tattoos, those infections can get quite deep and pretty unpleasant. However, by all accounts, the incidence is fortunately low. Michigan is one of the few states that maintains accurate records of tattoo infection and found only 18 in 2010.  Hepatitis C is some concern as well; this is a more serious problem but more difficult to track, due to the relatively high incidence of tattoo recipients who may engage in risky behaviors like IV drug use and unprotected and more aggressive sex practices. Obviously, sticking with licensed shops compared to illegal operations is better.  In NJ, shops must be licensed by the Health Dept. and artists must be OSHA certified in handling blood born pathogens. <18 year olds need parental permission for tattoos or piercings.

With piercings the risks are more varied.  Bleeding is uncommon with ears and noses but more so with tongue, uvula, nipples, and genitalia as these areas take longer to heal (3-9 mo compared to a few weeks for ears). Dental complaints can occur with piercings in the mouth–bleeding, chipped teeth, receding gums.  This is more common with “barbell” piercings (47% had some tooth chipping after 4 years–people tend to bite down on them).  Hepatitis C appears to be a greater risk with piercings compared to tattoos.

Historically, tattoos and piercings were problematic as young people grew and entered the employment pool, but my general feeling now is that that concern is passe. I don’t think anybody pays too much attention anymore. At any rate, if the involved body part is hidden, nobody notices anyway.

I think it is reasonable for parents to review these risks with teens who express interest in tattoos and piercings.  Of course insist on patronizing only reputable establishments; I think it’s fair for parents who object to require the kids to pay for it themselves.  But don’t force your choice on them–their lives, their bodies, their decisions, Mom and Dad.

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Stuttering

I have had several families asking about stuttering recently so it seems a good time to address the topic.  Stutter/stammering is usually merely a mild developmental issue most frequently between the ages of 2-5 years, more commonly among boys.  It may become more noticeable in situations where the child becomes nervous, anxious, excited, angry or generally with greater emotions.  On occasion it may be associated with other problematic movements like blinking, twitching, trembling, or other involuntary tic like behaviors.

There are several types of stutter/stammer utterances you may notice:

  • Repeating the first sound in a word (“w-w-w-water”).  Note that repeating a sound in the middle of the word (“wat-t-t-er”) may be of greater concern.
  • Prolonged first sound ((“ssssister”). Again, note that that phenomenon in the middle of the word(“sisssster”) can be more of an issue
  • Use of interjected sounds (“um”)
  • Long pauses
  • Frozen speech(mouth open, unable to get sound out
  • Appearing out of breath while speaking

Mostly there isn’t too much you have to do in this situation (I resist calling it a “problem”) as it will usually just dissipate on its own.  So generally watchful waiting and try not to worry.  Keep these general principles in mind:

  • Keep things calm and relaxed.
  • Speak slowly and clearly to your child. Pay attention.  Look at them when you speak to them and when they speak to you.
  • Do not criticize or tease; don’t rush or interrupt them.
  • Don’t emphasize their stutter; don’t avoid it, either.
  • Encourage them to talk about topics of interest to them.
  • It’s ok to ignore mild stuttered words.
  • If stuttering, you can look at your child and discretely, slowly repeat the troubling word with them.
  • Make teachers and ancillary caregivers aware of the stutter and of the above strategies.
  • It can be beneficial to practice difficult, problematic words. Use of poems or songs with the “problem” words may help.

While most stuttering is purely self limited and developmental only, there is stuttering that is neurogenic ( due to brain problems) or psychogenic (emotional/psychological trauma or mental health) related. If there is a family history of speech problems, if the condition lasts > 6 months or is associated with other speech difficulties, if your child’s school performance or social interactions deteriorate due to the stutter we should look into it more thoroughly.  Note that there are many healthy, intelligent, accomplished adults who deal with stuttering every day (including, unfortunately, facing up to the occasional ignorant or boorish remark).   

There are several specialists we may contact–speech pathologists, audiologists(hearing specialists), neurologists. I urge everyone to disregard most pitches about medicines, herbals/supplements, or on line fad pitches for miracle cures.  As in most situations, they are mostly a load of bunk.

Please let me suggest one of my late favorite movies where stuttering is an important part of the plot: “The King’s Speech” (Colin Firth, Geoffrey Rush, Helena Bonham Carter) 4 stars, inspiring(the pic above from the movie).  Find it “On Demand” I bet you’ll love it!

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Sleep and your Child

My own friends and family will attest to my personal fixation (not too strong a word) with sleep.  Yet, I’m not crazy (well, I am, but anyway)–adequate sleep is vital for your child’s good health.  Infants need 12-15 hrs, toddlers 10-14 hours, school age 9-11 hrs and teens 8-10 hours per night–note that that applies through teen years, so it includes high school seniors and college students as well . Additionally, continuous sleep is essential.   This enables the brain to go through the various physiologic cycles of normal sleep, including vital “REM”(rapid eye movement) sleep, so 6 hours at night and a 2 hour nap is simply NOT as restful, restorative, or beneficial to health.

Why is this important? There are almost too many ways to count.  Sleep is essential for brain development and plasticity (flexibility). Numerous animal models demonstrate proper sleep associated with more grey matter (brain tissue)  and better synapse (nerve cell connection) development.  Other studies show that children and adults with good sleep both perform better on memory tests compared to sleep deprived individuals.  A recent report in the journal Sleep found a higher rate of language and reading problems, as well as more ADHD symptoms in children who routinely got < 10 hours sleep/night before age 3.  I can tell you that my standard approach to ALL mental health evaluations–depression, anxiety, behavior/school discipline issues, ADHD, even headaches–includes a thorough and detailed review of the child’s present and historical sleep patterns.  It is not rare for me to discover a history of bad habits in that area in children coming in with those concerns, and, additionally, upon correcting those sleep problems many such complaints are improved if not outright resolved.

It goes beyond mental health, though.  A 2018 review conducted by British researchers of over 40 studies that included >75,000 children and adolescents, followed for 3 years, found poor sleep was a strong risk factor (as much as 58% greater) for obesity, cardiovascular disease, and Type II diabetes. Just getting poor sleep resulted in the kids gaining weight faster

In 2016-17, the National Survey of Children’s Health reported a review of almost 50,000 American youth that found only 63% of those aged 6-12 and 68% of 13-17 regularly got a proper night’s sleep.  This is a serious health problem.  What can a parent do?  There are lots of things, but  the simplest I recommend is summed up in 2 words ;  SHUT OFF.  I’m talking phones, computers, tablets, games.  Get your kids off of those things after a reasonable amount of time.  My advise is maximum use 1 hour/day weekdays, 2hr/day weekend/holiday (not including  school work) TOTAL; discontinue use >1/2-1 hour before bedtime, and DO NOT allow your child to store or charge those devises in their bedroom.  (You can BUY a real alarm clock!)

For more on sleep you can check out some articles from the American Academy of Pediatrics here. I have previously reported on public policy initiatives that can help with this problem here.

So please pay close attention to your child’s sleep habits throughout their growing years.  Contact me with any questions or concerns, and thanks for following.

Featured image courtesy of Alamy.

Antibiotics and allergy

A recent JAMA Pediatrics study has identified an association between antibiotic treatment 0-6 mo of age and risk of allergic diseases like food allergy, hay fever, eczema, and especially asthma.  The research looked at almost 800,000 infants from 2001-13 who subsequently received >160,000 prescriptions for antibiotics, finding the highest risk for penicillins and lower but significant risks for cephalosporins and sulfa drugs.  Asthma incidence increased by 47%, and multiple prescriptions–especially with different drugs– in that age group “upped the ante” on those risks.

Researchers and allergists speculate that use of antibiotics alters “the microbiome”which can disrupt the natural protective properties of those intestinal bacteria. Disrupting that balance, they postulate, interferes with normal body immune development which can explain the study’s findings.  I will stress that this study demonstrates an association.  In other words, it may be showing that taking antibiotics in infancy increases the risk of allergic disease, or that children with allergic diseases end up receiving antibiotics earlier and more frequently.  We don’t know which for sure, but it certainly is important to keep in mind when we are considering prescribing antibiotics, especially in these little kids.

One aspect of this story that I wish to note is the frequency of antibiotic prescription at so called urgent care centers.  Some studies report that 46% of patients received antibiotics for conditions that did not warrant their use; nationwide, 40% of all outpatient antibiotic prescriptions originate from urgent care encounters.  The CDC estimates that, nationwide, 23,000 people die each year from antibiotic resistant bacterial infections with names like MRSA, “c dif,”, VRE, CRE.  Many public health officials fear that, with antibiotic overuse, those numbers may explode into the millions in the decades to come.

To their credit, many urgent care center organizations are working diligently to improve their performance in that area by such initiatives as developing best practice protocols and partnering with organizations like the George Washington University Antibiotic Resistance Action Center to educate their providers about this issue.  However, as the patients and their histories are not well known to these caregivers–who are often nurse practitioners or physician assistants with less experience and clinical training than MD’s or DO’s–making progress with this is a great challenge for these facilities.

I recommend exercising caution in utilizing  urgent care centers for your children and in particular that age group–0-6 months.  Generally if you can get the fever down (even if it goes back up later), your child has an appetite for fluids and is holding them down, urinating at least 3-4x/24 hours, then the situation is likely stable and can wait for the regular doctor’s office to open.  Remember– fast does not necessarily equal good.  I stress the term “generally”–OF COURSE each situation must be judged based on the condition of that particular child at that particular time.

But before rushing off to the urgent care center or the ER keep the above in mind and give me a call before you go.  I’m here to  help you make the best decision for your child.

Image courtesy of Children’s Healthcare of Atlanta.  Thanks for following.