Chronic Cough

     One of the most bothersome problems a child can have is a chronic cough. It is defined as cough lasting longer than three or four weeks. There are many reasons for a chronic cough, but it is never due to “chronic bronchitis” in children. There is always a reason for chronic cough and it needs to be investigated.

     A continuous or recurrent cough in the first 6 months of life is unusual. It often is caused by something wrong with the anatomy of the infant’s airway and a study of the lungs and airway is usually in order. If an infant gets an infection with a virus called RSV, the infant can have a long-term, recurring cough with wheezing every time he gets a new cold. These infants are often treated the same way we treat asthmatics.

     Under three years of age, a common cold can give a child a cough for two weeks, but usually not longer. In toddlers, a cough that comes on with a cold but then lasts well over two weeks after the cold could be asthma. The child may not have the classic wheeze of asthma, so he might not get diagnosed or treated as asthma. It is especially likely in a child whose family has a history of allergies, eczema and asthma. Asthma can also be a cause of “recurrent croup”. The child has croup symptoms with loud high-pitched sounds on breathing in (“stridor”). Again, because asthma is usually associated with wheezes when breathing out, the child may not be diagnosed. If a child “gets croup every time he gets a cold”, he probably has asthma.

     Another cause of chronic cough which develops after a child has a cold is a sinus infection. The child may or may not have thick mucous. The cough is more frequent in the morning and older children may complain of headache or facial pain. The diagnosis of a sinus infection is mostly made by history and looking up into the nose. The regular X-rays taken to diagnose sinus infection are unreliable.

     If more than one member of a family has a chronic cough, infection is the most likely cause. Pertussis (Whooping Cough) and Mycoplasma are common causes of long-term cough. Fungal infection is another infectious cause of long-term cough. And we should not forget tuberculosis which is just a few hours away by jet flight.

     In any child under three, a chronic cough can be caused by something stuck in the child’s airway. Any time a chronic cough has not responded to treatment for infection or asthma, there might be a foreign object in the breathing tube. This can be true even if the X-rays are normal.

     Cough that repeatedly occurs in an older child after 15 minutes of exercise can be “exercise induced asthma”. Breathing studies are used to make this diagnosis. Loud wheezing without much coughing after exercise is usually not asthma but a condition called “vocal cord dysfunction”. The same breathing study usually shows it.

     Reflux of stomach contents up the esophagus and into the airway can be a cause of chronic cough or asthma-like symptoms, but it is over-diagnosed, especially in infants. Before starting an infant on “anti-reflux” medication, careful evaluation is warranted.    

     Finally, children can get “habit cough”. It often occurs in high expectation/ high stress families. It can begin with a typical cold and cough, but then develops into a long-term, dry, hacking cough which can be so loud and bothersome that the child might be sent home from school because he is disrupting the classroom. It can also be chronic throat clearing. The cough goes away when the child sleeps (cough that wakes you up at night is not habit cough). We all manifest stress in some way and this is how these kids do it.

     Cough and cold medications and cough suppressant medications are rarely helpful in children and can be dangerous because it is hard to judge the correct dosage. Rather than treating the cough, talk with your caregiver and find out what is causing the cough.

Teaching Your Infant Good Sleeping Habits

In the first years of life, parents can save themselves and their children a lot of problems by starting good sleep habits from the very beginning. As soon as possible, get your newborn out of your room and into the nursery. Nothing is more obvious than a tired infant – they go from happy and smiling one minute to out-of-control crying the next. If baby is crying, has been awake for over two hours, is not wet and is not hungry, then he is tired.  When human beings sleep, they cycle from deep sleep to light sleep. Some experts say that we learned that by sleeping in the jungle. We come up from deep sleep to check that our surroundings still smell, sound and feel the same. If something is different, we wake all the way up to check it out. With that in mind, you want to put you infant to sleep in the way that you want him to stay sleeping. You can try to feed him a little, but don’t let him fall asleep on the bottle or breast. You can rock and quiet him, but don’t let him go to sleep in your arms. Always put your infant in the crib a little awake. You can have the quiet sound-machine on, but remember that if it doesn’t stay on, he might wake up when he gets into light sleep in an hour. Basically, you want things the same all night. When your baby is tired, he feels miserable. He doesn’t know why, so he might cry but crying when he gets laid down is O.K. Forget the guilt. Teaching your child to quiet himself down is a skill that will be valuable in the future. Put him down awake; let him cry if he needs to and leave the room – you don’t want to be there all night. Don’t keep walking with a crying infant; don’t go for a ride in the car to get him to sleep and don’t allow him to sleep in the car seat at home – it is dangerous. Infants wake up at least once a night to eat up to at least 6 months of age. Feed him but don’t let him fall asleep eating. Once he starts to drift off, change him (which will wake him up a little) and put him back in the crib. You and your infant both need sleep and, contrary to the common idea, being as parent does not need to mean sleepless nights.

Long-Term Runny Nose

     From nine months of age until about three years old, it seems like every child’s nose is runny. Rather than being “just a snotty-nosed kid”, most of the time there is actually an explanation for it.

     The most common reason is, of course, a viral cold. The first thing that happens when a child gets a cold is that he gets a fever and feels miserable (See article on “Fever”). That is when the nasal discharge is thin and clear.The confusing thing for parents is that, in about three days, when the child loses the fever and feels better, the nose really starts to get bad - green, yellow or brown mucous – all colors and thickness. The child is eating and feeling fine, but the snot doesn’t stop coming. Usually there is a cough along with it.  This second, runny-nose phase of a cold can last up to two weeks and parents often begin to believe “he must have a sinus infection” just because the nasal discharge is so gross.  I’ll usually tell them to wait at least two weeks before spending money on doctor visits and antibiotics because most runny noses clear without treatment if the child is otherwise well. If it goes on longer than two weeks, Grandma will probably sneak him out of the house and take him to the doctor, anyway. If the child develops a new fever or seems more irritable he needs to be examined. Don’t worry if the child won’t blow his nose. When he sniffs, the mucous doesn’t go back in his head, it ultimately goes into his esophagus, he swallows it and it comes out - just  from a different end. Teaching him how to wipe his nose is good, though.

     Another cause for nasal congestion lasting over two weeks is allergy. These children usually have a family history of allergy, eczema or asthma and the nasal drainage is usually thin and clear.  This is not accompanied by fever or feeling ill - the child just “sniffs” and “coughs” a lot. He may have a crease across the lower part of his nose from rubbing up on his nose with the palm of his hand – the “allergic salute”. If the runny nose starts when you have had a change in the environment – a new living place, the #100 stuffed animal just got added to the collection or you have a new hairy pet (especially a cat!)– think allergy. Sometimes allergy will manifest as just a long-term cough or throat clearing. You get so used to hearing the sniff, you don’t hear it any more. If a one to two week course of daily children’s antihistamine (not decongestant) improves the symptoms, think allergy.

     Sometimes the chronic cough and congestion can be a sinus infection. This is a secondary infection. It comes on after the mucous has been in the nose long enough for the bacteria to grow. So a sinus infection occurs after over two weeks of runny nose symptoms from either a cold or allergies. The nasal discharge can be very thick and nasty and it is coming out of both nostrils. The child could have a headache or just not feel good. The diagnosis is usually made from the history and exam - X-ray studies are worthless. As I have mentioned in previous articles, any time your child has had any illness for a while and then takes a turn for the worse, the child needs to be seen.

     Finally, if a child has long-term thick nasty nasal discharge that smells very bad and is only coming out of one nostril, have your caregiver take the bean, rock or whatever it is out of your kid's nose.

Food Allergies (2)

Not all reactions to food are allergic reactions and parents need to be sure that their child has a true food allergy if they suspect it (See the previous article: ”Food Allergy”).  If the initial symptoms occur more than 3 hours after the exposure to the food or if the symptoms last for days or weeks, allergy is probably not involved. True food allergy involves a response from the immune system. An immune antibody called IgE is commonly involved in the allergic reaction, but there are other true allergic reactions which do not involve IgE. Because there was many ways of testing for food allergy and the test results can be very confusing, parents need to speak with their caregiver before eliminating a food from a child’s diet. Symptoms of true food allergy usually involve the gastrointestinal tract, the respiratory tract or the skin. Headaches, muscle pain or weakness or behavioral problems are not caused by allergy. Symptoms of a more severe allergic reaction include vomiting, wheezing, difficulty breathing, hives and fainting. Immediate treatment is needed.

     The treatment for an allergic reaction to food is an injection with epinephrine. People are often frightened by the thought of an injection but they must not be. The medication itself is safe. Before nebulizer treatment was available in the clinic, we used to give one, two or even three injections of epinephrine in a row to young children to stop an asthma attack. The injection needs to be given in the outside part of the thigh and it needs to be given immediately. A common cause of death is waiting “to see if the reaction is going to get worse”. Even if the child’s symptoms improve, the child needs to go to the ER and be observed. Sometimes a second severe allergic reaction can occur hours after the first. It is impossible to predict which children will have a severe allergic reaction. In one study of children who died from allergic reaction, 1/3 of the children had an initial reaction to food that was so mild that the doctor didn’t think it was necessary to give the parents an epinephrine pen.

     Parents of a child with true food allergy need lots of support and education. They need to be comfortable giving the epinephrine injection. They have to balance their fear of severe reaction against their child’s nutritional needs. They might have friends or family who question whether the allergy is real. They might have guilt that somehow they caused the allergy. They have to worry about eating anywhere other than home because ingredients are unknown or food could be cross contaminated. An excellent source for information is the Food Allergy and Anaphylaxis Network (www.foodallergy,org).

     If there is a strong family history of allergies, eczema or asthma, parents should consider steps to try to prevent allergy. Exclusive breast-feeding for the first 4 months of life and possibly holding off on solids until 6 months of age is recommended. If formula is used, the milk protein should be broken down – called hydrolyzed.  “Extensively hydrolyzed” formula lowers the risk of allergy but is very expensive. “Partially hydrolyzed” formula is cheaper but less effective and it still has some milk protein in it, so a severely allergic child shouldn't drink it. Other recommendations are to not give the child dairy until one year of age, eggs until 2 years of age and nuts until 3 years of age. It is not known whether following these withholding recommendations is worthwhile. Allergy are rarely helpful with food allergy.

    

Your child needs vitamin D

     Sometimes a trend in medicine will create a problem when combined with a second trend. For the last two decades, we have recommended breast-feeding for all infants. During that time we have also recommended minimal sun exposure for children. The combination of these recommendations can result in vitamin D deficiency.

     Vitamin D is necessary for the normal absorption and metabolism of calcium. It is necessary for good bone health. A severe deficiency in vitamin D results in a condition called rickets. Although this is rare, it is becoming more common and mild vitamin D deficiency is very common in both children and adults. It can cause bone pain, muscle pain, muscle weakness, poor growth and vomiting. Rickets can cause swollen joints, severe extremity pain, difficulty walking and even seizures.

     It is recommended that infants from birth to 1 year take in 400 IU (international units) of vitamin D daily and children from 1 year-olds to 18 year-olds 600 IU daily. Breast milk is usually low in vitamin D and an infant who drinks a normal daily amount of breast milk might only take in 10 – 40 IU of vitamin D in a day. It is estimated that to maintain an adequate level of Vitamin D, an infant would have to be exposed to midday sun for 30 minutes a week wearing only a diaper. This, of course, is against all sun-exposure recommendations. Using 30 SPF sunscreen decreases the body’s ability to synthesize vitamin D by 98%. So, doing what we are told to do – breast feeding, limiting sun exposure and using high SPF sunscreen – results in low vitamin D levels.

     Skin pigmentation serves as a natural sunscreen, so non-Caucasians have a greater risk of Vitamin D deficiency. It has been estimated that dark-skinned individuals need up to 3 times more sun exposure than Caucasians do. The only case of actual rickets I have diagnosed was in a 1 year-old African-American child whose mother still fed her breast milk all the time and also worked a late-night shift so neither of them was ever exposed to the sun.

     All formula, cow’s milk and soy milk are supplemented with Vitamin D. The risk of rickets is increased in children who are primarily breast-fed after 6 months of age, children allergic to cow’s milk or soy milk and in children on strict vegetarian diets. People living at higher latitudes or colder climates are also at greater risk for rickets. Some medications, especially anti-seizure medications, can decrease vitamin D levels.

     Dietary vitamin D is found in oily fish (salmon, sardines, mackerel, tuna), cod liver oil, egg yolk, and in foods and drinks fortified with vitamin D. For infants, it is recommended that they receive 400 IU of vitamin D supplementation daily which comes in a liquid you can purchase in a pharmacy without a prescription.

    

Feeding your 1 year-old (2)

      In a previous article I discussed how to transition your child into eating regular foods. In it, I mentioned that the choices that parents make in the first two years of life can give their children the gift of healthy eating habits for the rest of their life. Between six months and one year, breast milk and formula are still used, but they are given between meals. The main nutrition for infants is moved to solid food. During this time, begin the habit of feeding the infant fresh fruits and vegetables, no juice, no processed meats (hot dogs, lunch meat), no trans-fats and no foods that contain added sugar, corn syrup or fructose. At one year of age, all bottles – night-time, nap-time, any time – become only water - no juice, no milk. It is thought that the high carbohydrate diet we feed our toddlers is contributing to both the epidemic of obesity and the epidemic of diabetes in this country.  From one year of age on, develop the habit of coming to the kitchen to eat (no eating in other rooms of the house), sitting down with the family and having the meal together. Feed him what you are eating. Don't worry about likes or dislikes - one day he'll love peas and the next day he'll hate them. Put everything on the tray and let him eat what he wants - just like you do. As soon as more food is hitting the floor than hitting the mouth, he is done eating and you pull him out of the highchair. No "clean plate" rules. He can have a glass of milk with meals, but don’t give it to him until he is well into his meal. If your child gets hungry between meals, go back to the kitchen, sit down and give him some fresh fruit and a glass of water. If he wants a bottle to use as a pacifier at nap-time, make sure it is only water. Avoid all juice, fruit snacks, crackers, cheese slices and, most important, don’t teach your child that he needs to have sugar going into his mouth in all day long. Toddlers snack between meals, but go back to the kitchen each time and give a healthy snack - avoid the "juice-and-snack-all-day" habit. Especially avoid giving anything but water one hour before meals.

     Every parent should read about Metabolic Syndrome because it is the key to understanding the epidemic of obesity in this country. In essence, it is a change that occurs in the body’s basic way of metabolizing food when the person has consumed a diet low in fiber and high in trans-fats, refined carbohydrates like fructose, added sugar and processed foods. Once this change occurs, the child is on the road to a lifetime of obesity, diabetes and health problems. Don’t be fooled by package claims of “organic” and “natural” – these terms have become marketing tools and have ceased to have much meaning. Always read the labels.
     You set the healthy eating habits for your child and doing it from the start makes it easier. Limit the fatty foods, eat breakfast daily and limit eating at restaurants, particularly fast-food restaurants. Eat meals together as a family; limit portion size and don't use food as a reward. "You acted good - we'll spend some time at the park today" beats "You acted good  - I'll buy you a Happy Meal". Finally, It is clear that the more time a child spends in front of a screen, the greater the risk of obesity. Turn off the electronics.
     Good health and normal metabolism also come from a habit of regular exercise. Having a toddler is an excellent opportunity for parents to exercise and doing things with your child is good for everyone. Children do what their parents do – not what their parents tell them they should do.

Teething

     Infants usually begin teething about 4 months of age. An infant can be born with teeth (these are extra teeth and are usually removed right after birth) or still not have teeth at 9 months, but the average is 4 months. This is confused by the fact that all 4 month-old infants drool a lot and chew on anything that comes within a foot of their mouth because chewing and drooling are mistakenly identified as signs of teething. Actually it is just nature getting the infant ready for solid foods.

     Teeth come in gradually – pressure builds up and they move up and then stop for a while and move up again. Every infant responds to teething differently. Some infants don’t seem to feel a thing – one day the tip of a tooth just appears. Other infants have a horrible time with every tooth. They can be miserable for a day or two and some infants even develop low-grade fever or congestion, which is impossible to tell from a regular cold. When a parent asks me whether a fever is due to a viral infection or teething, I ask if the child has had fevers with previous teething episodes. If not, it is unlikely that the current fever is due to teething. As the tooth is moving up, it can cause a blue blister that appears on the gum and can sometimes bleed when the tooth pops through.

     The front teeth usually come through first (upper or lower). It is also not unusual for some of the front teeth to come in and then have some back teeth come in leaving a gap – don’t worry they’ll all come in eventually.

     A dose of any oral pain reliever can help children through teething. For younger children or children with a family history of asthma or allergy, I recommend ibuprofen (see the article on “Acetaminophen”). Cold teething rings also seem to help but chewing on anything helps. People who don’t want to use medication can use frozen fruits or vegetables as long as they are large enough so that the infant won’t choke on them. Tying a knot in a washcloth, getting it wet and freezing it works as something to chew on, too. Cloves have been used for centuries for local pain relief, and the most commonly used orally applied commercial product for teething contains eugenol – the ingredient in cloves. Using clove oil is more worrisome because the dose in the product you buy in an alternative medicine store can vary, and too much clove oil can be dangerous. People who believe in homeopathic medicines can use these, but the fact is that the dose in most homeopathic medicines is so small that they are only water. When you use them, the pain will go away because it always does, anyway. I also wouldn’t recommend Grandma’s suggestion of brandy on the gum. Save the brandy for yourself.

Diaper Rash

    

     There are three basic types of diaper rash. Parents can tell which kind they are dealing with by the way the rash looks.

     The most common diaper rash is caused by contact with stool and urine. This is a flat, raw, red rash that is on the areas of skin around the anus, on the buttocks or in the front on the scrotum or the labia. It is a chemical burn and looks like a sunburn. There can be small, open sores that bleed when they are wiped and the baby cries when wiped because the area is very tender.

     This rash occurs when there has been contact with stool and urine from infrequent changing, or contact with acidic stool that comes when the infant has diarrhea or even with normal loose stools (see the article on “Infant Pooping”). It can also come from overuse of store-bought diaper wipes. Finally, this rash can just be a consequence of wearing diapers. Some infants have sensitive skin and anytime they have urine or stool on their skin it causes irritation.

     The cure for a contact diaper rash is protection. Even frequent changing might not help because, once the rash has begun, even a few seconds of contact will make it worse. Use a thick diaper cream/paste that contains zinc oxide. There are many brands and everyone seems to have their favorite but the only important ingredient is zinc oxide which covers the skin with a thick, hard-to-rub-off layer of protection. What kind of cream you use is not as important as how you use it. Put it on much thicker than you would ever think necessary. It needs to be so thick that when you open the diaper, you should see poop lying on top of a layer of diaper cream. If you can see the skin, the stool can hit the skin and burn it. The sores should heal up rapidly but any further contact makes the rash come and go. When you change the diaper, only wipe enough to get the stool off. Don’t try to clean the area too aggressively because that will irritate the skin, too. Wipe the stool off the zinc oxide and put on more zinc oxide. Store-bought diaper wipes are handy in the diaper bag when you are on the road, but for normal cleaning at home, use a soft cloth and a little water.

     The next most common diaper rash is caused by a yeast infection. Because yeasts grow in dark, wet places, this rash is found more in the folds where the legs and the groin meet or are inside the labia and under the scrotum. This is a bright red, slightly raised, scaling patch of rash that slowly expands in the hidden area. It usually doesn’t have that “raw” appearance or cause open sores. The treatment for this rash is to use any of the anti-fungal/yeast creams which you can buy without a prescription. Again, use a lot of it with every diaper change. Sometimes you may see both a contact rash and a yeast rash together – the contact rash injures the skin and allows the yeast to infect the skin. In this case, rub in the antifungal cream first and then cover it with the zinc oxide. The yeast infection should gradually improve but less rapidly than the contact rash.

     The last type of diaper rash  is caused by a bacterial infection of the skin. This rash is the least common. It causes blisters and open sores, especially on the buttocks, without the surrounding raw contact rash. As with a yeast infection, the infant may start with a contact rash first that allows the bacteria a chance to infect the skin. But the primary thing with a bacterial diaper rash is spreading blisters. This rash should be treated with over-the-counter antibacterial ointment applied with each diaper change. However, if the blisters don’t clear rapidly or the skin appears to become more red or swollen, you need to consult the infant’s caregiver right away.

Head Lice

-->

     Nothing quite strikes fear and panic into the hearts of parents as much as the words “head lice”. Yet, it is almost impossible to get your child from preschool to high school without encountering these little beasts.

     Every time one of my children had head lice, my own head started to itch. I never had lice, but I treated myself just the same. The worst case we had was when the coach of the girls softball team insisted the players all wear the batting helmet without a cap on underneath. Sure enough, the whole team got infected.

     If you see your child itching his head – especially at the nape of the neck and behind the ears, look closely near his scalp. The egg casings (nits) are white or grey, oval or bullet-shaped and attached firmly to the side of the hair shaft. Dandruff brushes off easily. Nits don’t brush off. You may see actual lice crawling on the child’s hair (Eeek!), but most of the time you won’t.  The experts say that seeing nits doesn’t make the diagnosis of head lice – that you have to see live lice - but if your child is itching and you see nits, you’ve got lice.

     After the immediate panic, parents need to get into the right frame of mind. Head lice have become resistant to most forms of therapy over the years, so, you need to abandon the feeling that you MUST get rid of the lice RIGHT NOW! Know that, even though it is going to take a while and a fair amount of work, the lice will be gone soon. All you have to do is to keep up the attack. Getting rid of head lice involves two basic principles: Make the head a “not-so-nice-place-to-live” for the lice and then keep removing the eggs and lice until they’re gone. The first involves using medications that can be purchased without a prescription such as Nix or Rid. They are placed on wet hair after shampooing (don’t use conditioner), left on for a time and then rinsed off with water. Be sure to follow the printed directions. Next, use a good, metal nit comb (the free plastic ones in the lotion packages are worth what you pay for them) and get to work combing the wet hair. Wash the pillow cases in hot water and wash or change out the hats but don’t try to fumigate the rest of the house and don’t buy anti-lice furniture sprays. There is little evidence that lice live longer than 48 hours off of the scalp, so I’ve never understood why you would “put pillows and stuffed animals in a bag for two weeks". Lice can’t fly or jump, although they could fall off onto a stuffed animal, but any louse that leaves a nice, warm, bloody scalp to get on a piece of nylon probably wasn’t going to live very long anyway.

     Forget mayonnaise, olive oil, petroleum jelly and hot-air drying. A straightening iron could fry a few of the critters and makes the hair easier to comb, so it might help, but the main thing is to comb daily after treatment. The nits hatch after a week, so repeat the medicine treatment once each week followed by daily combing until the lice go.
     There are medications that your doctor can prescribe: malathion (Ovide) for children 24 months and older; benzyl alcohol (Ulesfia) and invermectin (Sklice) both of which can be used on infants down to 6 months and spinosad (Natroba). Be sure to find out what these medications will cost and whether your insurance will cover them.
      There are also oral medications which can be used. Speak with your child’s caregiver about them.

     Nits that are alive are usually closer than an inch from the scalp. If the nit is further than an inch from the scalp, it is empty or dead.

     

Toddlers and Bottles

     Up until 6 months of age, breast milk and formula are the only food that an infant needs. From 6 months of age until 9months, solid foods are introduced but the breast and bottle are still the main sources of nutrition.  After nine months, regular meals are introduced with a sippy-cup of milk. The bottle and breast become the “between meal” feedings. After a year of age, toddlers can still have bottles, but that is the time to introduce the “water only” rule. Drinking milk or juice from a bottle during the day creates multiple problems. First, it gives the toddler worthless extra calories that are sugar with little other nutrition. Next, it teaches the toddler that he needs to have something sweet going into his mouth all day – a precursor to the epidemic of obesity we see in this country.  Milk and juice between meals can kill the appetite and set the scene for picky feeding and, lastly, drinking milk or juice in a bottle before naps or bedtime (or, even worse, going to sleep while drinking milk or juice from a bottle) causes a severe form of tooth decay called “bottle carries”. Some two year-olds have all four of their upper front teeth rotted out from continuous use of the bottle or sippy-cup. If all bottles, day and night, become water after a year of age, all of these problems are eliminated. The toddler can carry around a bottle of water as much as he wants. He can be put down with a bottle of water if he wants to suck to fall asleep. (Although parents need to resist the temptation to put “a little” juice or milk in the bottle – use plain water). He can even have a bottle of water before meals when you are finishing getting it ready and he is hungry.

     There is no place for juice in a toddler’s diet. Milk should be given with meals (but wait until a good portion of the meal has been eaten before offering it) and parents should stick to water between meals. A healthy between-meal snack is a glass of water and a banana.