Croup - updated protocol August 2023

 Definition.

     Croup is a viral illness, usually caused by parainfluenza virus or respiratory syncytial virus. Croup is characterized by a distinctive cough that sounds tight, metallic, and like a barking seal. It occurs year-round, but it much more common during the fall and winter seasons. The virus infects and inflames the upper respiratory tract, especially the voice box. Severe croup is associated with a problem called stridor, which is a harsh, raspy, vibrating sound made when the child breathes in.

 

Expected Course.

     Croup begins a few days to a week after exposure to the virus. Croup is quite contagious, much like other upper respiratory viral illnesses. Mild symptoms of a cold, sore throat, or laryngitis (hoarseness and losing your voice) without the barky cough of croup occur in many persons with the parainfluenza virus. Therefore, many children with croup were not exposed to someone else with the same symptoms. Most cases of croup occur in children less than 5 years of age, with the peak ages for infection being 6 months to 3 years of age. We do see teenagers with croup symptoms, even stridor. Note: during certain strains of COVID, we saw cases of COVID that presented with croup symptoms.

     Croup symptoms can begin suddenly. Some children have no symptoms of illness prior to awakening with the cough of croup in the middle of the night. Other children have mild cold symptoms and perhaps a hoarse voice prior to the cough appearing. The cough of croup is worse at night and with more activity. Croup typically lasts about 3-5 days. A mild case may last a night or two and some cases linger on for well over a week. It is not unusual for the cough of croup to come and go throughout the illness. Cough spasms can occur where the cough is nearly non-stop for some time. During the day, many children will have long stretches without coughing.

     Other symptoms associated with croup include fever, fussiness, and a decreased appetite. A few children will have vomiting, usually around the time of the coughing spasms. Some children with croup, as with other respiratory illnesses, will develop a bacterial ear infection.

     Although some children have croup once, it is not unusual to have croup more than once. Some otherwise healthy children seem particularly prone to croup and will have it frequently. These children typically require the same treatment as other children with croup. Occasionally persons with asthma will present with barky coughs, we will hear wheezing in their chests, and they will respond to albuterol (bronchodilator) treatments. This is called spasmodic croup. Most children with frequent barky coughs do not have spasmodic croup.

 

Prevention.

     Because croup is spread so easily through casual contact with the virus, it is difficult to prevent. The virus can be spread from being close-by when someone with it sneezes or coughs. It can also be picked-up from toys, cups, door-handles, and other objects recently in contact with someone with the virus. Older children should be strongly encouraged to cover their mouth and nose during coughing and sneezing (teaching children to cough into the crease of their elbow can help, as your hands are more likely to spread the germs). Frequent hand washing or using hand sanitizer is important.

     Children should be kept home from school or daycare on those days in which they have a fever or frequent cough. Check with your child's daycare or school for their specific policy on returning there with symptoms of croup, as these may vary.

 

Treatment.

     Croup will run its course without special treatment. Because it is caused by viruses, antibiotics will not help with croup. However, certain treatments can be helpful.

-- Dry air makes the cough of croup worse and increased moisture in the air helps decrease the swelling and inflammation around the voice box. Therefore, the most effective treatment for croup is humidified air. Run a cool mist vaporizer (recommended over the warm mist vaporizers because some children burn themselves on the warm mist and studies show that either cool mist or steam vaporizers help equally) or a humidifier in the child's room. If the child is having their sleep disrupted by the cough and the vaporizer is not helping, run a hot shower in the bathroom with the door and windows closed. Sit on the floor with your child (toys or books or screentime can keep young children occupied). After 10-15 minutes, many children have their cough settle down and they can return to sleep. If they continue to cough and it is cool or cold outside, try bundling them up and taking them outside. The cool night air often helps the cough if the steamy shower did not. This also usually takes 10-15 minutes to work.

-- Tylenol® or Motrin® (acetaminophen or ibuprofen) can be given for fever or pain (sore throat).

-- Although the cough of croup does not usually respond well to cough medicines (the medications will not change the cough of croup significantly), it is okay to try an over-the-counter cold and cough medicine for children 4 years old and above. If it does help, it is fine to continue the medicine throughout the illness. However, if it does not help after a dose or two, stop.

-- Coughing spasms can be due to the sticky mucous of croup. Drinking clear fluids (water, apple juice, lemonade, etc.) can help relax the vocal cords and loosen the mucous.  

-- The laryngitis (losing your voice and sounding hoarse) gets better over a few days with resting your voice. Little kids do not rest their voice on request, even with encouragement. Their laryngitis will gradually get better without special treatment.

 

-- IF THE CHILD HAS STRIDOR OR OTHER SEVERE BREATHING DIFFICULTY:

     Some children with croup will develop the harsh, raspy, vibrating sound of stridor when they breathe in. This is caused by a narrowing of the airway in your voice box. Stridor gets worse with crying, coughing, and other activity. It needs treatment right away. Stridor often frightens both children and parents. Do your best to remain calm. Stridor is often worse in the night.

     If you hear stridor, the breathing becomes more difficult, or the breathing becomes tighter:

ð  Sit in the bathroom with your child with the door and windows closed. Run a steamy shower. It may take 10-20 minutes to help. If better, put back in bed with the vaporizer running in their room. This steamy shower treatment can be repeated as often as needed.

ð  If that has not helped, bundle up your child and take them outside into the cold/cool night air (it is not as effective, but standing right in front of the open freezer door also can help) for 10-20 minutes. If that helps, put back in bed with the vaporizer running in their room. This cool night air treatment can be repeated as often as needed.

ð  If not better and after office hours, your child needs to be seen right away at Nationwide Children’s Hospital Emergency Department or Urgent Care. If during walk-in hours at 8 a.m., we want to see your child at that time. During routine office hours, call for an appointment.

 

      

       CALL 911 (THE RESCUE SQUAD) IF YOUR CHILD TURNS BLUE OR DUSKY, PASSES OUT, OR STOPS BREATHING.

                                                                                                                                                                                                                      

      A few notes on "steroids": Some children seen in the office with more severe croup will need to be treated with steroids. These help the naturally occurring steroids in our body fight the inflammation in the respiratory tract caused by the croup virus. It has been shown that these steroids decrease the chances that the croup will worsen. They also seem to help decrease the worst of the symptoms of croup. They are given as either a shot (injection) of Decadron® (dexamethasone) or a few days course of a liquid called Orapred®, Prelone®, or Pediapred® (prednisolone) or a one-time oral dose of dexamethasone.  Most cases of croup seen in our office do not need these steroids. But, for those children that do, it is important to remember a few things:

     -- Either the shot or the liquid take a few hours to begin working in your child's system.

     -- The shot keeps working for few days after just the one dose.

     -- Continue having your child take the liquid medicine as instructed, even if they seem much better before they are done.

     -- Let your doctor know if your child has never had chicken pox but has been directly exposed to it in the last month (this is

       because the steroids could cause a worse case of chicken pox).

     -- Although there are no longer-term side effects from the steroids given for croup, some children get headaches, grouchiness, moodiness, an increase in appetite, or stomachaches while they are taking them or for a few days after the shot.

     -- If the liquid forms of the medicine do not taste good to your child, the liquid can be mixed with something to drink (such as a small amount of juice or chocolate milk) to make it taste better. Many pharmacists recommend flavoring this medication.

 

      Cough and Cold Medicines: If you choose to try a cough and cold medicine, here is one you may find helpful. Please realize more coughs of croup will not be better with these medicines. All of these have a cough suppressant (dextromethorphan, usually called "DM").

       Other cough medications are discussed on the Coughs, Colds, Allergies, and Sinus Infections protocol.

     

     Delsym® Children’s 12 Hour Cough Liquid 4-5 yrs.: 2.5 ml.; 6-11 yrs.: 5 ml.; 12 years and above: 10 ml. Every 12 hours.

                                                                                                               -- Dr. Tim Teller, M.D. -- Hilliard Pediatrics, Inc. – 8/2023  

 

 

 

Allergic Rhinitis ("Hay Fever") - an update!

Introduction.

     Allergies are a common health problem. At least 1 out of 5 people have allergic rhinitis sometime in their life. Allergies run in families (are genetic) and often occur in children with asthma, eczema, and food allergies. Allergies take some time to develop. Although you might be “born to have allergies” because of a history of them in your family, they often take 2 years or more to develop. For the rest of this information sheet, when I say “allergies” I am referring to what is technically called allergic rhinitis and allergic conjunctivitis. See below.

 

Symptoms of Allergies.

     Allergies cause a number of different symptoms. Allergies never directly cause a fever. Not everyone with allergies have the same symptoms, but there a number of common signs to look for:

-- runny nose                                    -- itchy nose                                      -- congested nose

-- clear nasal mucous                       -- itchy eyes                                      -- watery eyes

 

Common Allergy Seasons.

      Some allergies have a regular season, based on when the plant is releasing pollen into the air. These dates are based on Central Ohio seasons. Specific pollen counts are available online.

Ragweed: From early to mid August until late October (it takes 2 good over-night frosts to stop the ragweed from pollinating).

Trees: From March thru May. Remember that the fluffy stuff you see floating down from the trees is not the pollen itself, even if that is when the pollen is being released by the trees.

Grasses: From April thru early July.

Dust mites: From Fall until Spring, when we have our homes closed up and we are running the furnace. Dust mites live on fabrics such as clothes, bedding, carpets, and furniture.

Molds: There are two categories of molds that cause allergic reactions. One type is worse when it is damp and will worsen when it rains or moisture is trapped under fallen leaves (in the Fall). This type of mold is what often is in damp basements. Another type of mold likes dry conditions and can act up even when it has not rained recently. Molds often cause symptoms around Christmas time from live trees that are brought into the house.

 

Allergies that do not have a Season.

Pets: Exposures to pets happen at all times of the year. We expect the symptoms to be whenever someone is around the pet. Although any pet with fur (hair) can cause an allergy, cats are the most likely to cause allergies, followed by dogs. The hair, skin, and saliva cause the symptoms. A cat that sleeps on your bed or favorite chair will leave behind enough hair and dander that you will have allergy symptoms even when the pet is now somewhere else in the house.

Dust mites and Molds: If they are in your house and you are sensitive enough to them, you may have allergy symptoms to dust mites and molds year round. They will be expected to be worse when the house is closed up when the air conditioner or furnace is running.

 

Treatment for Allergies.

     The most effective treatment for allergies is avoiding the thing your child that causes your child’s allergies. In real life, this is not very practical. Your child wants to play outside, go to grandma’s house where the cat causes them to sneeze, and roll in the fallen leaves.

     The second most effective treatment is immunotherapy, also called allergy shots. Allergy shots work by desensitizing you to those things that cause your allergy symptoms. You are given shots on a regular schedule (usually weekly to start and then spaced out to 2-4 weeks) of tiny amounts of the proteins that trigger your allergies. Over time, you become less and less allergic. Depending on your symptoms, sometimes the shots are given for a few years and sometimes much longer.

     The most common treatment for allergies is medication. They can help many children and adults with allergies, but they do not “cure” the allergies. Almost all of the medications are available over-the-counter without a prescription, while a few of them require a doctor’s prescription. The medications that help with sneezing, itchy eyes or nose, and runny nose are antihistamines. These include Claritin® (loratadine), Zyrtec® (cetirizine), and Allegra® (fexofenadine). For the stuffy nose and congestion, many children will try decongestants, such as pseudoephedrine and phenylephrine. There is a prescription strength medicine that can help for chronic congestion called Singulair® (montelukast). For eye itching that does not respond to antihistamines by mouth, we recommend allergy eye drops. These include Zaditor® (ketotifen) and Patanol® and Pataday® (olopatadine). For nasal allergy symptoms (runny nose, congestion, sneezing, itchy nose) that do not improve with the above medicines, we recommend a nasal steroid spray. These include Rhinocort® (budesonide), Flonase® (fluticasone), Nasacort (triamcinolone), and Flonase Sensimist® (fluticasone). These steroid sprays are available over-the-counter. Astepro® Allergy Nose Spray is an anti-histamine nasal spray that is available without a prescription.

 

Specific ideas for avoiding what causes your allergy symptoms.

Grass: During the grass pollen season, playing in the fresh-cut grass will cause the most symptoms. If after playing outside in the grass, someone’s symptoms are bad, try having them take a shower and changing clothes to get the pollen off their hair, skin, and clothes.

Molds: Bringing live plants and trees from outside to inside your home will dramatically raise the mold count in your home. Changing from a live to an artificial Christmas tree will help. Also, avoid raking leaves when the leaves have gotten damp (it is better to wait when they are dry). The dampness makes the mold count greatly increase.

Dust mites: Dust mites live on carpets, rugs, bed clothes, clothing, couches, and chairs that have a fabric covering. They are often worst when the house is closed up and the furnace circulates them through the house. Since the bedroom can be a likely place to get exposed to dust mites, placing dust mite covers on the mattress and bed pillows can be very helpful. Wash the sheets and blankets at least once a week in warm to hot water to remove the dust mites. Remove carpets from living areas and clean rugs and carpets frequently to remove dust mites. An air filter (“HEPA filter”) also can help remove the dust mites.

Pets with fur: If you have a cat or dog that causes your child’s symptoms, do not let the pet in their bedroom (especially their bed), try to avoid having the pet lick your child, vacuum frequently to remove the pet hair, and consider having your dog live outside rather than inside.

Ragweed, other weeds, and trees: keeping the windows closed and running the air conditioner helps decrease how much of the air-borne pollen your child will be exposed to.  

 

What to do for your children’s allergy symptoms.

If you see seasonal and year-round allergy symptoms and your child is at least 2 years of age: try one of the over-the-counter antihistamines. These medicines can safely be given every day or as needed. Consider adding a nose spray if the antihistamines do not help or if they antihistamines cause side effects (especially drowsiness).

If your child’s symptoms do not improve with the over-the-counter medications, contact our office during regular office hours. Your child may benefit from an appointment to discuss other options.

When it is time to see an allergist for allergic rhinitis: 1. If maximizing what we can with medications does not help your child’s allergy symptoms. 2. If the allergies now cause your child to wheeze. 3. If you want to know if your child is allergic to a pet (especially if you plan on getting rid of one).

If your child’s allergies improve with the medication and they need the medicine during certain seasons, just keep using the medication as needed. If it seems to stop working, we can discuss other possibilities.

Note that ongoing research into diphenhydramine (Benadryl®) shows that, although it may help with allergy symptoms, the side effects (especially drowsiness) are enough to not routinely recommend it for allergies at this time. We would recommend Claritin®, Zyrtec®, or Allegra® instead.

If one of the Claritin®, Zyrtec®, or Allegra® is not working well, try another one. It is not unusual for one of these to work better than another in some people.

If the antihistamines are not working well on their own, add a nasal spray. Astepro® works best for sneezing and runny nose (as it is an antihistamine), while the inhaled steroid nose sprays (Flonase®, Nasacort®, etc.) work best against congestion.

The least volume of spray and the least scent of any nose spray for allergies is Flonase® Sensimist.

 

Medication Dosing.

Claritin® Syrup 2-5 years of age: 5 ml. once a day. 6 years of age and above: 10 ml. once a day.

Claritin® Reditabs 24-Hour 6 years of age and above: 1 dissolvable tablet once a day.

Claritin® Reditabs 12-Hour 6 years of age and above: 1 dissolvable tablet twice a day.

Claritin® Children’s Chewables 5 mg. 2-5 years of age: 1 once a day. 6 years of age and above: 2 chewables once a day.

Claritin® 10mg Tablets 6 years of age and above: 1 tablet once a day.

Zyrtec® 10mg Tablets 6 years of age and above: 1 tablet once a day.

Zyrtec® 5mg Chewable Tablets 2-5 years of age: 1 tablet once a day.

Zyrtec® 10mg Chewable Tablets 6 years of age and above: 1 tablet once a day.

Zyrtec® Children’s Allergy Syrup 2-5 years of age: 2.5 ml. once a day. 6 years of age and above: 5 ml. once a day.

Allegra® Oral Suspension 2-11 years old: 5 ml. twice a day.

Allegra® ODT Orally Disintegrating Tabs 6-11 years old: 1 tablet twice a day. It dissolves on the tongue.

Allegra® 60mg Tablets 12 years of age and above: 1 tablet twice a day.

Allegra® 180mg Tablets 12 years of age and above: 1 tablet once a day.

Zaditor® Ophthalmic Solution 3 years of age and above: 1drop twice a day, every 8-12 hours.

Patanol® Ophthalmic Solution 3 years of age and above: 1 drop twice a day, every 8-12 hours.

Pataday® Ophthalmic Solution 3 years of age and above: 1 drop once a day, every 24 hours.

Flonase® Allergy Relief Nose Spray 2-11 years of age (use Children’s Flonase): 1 spray per nostril per day. 12 years and above: 2 sprays per nostril.

Flonase Sensimist Allergy Relief Nose Spray 2-11 years of age (use Children’s Flonase Sensimist): 1 spray per nostril once a day. 12 years of age and above: 2 sprays per nostril once a day.

Nasacort Allergy 24-Hour® Nose Spray 2-11 years of age: 1 spray per nostril once a day. 12 years of age and above: 1-2 sprays per nostril once a day.

Rhinocort (budesonide) Allergy Spray 6-11 years: 1 spray per nostril; 12 years of age and above: 1-2 sprays per nostril once a day.

Astepro Allergy Nose Spray 6-11 years of age: 1 spray per nostril every 12 hours. 12 years of age and above: 2 sprays per nostril every 12 hours.

                                                                                    -- Dr. Tim Teller, M.D. -- Hilliard Pediatrics, Inc

Do we recommend the COVID vaccine for our patients?

 As of today, June 12th, 2021, the COVID vaccine is approved for 12 years of age and above. We strongly recommend it for our patients. From all available evidence it is safe and highly effective. We currently have the Pfizer vaccine (this is subject to change and I highly recommend you check our website for up to date information about our COVID vaccine clinics) and have given it to hundreds of adults and children 12 years of age and above. 

Some benefits of the vaccine: helps prevent the illness, helps prevent the spread of the illness to those in poor health, helps prevent the spread of the illness to those who cannot receive the vaccine, and eliminates having to quarantine after possible exposure if the vaccine-recipient has no symptoms.

We are happy and proud to have been able to serve the community during this challenging pandemic by vaccinating adults and teens with the COVID vaccine! We look forward to approval of the vaccines for children 11 years of age and below.  

Swimmer's Ear Season!

Swimmer’s ear is a common childhood infection where bacteria infect the skin or lining of the ear canal. It most commonly seen after swimming, but it can occur after long showers or getting the ears damp with baths. Swimmer’s ear is more common when the water is untreated (ocean, lakes, ponds). Often the outer ear will be tender when tugged or pushed. We want to see these children with possible swimmer’s ear in the office for an accurate diagnosis. You can help prevent this infection by using swim ear plugs or putting over the counter drops (SwimEar® and AuroDry® are two brands) in the ear canals after swimming (note: these prevention drops should not be used for a child with ear tubes).

Coronavirus and COVID-19

Introduction

     Coronaviruses are a group of viruses that cause illnesses in humans, mammals, and birds. In humans, the viruses typically cause respiratory illnesses. In 2019, a new (“novel”) coronavirus infection was first found in China. It has been named COVID-19. Since that time, the infection is spreading to other countries. As of 2/4/2020, the countries with the most widespread numbers of coronavirus infections are China, Japan, South Korea, Iran, and Italy. However, many other countries have had some cases and this list is likely to expand as the infection spreads. Because this is a new viral strain, people are not immune to it from a prior infection.

How The Illness Presents

     COVID-19 presents with symptoms similar with influenza: fever, cough, and fatigue. Sore throats and shortness of breath have been less common at the start of the illness. As with influenza, most of the cases of breathing difficulty (respiratory distress) are occurring later in the course of the illness – the average is 8 days after the onset of the illness. It is the respiratory distress that has caused the deaths associated with the COVID-19. A patient with COVID-19 infection with respiratory distress will be breathing hard and fast, as well as coughing very frequently.

     Most of the severe infections have been in adults, especially older adults. The more severe infections are also in those with underlying medical conditions, such as asthma, heart conditions, and diabetes. As with other respiratory illnesses, there will be some persons with COVID-19 infection where the illness is very mild.

Testing For COVID-19

     There are tests for this virus. The testing is NOT available at this point in doctor’s offices and urgent cares. The testing is more available through large hospitals, emergency departments, and health departments. At this time, we do not have this testing available to us.

     Who should be tested? If someone with worrisome symptoms with a known exposure to someone with the virus OR recent travel to a country where the illness is more wide-spread (China, Iran, Japan, South Korea, Italy). Realize, if a child had a possible exposure or concerning travel history AND had a cough, fever, and respiratory distress, they likely have another virus – often influenza with pneumonia.

What To Do

     If your child has traveled to a country where the virus is more common OR they have had an exposure to someone known to have the infection AND has a fever and cough, especially if they have breathing problems, they should be seen at the pediatric emergency room. You should CALL AHEAD to alert the emergency room before you arrive to discuss how to avoid exposing others to the infection.

     As with avoiding all common respiratory viruses, frequent hand washing, avoiding places where ill people may be (large gatherings), and covering your nose with sneezing and covering your cough. Wearing a mask Is appropriate IF you have symptoms, but it is not currently recommended if you are trying to avoid getting the virus.

     This information will very likely change quickly. The www.cdc.gov website is an excellent source of up to date information.

Dr. Jeff's retirement on April 30, 2018

     We are fast approaching Dr. Jeff's retirement on April 30th, 2018!
     Dr. Jeff founded Hilliard Pediatrics in 1990 after finishing his pediatric residency at Columbus Children's Hospital. Starting a practice on your own meant seeing all the patients, taking all the nighttime and weekend call, and seeing both healthy newborns and children hospitalized at Children's Hospital.           The practice grew and grew with Dr. Jeff's hard work and excellent care. 
     Over the years, the office has moved locations - from Leap Court to Berry Leaf Lane (in 1996) to Trueman Court (2011) - and grown as other doctors joined the practice.
     Dr. Jeff has been passionate about Hilliard Pediatrics, his family, sailing and painting, and the environment. Dr. Jeff has run marathons, raised bees, painted exam rooms and portraits, and had some great life adventures.
     What has never changed is Dr. Jeff providing excellent pediatric care for his patients. The patients will miss him and we at the office will sure miss him. He will be remembered for his dedication to his patients, his infectious laugh, and how many lives he positively impacted.
     Thank you Dr. Jeff for all that you have done!

Dr. Mike Patrick's Pediacast pediatric podcasts

     Dr. Mike Patrick, M.D. from Nationwide Children's Hospital has a podcast called Pediacast that has an amazing amount of information for patients and families. I highly recommend it! He and guests cover many topics. If you are unfamiliar with it, http://www.pediacast.org/ is the web address. It can also be found wherever you find other podcasts (iTunes, etc.).