Wednesday, September 24, 2014

When to start fluoride toothpaste for your child.

     I have now been a pediatrician for 20 years. During that time, the amount and timing of giving fluoride to children to protect their teeth has changed every couple of years. Pediatricians have a hard time keeping up with the latest recommendations. We realize it can be difficult for parents to keep up to date about fluoride recommendations.
     Fluoride is a safe way to prevent "dental caries" or cavities of the teeth. However, too much fluoride can cause "dental enamel fluorosis", which is a spotty discoloration of the teeth that is permanent. Fluoride is in most public water supplies (it is added to help prevent cavities), so many people have tap water at home with a good source of fluoride. Here is a good source of information about whether your wattle supply has added fluoride to protect the teeth. Bottled water that you can purchase has some fluoride in it, but the amount can vary widely. Bottled water also very rarely lists how much fluoride is included. Well water usually does not have fluoride in, but occasionally it does. The water can be tested to determine how much fluoride is in the water. Here is more information from the CDC about fluoride in well water.
     We have recommended against using fluoride toothpaste for young children as they could easily swallow too much toothpaste, increasing their risk of the excessive fluoride staining the teeth. The previous recommendation was to wait on fluoride containing toothpaste until the child could spit out the toothpaste after brushing. We found this was often 2 1/2 or 3 years of age. The recommendation now is to use fluoride toothpaste for children as soon as the first tooth erupts (breaks through the gums). But until age 3, use just a "smear" or the size of a grain of rice. After age 3, a pea-sized amount of fluoride toothpaste is recommended.
     Our recommendation is to follow the above recommendations: Once your child has their first tooth, start using a grain of rice sized smear of toothpaste with tooth brushing. After the 3rd birthday, use a pea-sized amount of toothpaste. We will keep you updated as the recommendations change!

Sunday, September 14, 2014

HEV 68

     HEV 68 is a human illness first recognized in 1962 as a cause of pneumonia and wheezing. It has occurred on occasion over the years since then but is being recognized as a major cause of respiratory illnesses in children in 2014 in the Midwest states. There was a cluster of cases in children in St. Louis, Missouri prior to the illness appearing in large numbers in August and beyond in Central Ohio. Cases are occurring throughout the Midwest as well. Children are more ill than adults with HEV 68. The peak age nationally has been 4-5 year olds, with an age range of 6 weeks of age to 16 years of age. Many children may have mild upper respiratory illness symptoms with HEV68, but some children will wheeze with the illness (even if they have never wheezed before) and show signs and symptoms of respiratory distress.
     The enterovirus family of viruses also causes hand-foot-and-mouth disease, aseptic meningitis, and paralysis, along with more milder illnesses with rashes or vomiting and diarrhea illnesses. The HEV68 also called EV-D68) has typically caused nose and throat congestion, cough, headache, chills, achiness, runny nose, sore throat and occasionally fever. Like other upper respiratory viruses, HEV 68 is believed to be spread by coughing, sneezing, and touching items after touching the face, nose, or mouth. Because it is a virus, antibiotics have no effect on the course of the illness. Although we believe all eligible children should receive a flu vaccine each year, the flu vaccine will not effect whether someone becomes ill with HEV68.
     What is causing hospitalizations with HEV 68 is respiratory distress and oxygen requirement. These children are breathing faster, coughing frequently, retracting (muscles of the chest, belly, and neck working to help them breath), and often wheezing such that you can hear it without a stethoscope. The cough sounds moist and mucousy, not dry and barky (such as with croup -- which is also going around). The wheezing and other breathing problems caused by HEV 68 have responded well to the same treatments that we use for asthma: albuterol and prednisone. The albuterol is often given as a nebulized or aerosol treatment. Some children, especially older children, will respond to albuterol treatments with an inhaler. The prednisone helps the breathing issues by fighting the inflammation in the chest. Children not responding to outpatient treatments with albuterol and prednisone may need to be hospitalized at Nationwide Children's Hospital for close monitoring, further treatments, and possibly oxygen.
     Since most children have milder symptoms, who needs to be seen promptly for respiratory symptoms? It turns out, the same signs and symptoms we would always caution you about:
1. Breathing rapidly (especially more than 50-60 breaths a minute).
2. Retracting (seeing the skin around the neck, chest, or belly sink in and move out with each breath).
3. Wheezing you can hear without a stethoscope.
4. Frequent coughing (if your child is coughing every 30-60 seconds, they need to be seen).
5. Blue lips or blue color around the nose and mouth.
6. Passing out because of difficulty breathing (if this occurs, call 911).
If these are going on, your child needs to be seen right away: call during routine hours, come in for walk-ins at 8 a.m., go promptly to Nationwide Children's Hospital, or to the emergency department at Nationwide Children's Hospital. So many cases have occurred at the hospital (and because it is acting like asthma), it is being referred to as "Asthmageddon".
     If your child has routine upper respiratory symptoms without the worrisome symptoms, watch carefully over the first few days or week of the illness to make sure the symptoms do not worsen as detailed above. The children we have seen so far seem to have milder symptoms for a day or two before worsening -- it does not take much time into the illness to notice worsening symptoms if they are to occur. Most of the children with worse symptoms seem to improve after about a week.
     Many things we do not know yet: How long this outbreak will last? Just how contagious is it? Will many families with one child with it have it spread throughout the house? Are most children in the community with "just a cold" ill with this virus? How many children are getting a fever with HEV 68? Will these children go on to develop further wheezing episodes or asthma down the road? We will know more in the coming months.

Tummy Gas

     I am often asked about gassiness. The gas in our stomach and intestines is both swallowed air and created in our gut as we digest things that we eat and drink. That is true with infants, children, and adults. The gas is normally passed from above (belching or burping) and below (flatus or farting). Many times the gas does not cause any significant pain. So what is important is whether the gas causes pain. Many times the stomach discomfort happens first and we do not know that is the culprit is gas until it is relieved. A full, uncomfortable belly in a toddler that is relieved by passing gas or an infant that fusses for 20 minutes until they pass gas then calm down are good examples. Babies that pass gas frequently but are not uncomfortable are thought to be just fine -- we do not consider that gas to be a problem. In that case, the swallowed gas or created gas is just moving through their system.
     Is there anything we can do to reduce or relieve the gas that is swallowed? Yes. (1). For breastfed infants, a good latch helps them swallow less air. For bottle fed infants, the nipple and bottle combination may make a difference. Sadly, there is not one perfect bottle for every baby. In fact, if the bottle/nipple combination your infant is using is not working for them, you may have to try a few. Some brands that may be helpful: Dr. Brown's, Evenflo Pure Comfi, Playtex with drop-in liners, and Bare Air-free. (2). For infants bothered by the gas they swallow, making sure you do your best to burp them well after the feedings. Young infants may need to be burped after each breast or ounce of formula or pumped breast milk. (3). Simethicone (as generics and name brands such as Mylicon©, Gerber©, and others) gas drops can help some infants. The simethicone breaks up the gas into smaller, more comfortable gas bubbles. For infants, the dose is 0.4 milliliter by mouth as often as every feeding. Simethicone is very safe and can be used every feeding for as long as your child needs the drops. 2-11 year olds, the dose would be 0.4 milliliters per dose.
     Is there anything we can do to reduce and relieve the gas produced in the intestines? Yes. (1). Here is a terrific recent article in our Columbus Dispatch that has a great review of the issue with a chart of the low-FODMAP foods and beverages (I realize you may need to be a Dispatch subscriber to fully access this article). Another good source of information is here from Stanford. If your breast-fed infant has troubles with gas, the most common food and beverages we suggest avoiding for the mother are milk and dairy, asparagus, peas, and cabbage. But as you can see from the FODMAP information, there are MANY foods that may cause more gas. You will likely need to do some detective work at home to discover what you eat or drink that causes more gassy discomfort for your infant. Dramatically reducing or stopping your intake of those things that bother your infant should help your infant. (2). For infants who are formula fed, there are many infants bothered by gas who improve with a formula change. Similac Sensitive©, Similac Total Comfort©, and Similac Soy Isomil© are the formulas that I would recommend if you are going to try something different, in that order. Give a new formula at least 5-7 days to see how it works because it takes 3 days for the previous formula to get out of their system.(3). Massaging a baby's tummy can help if they are crying with gas. Gently massaging in a clock-wise motion is recommended. You can use some baby oil to lubricate your fingers.
     For toddlers and older children bothered by tummy gas, consider these things to help: (1). Encourage chewing with the mouth closed. (2). Encourage your child to eat slower. (3). Avoid carbonated beverages, such as sodas. (3). Consider changing the food and beverages that your child takes in -- especially milk and dairy. Check out the FODMAPs data for other ideas of foods to reduce or eliminate. As said before, it can take some significant detective work at home (consider a food dairy) to figure out what aggravates their tummy and what helps. (4). Consider the simethicone gas drops. Just 0.4 milliliter by mouth every 4 hours or every meal may help reduce the gas pain.
     Call during regular office hours if the above measures are not helping your child or you have other questions not answered here.