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.).

Is it too late to get the flu shot?

     The simple answer is no. It is not too late to receive the flu vaccine if you or your child has not yet received it this season.
     The influenza season started early this year. By late November, a number of cases were appearing in Central Ohio. The season usually runs from December through March.
     Although a report out of Australia reported that the vaccines effectiveness versus the H3N2 strain (one of 4 in the vaccine) was only 10% last year, the Centers for Disease Control and Prevention report the U.S. effectiveness was between 30-40% (significantly better) and it is likely going to be closer to that percentage in the U.S. this influenza season. Here is a link to more information from the CDC.
     We have been out of the vaccine since early November. But there are other ways to get the vaccine:
1. The Franklin County Health Department is able to give the vaccine to those 6 months and above. You can schedule an appointment to receive the vaccine by calling 614-525-3719 or going to www.myfcph.org/shots to make an appointment.
2. The urgent cares staffed by nurse practitioners (such as Minute Clinics) are able to give the vaccine to children 18 months or 24 months and above (it varies). Check here for more information.
3. Many pharmacists are able to give the flu vaccine to those 7 years of age and above. Check with your favorite pharmacy for more details.

Storing Breast Milk and Formula

     We are frequently asked in the office about how long breast milk and formula can be safely stored. The major risks for going past this limits is accidentally introducing an unhealthy bacteria to the infant ("spoiled milk") or the breast milk or formula having its ingredients break down.
     Although you can find a wide variety of guidelines on the Internet, I find it easier to keep it simple to remember: follow the Rules of Six for breast milk storage. Breast milk can be safely consumed if stored for 6 hours at room temperature, 6 days in the refrigerator, and 6 months in the freezer. If the breast milk is kept in an insulated cooler bag, it should be used within 24 hours.
     The guidelines for formula are different. A bottle of formula should be kept at room temperature for no more than 1 hour. Formula prepared from powder then stored in the refrigerator should be used within 24 hours. Formula prepared from concentrate or ready-to-feed formula may be stored in the refrigerator for 48 hours. A can of powdered formula should be used within 30 days of opening.
     Here is a link to some more detailed information about safely storing breast milk from the Centers for Disease Control. Here is a link to an article about storing infant formula from Healthy Children.

Updated Information on the Prevention of Tooth Decay

     In the 23 years I have been in practice, the recommendations about fluoride and children has changed. Although there is great deal of information supporting the safe use of fluoride to prevent tooth decay, recommendations about how much and how often have frequently changed. Here is an updated description of the current recommendations.
     One note: you can find a lot of misinformation on the Internet. And a great example is the misleading, non-scientific, and sometimes outright false and outrageous anti-fluoride information on the Internet. Do not believe this misinformation. It safe to use fluoride to prevent teeth decay.
     The current recommendations:
1. It is helpful to have your child drink fluoridated water and to cook using fluoridated water. In Central Ohio, our public water supply has fluoride added. Drinking bottled water does not reliably give enough fluoride. Most household water filters do not remove fluoride, but it is worthwhile making sure (by reading the filter's information).
2. Once babies have their first teeth, brush their teeth daily with a grain of rice sized amount of fluoride containing toothpaste. Once they reach 3 years of age, it should be a pea sized amount of fluoride containing toothpaste.
3. Routinely see the dentist by 3 years of age, sooner if recommended by the pediatrician.
4. Fluoride varnishes are recommended once a number of teeth have extruded. We now do the fluoride varnish at 18 month, 24 month, and 30 month check ups. The kids seem to be tolerating it just fine. The varnish stays on your teeth for 4-6 hours. During those 4-6 hours, it is best to maintain a soft diet and avoid hot liquids. Do not brush or floss during that 4-6 hours after the varnish (you can resume normal dental care the next day). If you take supplemental fluoride, stop for 3-4 days after the varnish is applied.
     If you interested in reading more, here is a link to more information from the website Healthy Children.

What to do when children and teenagers vomit with exercise.

     Some athletes vomit during exercise. This can happen at younger ages, but typically occur when teenage athletes push themselves hard during workouts. There are some things to do to help prevent this issue.
     One of my teenage sons has struggled with vomiting when pushing himself during workouts. He does vomit more easily with bad coughs or stomach upset versus some other folks, but he did not have vomiting with exercise until high school.
     If someone struggles with this issue, we would ask some other questions to make sure it was not from something more complicated. We ask questions about acid reflux and and whether the vomiting happens after coughing. We ask about timing of eating and drinking when it comes to exercise.
     If nothing else is complicated about the history, there are some helpful recommendations to help reduce the chances of vomiting during exercise.
-- Eat a small snack 30 minutes before exercise.
-- Avoid exercising in extreme heat.
-- Watch your exercise intensity. The athlete may need to dial-back their intensity.
-- Stay hydrated. Drink 8 ounces of water every 20 minutes of exercise. If the exercise is going to be high-intensity for more than 45-60 minutes, drink sports drinks instead of water.
-- Cool down gradually.

     If your child struggles with this issue and is not improving while following these recommendations, call during routine office hours to discuss.
    

Why do children tell lies?

     At some point during your child's early life, they will lie to you. It is aggravating and frustrating for parents, but inevitably it happens. Our hope as parents is that it does not happen very often. Here is some more information about how to approach this issue.
     Why does anyone lie? To get what they want or to avoid punishment. "No, Dad did not give me a cookie today!" (when they have already had their once-a-day treat). "I was not running in the living room!" (when the lamp got knocked over again). "My brother was on the iPad longer than me!" (when they want more iPad time).
     Sadly, we are in a current situation where it is hard to point to well known adults that your child may look up to - athletes, politicians, etc. - as good examples of "always tell the truth". This makes it difficult when we all get mixed messages from daily life, including for children. When others see someone not tell the truth then get what they want or avoid punishment, even otherwise well-behaved children (and adults) are more tempted to not to tell the truth.
     Certainly, when you know (or are quite certain) that your child is not telling the truth, your best bet as parent is - as always - consistency. By that I mean that you should routinely give your child some negative consequences for lying whenever it happens. We all are more likely to keep repeating an action or behavior if we are not negatively reinforced for it. And we are more likely to stop an action or behavior if we are regularly and consistently negatively reinforced for it.
     Those negative consequences may be a time-out, a removal of privileges (no iPad for the day or no cookie for tomorrow), etc. Stick to your guns: if you say it ("no TV today"), follow through with it (they get no TV today). Otherwise, you are accidentally giving your child the idea that they can sometimes "get away with it".
     One more note: I think it is important to model good behavior to your children. I truly believe if you model to your child that it is important to tell the truth, they are more likely to tell the truth themselves. I recall a time my one son and I were in a fast-food restaurant. When I handed the cashier money, they gave me back too much money. I said "Here, take the $5 back. Then we are even. You gave me too much cash back." The cashier was happy and I was happy for a small moment to emphasize to my son that telling the truth is important.
     So to conclude, do not be too frustrated if your children lie, be consistent with your negative reinforcement, and - as always - call us during routine office hours if you have other concerns.

Keratosis Pilaris

     Keratosis pilaris is a chronic skin condition that is quite common. It is one of the skin issues we are asked about frequently in the office. It often appears in the first few years of life, it is worse when the weather is colder, and cannot be entirely cured. The rash rarely itches, but it does for some folks. It tends to be genetic with some families having multiple folks who have keratosis pilaris.
     Keratosis pilaris appears as small rough bumps on the back sides of the upper arms, sides of the thighs, and cheeks of the face. It tends to look flesh colored in paler skinned individuals, but can look darker pigmented in persons with naturally darker pigments. It can spread from these areas or be just in one of these areas (arms) but not others. It may worsen when the air is more dry (during the winter months when heating the house drops the humidity in the house).
     Keratosis pilaris is more common in families with allergic illnesses - eczema, allergic rhinitis/hay fever, asthma, and food allergies. Many times, a person only has some of these issues, not all. So if dad has allergies and mom has had eczema, their children could have keratosis pilaris even if they have no other of these issues.
     Keratosis pilaris is not curable. You can keep it under control, but it cannot be made to go away permanently. It keep it under control, it needs to be regularly treated. Often that treatment will be on a daily or multiple days per week.
     For many years, our go-to treatment for keratosis pilaris was a lotion called Lac Hydrin Lotion. Sadly, it appears the manufacture has discontinued the product. Some of the available products are ones you may need to check in stores and online to find. All of these products are available at Amazon.com. Here are the products I would recommend now, with the CeraVe product being the best:

CeraVe Renewing SA Lotion
AmLactin Alpha-Hydroxy Therapy Daily Moisturizing Body Lotion
Geritrex Geri-Hydrolac Lotion

If you have tried one of these for a few weeks without relief, try a different listed product. Note that many other great creams and lotions used for dry skin (Eucerin, Aveeno, Cetaphil, or other CeraVe products) often do not work on keratosis pilaris.
     If all else fails and the rashy bumps are bothersome, we often refer a patient to a dermatologist for further help.

Prenatal Meetings With the Pediatrician

     Many pediatricians hold meetings with expectant families. This allows parents who are expecting their first child to meet with the pediatrician before the birth of their child. This allows you to meet the doctor, see the office, and ask questions.
     We call these meetings "prenatals". We schedule those with one of our doctors and a handful of couples. They are scheduled in the early evening and we meet in our lobby. The doctor will tell you more about themselves, our office, and what you can expect at the hospital and with bringing your child to our office. We will show you our exam rooms. You will have an opportunity to ask questions of the doctor. The meetings usual last 20 minutes or so. If there are a number of questions, they can go longer. If you see a particular doctor at a prenatal, we anticipate that you will have that doctor as your primary care doctor here in the office.
     You do not need to do a prenatal to bring your newborn to our office. You also will not need to let us know prior to the birth of your infant that you are bringing your infant to our office. In other words, you do not need to tell us at the prenatal that you will bringing your child to our office.
     If you are interested in scheduling a prenatal meeting with a doctor here in the office, call our routine office number 614-777-1800 during routine office hours and speak with the front office staff.

What happened with your flu shot supply?

     You may be asking yourself this question: what happened with Hilliard Pediatrics flu shot supply?
     I will answer that. But some background. We order the vaccine from a supplier. Most offices place their order in February to receive the vaccine in August to September. How do we determine how much we order? We look at previous years supply and use and make an educated guess. The year that FluMist went off the market, we dramatically increased our flu shot order to have enough vaccine for those who had received the flu shot and those who received the FluMist in the past.
     We have about 10,000 patients. If we gave each of the infants two doses and all the older children 1 dose a year, we would go through more than 10,000 doses a year. We do not use that many. We realize some families do not vaccinate their children with the flu vaccine routinely. Other patients receive the vaccine in other places.
     Last year, it was the second year without the FluMist. We felt like the demand in the office was steady but not high. By the end of January, we ran out of our supply and most of the families seeking the vaccine from our office received it here. Typically we run out of the vaccine between late November and early January.
     This past Winter, we placed our current order for the same number of flu shots as last year. Although we added a new doctor, our total number of patients has not changed much. We received the vaccine in August (earlier than some years) and then began vaccinating our patients. As usual, we were giving the vaccine in the office and check-ups and (were appropriate) sick visits. We also had our usual flu shot walk-in clinics. How busy each flu shot clinic is seems to vary over the years. This year, we were less busy than usual until the last few clinics where the numbers went up.
     The week before we ran out, we realized we would need more vaccine. When we called, we were initially told we could order as much as we needed. After discussing in the office, we called the next day to be told the previous days information was in fact not true -- they could not supply us with any further vaccine.
      We have been asked why we do not hold back vaccine for the youngest of patients who need a second dose. We do not do that. In fact, we could not as we believed up until the last minute that we could order more vaccine. And we fully intended to order more. There other logistical issues with holding back vaccine to give to someone else.
     So what about next year? Surely we will order more vaccine. But we have found that each year has its challenges. We appreciate that many of our patients are able to and do receive the vaccine in the office each year.
   
   
   

Children with Easy Bruising Who Take Fish Oil Supplements

     We are asked regularly about children who bruise easily. If children have impressive bruises that occur after minor injuries, we will likely ask about your child's history with other issues that make us worry about a bleeding disorder. These questions include:
     Does your child have easy bleeding with minor mouth injuries or teeth cleaning?
     Does your child have frequent or hard to stop nose bleeds?
     Has your child had excessive bleeding after minor procedures?
     Does your child pass blood with a bowel movement?
     Has your child had painful, swollen joints after minor injuries?
     What medications or supplements does your child take?

     A combination of history and physical exam can prompt us to do screening labs or a referral to the hematologist at Nationwide Children's Hospital. Other histories and physical exams are reassuring.

     On a personal note: I spoke with my eye doctor in the last year about my eyes being dry. I had already tried some other remedies, so my eye doctor recommended that I try taking fish oil supplements. I began taking Occuvite and noted only so much improvement. I then switched to a higher dosed supplement, this time Member's Mark Triple Strength Wild Alaskan Fresh Fish Oil Softgels with 900mg of Omega 3. At my annual check up last week, I mentioned my easy bruising this year and the first thing my doctor said was "It is those Omega 3 supplements you take!". So now I am weighing the "eyes less dry" with the "easy bruising" tendencies.

     So a good thing to know is that fish oil/omega 3 supplements can increase the tendency to easy bruising. If your child is regularly taking these supplements, let your doctor know this if they are going to have surgery or if they have been prone to easy bruising.

Safe Sleep for Newborns and Beyond

     My oldest son is now 22 years of age. Back in 1990's, the cribs had wide enough slates that it was possible to get an arm or leg stuck between the slats. This prompted it to become nearly universal to use bumper pads to keep the arms or legs getting stuck and to pad the area so an infant would not "get hurt".
     This was not the safest sleep environment. We know now that there were more cases of SIDS and injured arms and legs with that setup. Now the slats are close enough to prevent these issues and it is recommended to not use any bumper pads. The chairman of the Consumer Product Safety Commission, Elliot Kaye states "I reiterate my belief that the public should stop using padded crib bumpers. The overwhelming evidence show that they do nothing more than contribute to the deadly clutter in many of our nation's cribs. Based on the real risk they present, it is a mystery to me why they continue to be sold." I agree.
     The Ohio legislature recently passed a law, Sub Senate Bill 332. It includes a bumper ban. I believe it goes into effect at the end of 2017. The law prohibits the manufacture or sale of non-mesh crib bumpers. The law allows for the sale of mesh crib bumpers for the next 3 years. The law will then ban the mesh crib bumpers if the Consumer Product Safety Commission (CPSC) has not created safe standards for mesh crib bumpers.
     "Bumpers are unnecessary and pose a real risk to the safety of infants." - Dr. Sarah Denny, Nationwide Children's Hospital.
     For more information about safe sleep for infants: here on the Ohio AAP website.

2017 Flu Shot Walk-In Clinic Dates and Times

     It is the flu shot season! We have a good supply this year of the flu shot. We are announcing the dates for walk-in flu shots for Sept.-Nov. 2017. Depending on the supply, we will schedule further dates in the Fall. We have shifted the weekday clinic date to Wednesday from Thursday (to accommodate our exam room needs in the office).
   
     Wednesday clinics are from 2-5 p.m. Saturday clinics are from 9 a.m.-12 noon.
     Wednesday dates: September 13, September 27, October 11, October 25, and November 8.
     Saturday dates: September 23, October 7, October 21, November 4, and November 18.

     We occasionally have to cancel/reschedule dates due to our supply of the vaccine. We will announce on the Hilliard Pediatrics Facebook page (maintained by Dr. Tim) if that occurs.

Solar Eclipse Safety

     Here it comes! The solar eclipse! Exciting as it is a fairly rare event. Now let us experience it safely!
     I love the Healthy Children website. Here is their article about safely enjoying the solar eclipse. Here is an article about eye safety during a solar eclipse from the American Academy of Ophthalmology.
     Be safe out there!

Car seat and car safety website

     I became aware of a very nice, accurate website recently. It is maintained by the National Highway Traffic Safety Administration. It has lots of resources regarding proper car seat use, safety tips for teen driving, and other safety information regarding cars. The website can be found at the Safer Car website.