Posts for: May, 2012
9-week old Natalie was seen recently for her 2-month well child visit and her Mom is back today with concerns about sneezing, clear runny nose and newborn not tolerating breastfeeding well. Mom grabbed a bottle of nasal decongestant from the store and wants to know if it’s ok to give a “tiny little bit” to the baby.
Natalie had no other concerning findings and no fever. Her physician makes the determination that this is a cold infection and likely caused by a viral infection. Walk with us as we share some facts about colds in young children and the role of nasal decongestants and ahhh..., Antibiotics.
For young children with findings as described above with no perception of increased effort of breathing and a normal physician evaluation, supportive therapy or comfort measures are all that is necessary. Newborns are obligate nose breathers and really get fussy when compelled to choose between breastfeeding or bottle feeding and breathing through partially blocked nostrils. It really is nerve-wracking for both the newborn and mother! Over-the-counter Saline Nasal drops to loosen the congestion and encourage spontaneous drainage with gravity and with gentle suctioning with bulb suctioning will be appropriate for most situations. Clear nostrils makes breathing easier and encourages better suckling on the nipple and thankfully, a happier infant.
The use of nasal decongestant medication like Natalie’s mom intended to, should be discouraged. These products contain medications that are effective in reducing congestion but have not been shown to be safe in children younger than 6-years old. Some of the common chemical names to watch out for on product labeling include: phenylephrine, oxymetazoline and pseudoephedrine. A disproportionately high number of adverse effects and death was seen with use of products containing these chemical medications in different amounts in children aged less than 2-years in a survey of cases between 1969 to 2006 by the United States Food and Drug Administration. This informed the 2008 advisory strongly recommending against use of products containing these medications in this age group which stands to date. The comfort measures as described above will suffice. The posterior nasal airway congestion is also helped by the Saline Nasal drops and gravity as these drain into the throat when child is positioned on the back for sleep and it flows posteriorly and is swallowed into the stomach. Suctioning with the bulb should be gentle and carefully done to avoid trauma to the lining of the nostril. This trauma can worsen the congestion and lead to increased noisy breathing and more discomfort for infant and distress for the parent.
The nasal sinuses are present at birth and new ones form and enlarge as we all age and this is one of the reasons why facial appearances change through infancy and childhood. There are more potential viral infections that favor the nasal airways and the upper respiratory system than modern science can accurately track. They cause their mischief and for the most part begin to improve within the first 3-5days of the illness. Antibiotics do not kill viruses and have no role in the management of a physician documented viral upper respiratory infection. There are powerful medications capable of killing some of the medically important viruses. These are used in select situations only and not routinely prescribed for common cold infections. Occasionally this recovery process is hijacked by bacteria previously hanging around the upper airway as casual by-standers or new ones introduced by the patient from the environment. They take advantage of the worn-out local defense mechanisms as a result of the viral infection and nest, then flourish in the airway passages and the sinuses. The symptoms begin to follow a different course from what is anticipated and often worsen, with or without fevers and prolonged for more than 7-10 days. A physician evaluation is warranted again at this point for reassessment and proper management.
This information is for educational purposes only and not a substitute for professional medical care or advice. Always follow your healthcare provider’s instructions.
Ah! Sunshine is here- they very bounty of nature. Without it life as we know it wouldn’t exist on our beloved good green planet. We do need to be careful in how we enjoy this bounty, as lifetime risks for different forms of skin cancer can be influenced by inappropriate exposure to sunshine and repeated sunburn injury. So here comes the age old advice on sunburns and sunscreen.
If you are like many and a walk down the store aisle, leaves you wondering which sunscreen to grab for you or your children? and why is this brand so much more expensive than that brand? what do the SPF numbers really mean? We’ll share a few tips with you in this post that would help you make an informed choice.
Sunlight contains a wide spectrum of different kinds of light. We would limit ourselves to the ultraviolet (UV) light portion which is composed of three kinds described as UVA, UVB and UVC. All UV light forms are capable of different forms of skin injury.
UVA causes tanning like skin changes and little redness and burning. It also produces aging, photosensitivity and toxic skin reactions. UVA rays are present in sunlight throughout the day and the year and can pass through glass. UVB rays are the most harmful and more UVB is radiated during the summer months compared to other times of the year and is primarily responsible for sunburn, suntan, inflammation, redness, and pigmentation changes. It produces tanning more efficiently than does UVA, unlike UVA they are absorbed by glass. UVC, is especially capable of causing changes that could lead to the formation of skin cancers over time. This concern regarding UVC is often muted because it is filtered out by the ozone layer around the earth long before it gets to the earth surface and this why concerns about holes in this layer and ozone depletion are important.
Most chemical sunscreen brands block UVB but are less effective at blocking UVA rays. These products effectively screen changes that lead to sunburn from UVB, but may leave the door open for UVA to act on unhindered on the skin. Sunscreens with a broad spectrum of coverage to both UVA and UVB are preferred since they would prevent excessive exposure of the skin to UVA while protecting against UVB. Scientific data and testing in laboratory animals show that the dreaded form of skin cancer called melanoma is promoted by UVA acting on skin changes triggered by UVB rays. Broad-spectrum sunscreen products are recommended for this reason. Product packaging vary and they may be sold as gels, lotions, creams etc.
The American Academy of Pediatrics and the American Academy of Dermatology recommend sunscreen with SPF “sunburn protection factor” of at least 15. As explained above products labeled as “broad-spectrum” sunscreen should be preferably used as these protect against both UVA and UVB rays. Sunscreen use may give people a false sense of security and encourage excessive exposure. Sunlight avoidance between 10.00am and 2.00pm, along with wearing of wide-brimmed hats, use of light protective clothing, and avoiding sunbathing offer more protection than any chemical sunscreen product by itself.
Light-skinned, freckled children, have to use broad-spectrum sunscreen with a high SPF rating as this helps to decrease their risk of developing additional skin injury and skin changes that may lead to skin cancers. Proper sunscreen product selection is important, but proper use and application is even more important. It is recommended that sunscreen be applied at least half-hour before planned exposure to sunlight to allow for adequate skin absorption. The exposed skin should be evenly covered with the sunscreen with repeat applications every 2-4 hours while still in the sun. Our earlier post on sun safety discussed the peculiar situation for infants aged under 6-months and use of sunscreens.
How many shots are we getting doc? We hear this a lot in primary care pediatrics. As I run through the vaccination counseling and touching on key points in the Vaccine Information Statement, the brow crease I often see on the forehead in the visibly anxious Mom and ah! yes, the crying infant - I get the keen sense the number of shots to be administered and by attrition the pain is a far bigger concern to the family in front of me than the peculiarities of each vaccination type I’m talking about.
How can we best relieve pain in these young ones during vaccination visits? We traditionally use comfort measures that often include administration of Acetaminophen to young ones after vaccinations as an adjunct in our practice. A group of researchers conducted a well designed study, on Effective analgesia using physical interventions for infant immunizations published this month in Pediatrics, 129(5):815-22 May 2012.
The 5 S’s (swaddling, swinging, shushing, suckling and side/stomach positioning) are well known comfort measures, what’s not known is how these fare when compared to a popular method of analgesia using pacifiers dipped in concentrated sugar solution (24% Sucrose). The sucrose is believed to soothe the infant in a complex way that involves the body releasing chemical signals from within that have a lot of similarity to powerful pain medications like morphine. Sucrose dipped pacifiers are popular during procedures like circumcision.
Groups of patients with infants at their 2-month and 4-month vaccination visits were assigned into a group that received comfort measures with the 5 S’s and another group that received 24% Sucrose dipped pacifiers. Their pain response was assessed using a standardized pain scale tool. The results which were recorded over a 7-minute period of observation in both groups and scoring assessment showed that the physical interventions of the 5 S’s decreased crying time and provided proof of effective analgesia that was as effective as what was seen in the group treated with the 24% Sucrose dipped pacifiers.
Hello Moms, lets cheer up! swaddling, rocking and raining all your best TLC moves on your babies after shots works very well for pain control. Now, we can continue the vaccination counseling conversation....
Mom: Doc, Johnny has been pushing hard to go! each time he tries to poop, he strains to go because he’s constipated and I think the formula I switched to after I stopped breastfeeding when he turned 4 months, three weeks ago is responsible. I want you to give me a note for WIC to change his milk to soy formula. My neighbor says that helped her baby when he was younger.
This mother is expressing an often stated concern in clinical practice. She breastfed exclusively for the first 4 months and switched to cow-milk based formula when she found it harder to express adequate amounts of breast milk after resuming work. Breastfeeding is recommended exclusively for the first 6 months and through the first year of life. Other circumstances as in this mother affect adherence to this key recommendation. The urge to change formulas as a direct response to address perceived constipation problems as in the above scenario are very common. We’ll examine the facts together in this post.
The type of sugar in proprietary soy formulas is different from the lactose sugar commonly found in mammalian milk. The sugar type in soy formulas usually are slightly compounded forms of glucose or sucrose. These are more efficiently absorbed from the gut of young infants and are more likely as a matter of fact to result in firmer stools being passed when compared to lactose sugar based milk. They may actually make the defecation more exerting for the infant and trend towards true constipation by increasing the stool consistency.
Parents need to be counseled appropriately on newborn stool patterns. Straining in infancy is due to the developing maturation process which requires the infant to coordinate stool evacuation on many levels. This process starts by bearing down during closed expiration, followed by relaxation of the muscles lining the pelvic floor to straighten the bowel loop formed by the anal canal, all in someone lying down flat on their back! - this is usually no cake walk for the infant. Advances in age and maturation with development of trunk strength with time often make this process easier.
Pediatricians refer to stool consistency when talking about constipation in the newborn period. The passage of hard pellet-like stools, or adult-like formed stools are other clues to the possibility of true constipation in an infant. It is normal for infants like Johnny above to strain and grunt during the passage of soft-formed stools which are often pasty or “mustard-like” during infancy. The frequency of stool passage varies when breastfed and formula fed infants are compared. This variation is more marked in the first 4- 6 months of life before dietary supplements are introduced. Stool passage frequency can range from one small stool passed shortly after every feed in response to the in-built reflex that propels the gut after eating to once in a 5-7 day period in some exclusively breast fed infants.
The rush to home remedies for perceived constipation is just as as popular as formula changes and is often not warranted. Poorly absorbed carbohydrates like sorbitol in some fruit juices in the gut may aid true constipation, malt extract, Prune & prune juice etc are popular options lacking in direct evidence recommending routine use . Their use as with any intervention needs to be discussed first with your doctor if contemplating administration.
This information is for educational purposes only and not a substitute for professional medical care or advice. Always follow your healthcare provider’s instructions.
Here in Arizona- the valley of the sun, the summer comes with a good amount of warmth and sunshine as it does elsewhere. The relatively low humidity improves the tolerance of the triple digit temperatures we often get here. Proper hydration orally along with sensitivity for modifications in out door sport training programs are popular recommendations. Young children however need special precautions taken in addition.
Newborns do not move as spontaneously as we would wish when compared to older children and adults in response to a painful sensation as would happen from sustained direct exposure to sunlight. This makes them vulnerable to sunburns within a few minutes of direct sunlight exposure. More than half of a lifetime exposure to the harmful rays of the sun occur in the first 20-years of life and repetitive injuries from harmful sun rays in early life can increase the average lifetime risk and set the stage for skin cancers and related conditions over many years later in adulthood. Lightweight cotton clothing covering the extremities along with wide-brimmed hats are great options for newborns aged less than 6-months and older to prevent harmful sun rays and sunburns. Sunscreens are not routinely used in infants aged 6-months and less and are discouraged without prior review and discussion with your medical provider. Preventive measures as above and avoidance of direct exposure to sun rays with attention to shaded areas help. Sunburns when they occur can be treated with cold compresses to the affected area and Vaseline skin dressings to optimize healing.
Children aged more than 6-months still need similar precautions with weather appropriate clothing when ample direct sunlight exposure is anticipated with wide-brimmed hats, and lightweight cotton apparel. Staying in the shade whenever possible and avoidance of direct exposure to sunlight should be encouraged especially between 10am to 4pm daily when the sunshine intensity is maximal. Parents should apply sunscreen of at least 15 SPF rating or more for protection. Uniform application of adequate portions of sunscreen over exposed skin is recommended with repeat applications at 2-hourly intervals. Sun shades fitted with special lenses that filter out harmful UVA and UVB rays are helpful, however direct glare into sunlight with even these on should be discouraged. Sunburns when they occur can be painful as they often affect the superficial layers of skin where sensitive nerve endings are present. Some of the usual comfort measures include OTC pain medications, cold compresses and skin dressings with Vaseline followed by prompt medical evaluation if additional concerns are present.
This information is for educational purposes only and not a substitute for professional medical care or advice. Always follow your healthcare provider’s instructions