Saturday, June 1, 2013

Swaddling: Is it Safe?

Despite our desire to help our babies sleep, what we want most is for them to be safe. We all want to help soothe the crying baby in the first picture, and help her achieve the serenity she appears to have in the second picture. How do we do that without constricting the chest, improperly positioning the hips, or endangering her if she happens to roll onto her stomach?

The link will take you to the American Academy of Pediatrics website "". To summarize the points briefly:

1. Safe swaddling snuggles the arms, not the legs. The legs should be wrapped loosely enough to be in a flexed posture, allowing proper development of the hip joints.

2. Safe swaddling is loose enough to allow an adult's hand to fit between the blanket and the baby.

3. Safe swaddling is only OK until age 2 months. After that the baby may be able to flip onto his stomach and needs his arms free to be able to safely do that.

4. Safe swaddling does not overheat a baby. If she is sweating a lot the baby may be too warm.

5. Safe swaddling is done with the baby alone in her own crib or bassinet, with no soft bedding/toys/wedges/bumper pads/pillows. - Swaddling: Is it Safe?

Sunday, April 14, 2013

Ear Infections: What's New?

You may have heard the news: this year the American Academy of Pediatrics published a revised, updated set of guidelines for the diagnosis and initial treatment of acute otitis media in otherwise healthy children ages six months to twelve years.

You might be wondering what this means for you and your child.

The purpose of the new guidelines was to consider the substantial amount of research done since 2004, when the last guidelines were published, in order to assist primary care clinicians in the diagnosis and initial treatment of acute ear infections according to scientific evidence.

Evidence-based medical practice is important because we want to provide care to your child that is necessary, effective, and beneficial. Accurately diagnosing an ear infection is the first step in this process. The first part of the new guidelines addresses the importance of making the correct diagnosis of acute otitis media, and determining if it is a severe or not severe infection. The guidelines go on to address treatment and prevention.

Acute otitis media is diagnosed when there is fluid in the middle ear (fluid behind the ear drum, a middle ear effusion) PLUS one of the following circumstances:
1. There is moderate to severe bulging of the ear drum (tympanic membrane), OR new ear drainage that is not caused by swimmer's ear (otitis externa).
2. There is mild bulging of the ear drum PLUS severe ear drum redness or recent onset of ear pain (or signs of ear pain such as holding/tugging/rubbing the ear in a child who cannot talk).

The guidelines further define acute otitis media as SEVERE if there are severe signs or symptoms such as moderate to severe pain, over 48 hours of pain, or fever of equal to or greater than 102.2 degrees.

NONSEVERE acute otitis media is diagnosed when the pain is mild, less than 48 hours, and fever is less than 102.2 degrees.

The recommended first step in management of acute otitis media is assessment and treatment of pain. Over-the-counter pain relievers such as ibuprofen and acetaminophen are the first choice because they are effective, best tolerated, easiest to give, and most available of all the options. Managing pain is important even when antibiotics are used to treat acute otitis media, because pain may continue for 48 to 72 hours after starting an antibiotic.

The next step in managing acute otitis media is deciding if antibiotics will be necessary. That's right, not all children with ear infections need antibiotics! The guidelines state that children who are 24 months of age and older, who have NONSEVERE acute otitis media in either one or both ears, may be safely and effectively treated with initial observation and pain management. The decision to hold off on antibiotic treatment is made jointly between the pediatrician and parent. A plan is put in place to ensure follow up or treatment if symptoms get worse or are not improving in 48 to 72 hours.

In general the guidelines recommend antibiotic treatment for SEVERE acute otitis media at any age, or for children under 24 months of age with NONSEVERE acute otitis media that is BILATERAL (on both sides).

Amoxicillin is the first choice if the decision has been made to treat with an antibiotic AND the child has not had amoxicillin in the last 30 days, is not allergic to penicillin, and does not have signs of bacteria that is resistant to amoxicillin (such as repeated poor response to amoxicillin or purulent conjunctivitis--"pink eye" with lots of thick, crusted, colored drainage).

Raising the amoxicillin dose from the traditional 40 milligrams of amoxicillin per kilogram of the child's weight per day to 80-90 mg per kilogram per day will overcome most common bacterial resistance to amoxicillin seen in acute ear infections.

If amoxicillin has been used in the last 30 days, the child is allergic to penicillin, or the bacteria is believed to be resistant to amoxicillin, then amoxicillin-clavulanate (Augmentin) or a cephalosporin (such as cefdinir, cefuroxime, cefpodoxime, cefixime, or ceftriaxone) are the next choices.

Of note, recently (as of 4/14/2013) there have been back-orders on certain cephalosporins, or a delay in pharmacies being able to supply prescribed liquid cephalosporins to our patients. Effectiveness, availability, taste, and cost affect the choice of the prescribed antibiotic.

If symptoms worsen or do not respond to initial antibiotic treatment in 48 to 72 hours, then the child may need to be reevaluated. Even with effective antibiotic treatment pain may worsen for the first 24 hours or not improve for 48-72 hours. Most of the time pain will be treated with ibuprofen or acetaminophen.

All children are recommended to receive the pneumococcal conjugate vaccine when they are eligible (the routine vaccination schedule for pneumococcal conjugate vaccine is ages 2 months, 4 months, 6 months, and 12-15 months). Annual flu vaccine is recommended for all eligible children (starting at age six months). Six months of breastfeeding is encouraged. Avoidance of tobacco smoke exposure is important. Avoiding giving a bottle while the child lays flat on her back may help prevent ear infections. Reducing or eliminating pacifier use after the age of six months may also help. Decreasing the frequency of viral upper respiratory infections may help reduce ear infections--the only identified way to do this is to reduce exposure to group day care.

A few studies have show xylitol (which is "birch sugar") is effective in reducing ear infection frequency by 25 percent for children in group day care. The best way to give it is in chewing gum or lozenge form, 3-5 times a day, every day throughout the cold and flu season. Gum and lozenges are not appropriate to use in young children because they are a choking hazard. Xylitol does not help treat an active ear infection and does not work if used only occasionally. Of note, xylitol is not really considered a practical solution for the prevention of ear infections at this time due to the limitations in availability for younger children and the difficulties in regular and consistent administration.

Preventative antibiotics (such as a daily small dose of an antibiotic) should NOT be used because they are likely to be more harmful than helpful.

Ear tubes may be an option for recurrent acute otitis media (three episodes in six months, or four episodes in one year with one episode in the preceding six months), however the benefits versus the risks of the procedure must be considered.

The new guidelines point out that many families turn to complementary or alternative medicine for the treatment and prevention of ear infections. However, in the comprehensive review of the available research-based evidence, no good studies of the effectiveness of such treatments have been published. The guidelines made recommendations about the need for research in this area, and cautioned about the potential costs of treatments that have not been proven to be effective.

Saturday, January 26, 2013

It's Flu Season!

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It is flu season (and has been since December)! The media tells us that influenza (flu) is on the decline. Maybe so--but there is still plenty of it out there. 

Friday in the office I evaluated 8-10 children with flu-like symptoms: sudden onset of high fever, cough, body aches, headache, runny nose, sore throat, and fatigue. They all looked miserable, with fever and sometimes chills, slightly glassy and reddish eyes, cough, and exhaustion.

Flu looks different from a cold. Kids with the flu are not usually smiling and perky in the office. Sometimes there is vomiting and loose stools--but these are just part of the whole picture, not the main symptoms.

Flu vaccines ARE helping this year--though we have had a few break through infections even in those who were immunized. Overall, the majority of children with confirmed influenza have not had their flu shots. Even if the vaccine did not completely prevent the flu, the symptoms in the immunized have been less severe and lasting for a shorter amount of time.

The high fever, cough, body aches, headache, runny nose, sore throat, and fatigue that come with the flu often last for a full week. It is important to be sure the patient gets enough fluids throughout their illness so they do not become dehydrated. Rest is also important. People with flu and fever should not go to school or other activities. Even if the fever comes down with some ibuprofen or acetaminophen the patient is still contagious to others and needs to rest to achieve a full recovery.

Medication for the flu includes Tamiflu, an antiviral antibiotic. In cases of influenza, if started within the first 24-48 hours of the symptoms, it can reduce the severity and length of the symptoms. Unfortunately, Tamiflu suspension tastes terrible and it has been quite difficult for parents to get their young children to take it. In addition, sometimes Tamiflu can be hard to find in the community. Tamiflu is not as good for flu as amoxicillin is for strep throat--it's definitely not an instant cure. Although pediatricians are encouraged to prescribe it for flu patients, I have found parents have a very difficult time getting it into their children. I tried it with my own kids a few years ago, and it is not a happy memory (as the doctor did not succeed in getting her own children to take it!).

Get a flu vaccine for your children if you are able to do so. Keep your children at home, resting, and drinking lots of fluids if they have the flu. Go to the doctor's office early in the illness if you think your child might benefit from Tamiflu. Good luck, I hope it's over soon!