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.

http://pediatrics.aappublications.org/content/113/5/1451.full

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.

DIAGNOSING ACUTE OTITIS MEDIA AND DETERMINING IF IT IS SEVERE
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.

PAIN RELIEF
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.

DECIDING TO USE ANTIBIOTICS
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).

DECIDING WHICH ANTIBIOTIC TO USE
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.

FOLLOW UP
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.

PREVENTION
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.

ALTERNATIVE MEDICINE
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.

What to do with a Fever

Fevers are common in children.  They are probably the number one reason for after hour phone calls to the doctor.  Many parents feel panicky when the thermometer indicates fever.  So what should you do? 

First, and most important, don't panic!  Keep trying to think logically and stay calm.  Your sick child needs you to be able to make rational decisions.  Understand that if the temperature is under 100.5 F, then it is not actually a fever, and you should simply monitor the situation.  Also remember that fever can be helpful in fighting some infections. 

Fever is a sign that your child's body is reacting to an infection.  When there is a fever we try to figure out if the infection is a serious one.  The fever itself won't hurt your child, but a serious infection can be a cause for concern.  If your child has a fever, but is older than three months of age and is looking and acting just fine, you do not automatically need to call the doctor.  Fairly normal behavior and energy level often mean the fever is caused by a more minor infection.

Here are some things to think about.  If your child is under three months of age and has a rectal temperature of 100.5 or higher, you should probably call the doctor.  You could consider unwrapping your baby, making sure that too many blankets isn't the problem.  In general, though, for an infant under three months old with a fever, you should call.

If your child is over three months of age, then her behavior and appearance are important in evaluating how serious of an infection it is.  There is no automatic temperature at which you should "panic" and rush to the ER.  103, 104, and 105 F are all "high" fevers.  When the fever is high you also need to consider how sick your child looks.  If they are very irritable or lethargic, it is more concerning.

When I am called about a child's high fever I frequently ask parents to give a dose of ibuprofen or acetaminophen, and then reassess their child in an hour.  If she feels and looks much better with such a simple intervention, then it may be ok to wait until the next day before bringing her in.  The goal of using anti-fever medicine is not to bring the temperature back down to normal, but to temporarily bring it down a little and to make your child feel better.  It is a good sign if something basic like acetaminophen or ibuprofen can make a big difference in how your child feels.

Giving a cold bath is kind of dramatic and old-fashioned.  I don't usually recommend it because I don't think it would be very soothing to already feel awful with a high fever and then get plunged into icy water.  Cool wet washcloths on the forehead and back of the neck will be much more comfortable for your child.

106 F or higher makes me think of heat stroke, so at that level you should call or take your child to the hospital.  103 F and higher, in addition to a lethargic or irritable child who does not improve with acetaminophen or ibuprofen, would be another reason to call or have your child evaluated right away.
In addition, with any level of fever (that's 100.5 or higher) when your child is also very irritable or lethargic and not improving with anti-fever medicines, you should consider calling or taking your child in.

A child who is lethargic and irritable is usually not smiling, not eating and drinking, is very sleepy or won't stop crying or moaning.  The child can be very restless or almost impossible to comfort and console.  When the doctor asks about "lethargic" she does not mean that your child just wants to sit around and watch TV, or that they seem a little more tired than usual.

When there is a fever, this is what you should do:

Before you call the doctor, take a few seconds to think clearly about your child and his fever.  What other symptoms does he have? What illnesses was he exposed to?  How long has he been sick?  Can you help him cool off by undressing him, using cool cloths on the forehead and neck, and giving him anti-fever medicine?  Did you give the right amount of ibuprofen or acetaminophen, and did you give the medicine enough time to work?  Was there improvement in his appearance, mood, discomfort, and energy level? 

If you are reassured by improvement in your feverish child's appearance, then you may be able to manage this at home for the time being.  You could make an appointment in the next day or two if the fever doesn't go away.  If you continue to be quite concerned and worried about your child even after trying some things to help them feel better, then don't wait to check in with the doctor.

Disclaimer:  As usual, my advice in this blog is general and may not apply to your specific situation, or to your child's special circumstances.  This blog is not intended to be a substitute for the personal attention your own doctor can provide.

Strep throat?

How can you tell if your child has "strep throat?" I'll give you some things to look for, and some information for you to think about in determining when your child should be evaluated by a doctor.

As always, please keep in mind that I intend my blog, and this information, for general and informational use. It cannot, and is not intended to replace the attention of your own personal pediatrician. You should not try to diagnose your child or expect treatment based upon what I am writing in my blog! If your child is ill and you need more information or evaluation then you should contact your child's doctor.

Strep throat is a bacterial infection caused by a bacteria called Streptococcus pyogenes. It is contagious through respiratory secretions or saliva, has an incubation period of three to six days (that's how long it takes to get sick after being exposed to the germ), and is treated with antibiotics. After a person has taken antibiotics for 24 hours they are no longer consider contagious to others. A quick test can be done in a doctor's office to detect strep, or a culture can be done over several days in a laboratory.

The classic symptoms of strep throat are the sudden onset of a sore throat, headache, stomachache, and fever, without any symptoms of a cold such as a runny nose or cough. Sometimes there is a stuffy nose, but it is not usually runny. Some people do not have a fever with strep throat. The location of the throat pain tends to be more in the back of the mouth, not as much in the front of the neck. It hurts to swallow. Sometimes the voice sounds as if there is some swelling in the back of the throat--not like you are losing your voice or have laryngitis, but more of a sound of fullness there.

In strep throat the throat is often very red, with swollen tonsils. Sometimes there are red dots on the back of the palate, near the uvula. Sometimes there are whitish spots on the tonsils. "Glands" (actually lymph nodes) in the neck can be swollen and hurt to touch. If you are checking your child's throat and neck at home it is good to have some experience looking at your child when she is not ill. Healthy children have throats that are normally somewhat red, and many children who are not ill have tonsils that can look big, or lymph nodes that can be felt during an exam.

A sore throat that is pretty significantly associated with cold symptoms such as a runny nose or cough is less likely to be caused by strep. This kind of non-strep sore throat is often located in the front of the neck, lower in the neck, worse in the morning, and is improved after drinking fluids or being out of bed for a while. Coughing can make this kind of sore throat worse.

Infants and toddlers can get strep throat, and may not have classic symptoms. In younger children like these there can be prominent cold symptoms along with the fever. There is often a history of exposure to strep throat from an older sibling or in daycare.

In general I tell my patients' families they should have their child checked at the doctor's office during regular office hours if they think she has strep throat. Antibiotics for strep throat will help your child recover more quickly, and reduce how contagious your child will be to others. Rarely, an untreated strep infection can affect the heart or the kidneys. Antibiotics can help prevent these complications.

Strep throat is not usually an emergency. Treating the infection within seven days of the start of the symptoms is the goal in order to help prevent complications from strep. Confirming the diagnosis with a strep test before treating with antibiotics is best for your child. An evaluation in the doctor's office is the best way to ensure your child is treated properly, that he does not receive unnecessary antibiotics and risk the development of bacterial resistance to antibiotics, that the correct antibiotic at the right dose is chosen for your child, and that there is no other explanation for your child's symptoms that could be better treated in a different way.

Making an appointment for your child to be evaluated for strep throat within a day or two of the onset of symptoms usually "catches" the infection early enough to keep your child comfortable. If your child is very ill (repeated vomiting, appears very ill, is dehydrated, has a "stiff" neck, seems delirious, or has other symptoms that really worry you) then you should not wait to contact the office. It would be unlikely that an antibiotic would simply be "called in" for your child, more likely an evaluation in some type of health care setting will be recommended.

Another interesting tidbit about strep throat is that, even though it is a contagious illness, at least 75% of family members will not become ill from strep throat when someone at home has the condition. For that reason we do not automatically treat exposed family members with antibiotics.

Even if someone has all the symptoms sometimes they do not have strep throat. There is a virus called Adenovirus that can appear very much like strep throat. "Mono" (more correctly termed infectious mononucleosis) can look a lot like strep throat, too. "Mono" is caused by the Epstein Barr virus. You may remember that viruses like these cannot be cured with antibiotics. Instead your child's own immune system will fight off the germ and treatment will involve rest, fluids, and symptom relief--but not an antibiotic.

Norovirus in Kalamazoo

Our office received a "Health Advisory" from the Kalamazoo County Health & Community Services this week. It announces laboratory-confirmed cases of Norovirus in Kalamazoo County. Norovirus is the new, official name for viruses previously known as Norwalk viruses. Noroviruses have been responsible for relatively large outbreaks of vomiting and diarrheal illnesses on cruise ships, in schools, and in day care centers.

My factual information in this blog comes directly from that Health Advisory, and a fact sheet about Norovirus from the Michigan Department of Community Health, Communicable Disease Division, 201 Townsend Street, CVB-5th floor, Lansing, Michigan. The advice on oral rehydration is the general advice I and my colleagues at Trestlewood Pediatrics give to parents whose children are suffering from a vomiting and diarrheal illness.

Noroviruses are contagious viruses that cause stomach and intestinal illnesses in people. These kinds of illnesses are often incorrectly referred to as "stomach flu" or "flu". Actually, the correct term is gastroenteritis. Gastroenteritis has no relation to influenza (correctly termed "flu"), which is primarily a respiratory illness.

The most common symptoms of a norovirus infection are nausea, vomiting, diarrhea, and abdominal cramps. They occur 10 to 48 hours after exposure to the germ. Other symptoms can include fever, chills, headache, muscle aches, and fatigue. The symptoms last 1 to 2 days, and can be very severe for some people. Dehydration is the most worrisome problem that can result from a Norovirus infection. This would occur if the sick person cannot drink enough fluids to replace what they are losing in vomit and diarrhea.

Treating Norovirus infections means replacing fluids and waiting for the symptoms to subside. There are no antibiotics or vaccines for Norovirus. Fluid loss should be replaced with clear liquids. The best fluids, especially for children five and under, are oral rehydration solutions such as Pedialyte. Sports drinks are not a good substitute because they have too much sugar. Diluted juice or water could also be given, but preferably to an older child. Infrequently a child may need to see a doctor to determine if intravenous fluids are needed.

When orally rehydrating an infant or young child you may need to give them the oral rehydration solution in a syringe. Wait one hour after the last vomiting episode, and then syringe feed Pedialyte 1 to 2 teaspoons (5-10 ml) at a time every ten minutes for two hours. Set a timer on your stove so you can stay on track.

If vomiting starts over, wait an hour and start the oral rehydration process again. If your child tolerates 5 to 10ml every ten minutes for two hours, you can then let them have more at a time (maybe 20-30ml every 15 minutes). Continue with only clear liquids for at least half the day. If everything is going well after that you could try a little milk, or one small cracker or piece of cereal. Start over if they vomit again. Don't let your pathetic little sick child sweet talk you into giving them food or milk until you know they are tolerating the clear liquids quite well. If you introduce food or milk too soon you will set everything back by hours because it will almost certainly induce more vomiting. Crackers do NOT settle the stomach of a vomiting child. First go slowly with oral rehydration solutions such as Pedialyte. Don't let your child refuse the Pedialyte, give it to them in a syringe, as if it were medicine.

The nice thing about Pedialyte is that it can be partly absorbed from the stomach (instead of having to travel all the way to the intestine first)--so even if some of it gets vomited back up, some will still be absorbed. This is not true of sports drinks, water, or juice.

The most interesting thing about Noroviruses is how very contagious they are. They are quickly spread from person to person, by ingesting contaminated food and drink prepared by infected food preparers, by touching contaminated surfaces and then touching the mouth, or having direct contact with an infected person and then touching the mouth before washing hands. Stool and vomit from an infected person is definitely contaminated with norovirus. In some cases undercooked oysters or drinking water contaminated with sewage have been the cause of an outbreak.

If you have norovirus, you are contagious from the time you start feeling ill or nauseated until at least 3 days after recovery. The contagious period after recovery can last as long as two weeks for some people.

Good hand washing with SOAP AND WATER is important to prevent further spread of the virus. Infected people should not prepare food, work in nursing homes, or take care of patients while they have symptoms, and for three days after the symptoms are gone. Children may return to school and daycare when the diarrhea and vomiting is gone. Then hand washing with soap and warm water must be strictly enforced. Alcohol based hand sanitizers do NOT work against norovirus. Soap and warm water is the best way to eliminate the germ from your hands. A household chlorine bleach-based cleaner should be used to disinfect contaminated surfaces.

So, wash your hands with soap and water, disinfect your surfaces with some kind of bleach solution, don't go to work or school if you become nauseated, vomit, and/or have diarrhea, and don't return to work for three days after you are better if you have a job preparing food or taking care of patients. Don't return to school until vomiting and diarrhea have stopped, and then use careful handwashing methods with soap and water. Have some Pedialyte on hand, or know where you can get it. Stock up on medicine syringes in case you must force feed the Pedialyte. And wash your hands again.

Please call your own personal pediatrician for more specific advice for your child. My blog is meant to provide you with general information, and is not a good substitute for the personal attention your own doctor can provide.

The Michigan Department of Community Health norovirus cleaning and disinfection guidelines, as well as other information, are available at the following link. Once at the main web site, click on the icon for Health and Services, then type Norovirus into the search box.

www.michigan.gov

Flu and Flu Shots

Hey, I got my flu shot today! Tina (one of Trestlewood's nurses) gave it to me in my left arm about an hour and a half ago. I feel fine. I could hardly tell the needle went in, and my arm doesn't hurt a bit. I don't ache, I don't have a fever, I didn't catch flu from the vaccine, and I am so happy to be protected from this season's flu viruses. I am sure to be exposed to them many times this year.

My girls had their flu vaccines on Sunday, just two days ago. They prefer the FluMist (a flu vaccine that is given via drops squirted in the nose). My husband will probably drop by my office soon and surprise one of Trestlewood's nurses to get his vaccine. Everyone in my family gets a flu vaccine every year. We started this tradition after my oldest got the flu in first grade. It was quickly followed by pneumonia, and then in her weakened state, strep throat. It was awful, and I never wanted a child of mine to go through that again. Unfortunately, my middle daughter had the flu a few years ago. She was coughing, had fevers upwards of 104, and was utterly miserable for a week.

I also take flu shots to Indiana to give to my parents and my mother-in-law. I think giving out flu shots each year is one of the biggest contributions I can make to the health of my community and my loved ones. The other big impact I have on public and individual preventive health is the rest of the recommended childhood vaccines--but that's for another blog.

Flu, at least the flu we vaccinate for, is NOT the stomach flu! I am told daily how this or that family had "the flu" last week, or last month, or last year. Or how they never get "the flu." Or, how the flu vaccine didn't work for them because they still got "the flu." When pressed for details it is clear that most people mean gastroenteritis when they say "the flu." Gastroenteritis is an illness that is very contagious, lasts a day or two, and involves vomiting and diarrhea. The flu I am talking about is influenza, a RESPIRATORY illness.

The symptoms of influenza are fever, severe muscle aches, coughing, sore throat, runny nose, extreme fatigue, chills, with occasionally some stomach symptoms. It lasts for about a week. It is also very contagious. Flu weakens and can kill its victims, especially those who are already debilitated. It can lead to complications, such as pneumonia. At the very least it is a miserable week to spend in bed with a box of tissues, cough drops, and other cough/cold/anti-fever medicines.

Flu vaccine is recommended yearly for everyone who is six months or older who does not have an allergy or other contraindication to the vaccine. While it is especially important for people with chronic illnesses such as asthma or diabetes, it is recommended for all of us. We can all benefit from a yearly flu vaccine.

Have you and your children had your yearly seasonal flu vaccine? Get yours as soon as you can!

The following are some links to reliable information about the flu and flu vaccine. This year's vaccine includes the H1N1 subtype, so a separate shot for that one isn't necessary. Children under age nine who are getting the flu vaccine for the first time, or who have not had at least two previous seasonal flu vaccines plus one of last year's H1N1 vaccines, will need two doses of flu vaccine spaced one month apart to be completely immunized.

http://www.cdc.gov/flu/

http://www.healthychildren.org/English/tips-tools/Symptom-Checker/Pages/Influenza.aspx

Croup and a Croupy Cough

It's easy to be scared when you wake up in the middle of the night to hear your baby or young child coughing with a deep, loud, barky cough and making raspy sounds when she breathes. Chances are this is croup!

It's important to hear what croup sounds like. The following videos are from YouTube. All give a pretty good idea of the distinct barky, croupy cough. It sounds like a barking seal.

CROUPY COUGH
A croupy cough sounds loud and barking, like a seal's bark:





STRIDOR
Raspy breathing, also known as stridor, is another characteristic of croup:



This next link is to a video that demonstrates a significant case of stridor, just click on the link to go to YouTube (the video did not allow itself to be embedded):
http://www.youtube.com/watch?v=Z1_uKqmPyLA


Croup is usually caused by a virus (a common one is parainfluenza virus). It causes cold symptoms (runny nose, stuffy nose, cough, fever) and it likes to settle in the upper airway. It causes swelling in the upper airway and vocal cords, giving the funny sounding cough, causing raspy breathing, and a hoarse voice (laryngitis). The barky cough and raspy breathing are always worse at night.

Croup often sounds much worse than it is. In two of the videos above, the ones demonstrating stridor, you can see completely happy babies who have raspy breathing. They look pink, are smiling or talking, and are not bothered by the "trouble" they are having with their breathing. Croup can be serious, and require a trip to the emergency room. However, usually it is manageable at home.

For a croup attack, first sit your child up, and then calm him down. Sitting up usually helps the airway stay open. Crying and panicking tend to make the airway close even more. Take your child into a steamy bathroom. To do this--run the hot water in your shower and don't turn on the fan. Sit in the bathroom and sing to your child, rock her, read to her. Try this for about fifteen minutes at a time. If it works, you can put your child back to bed--then repeat the treatment as needed through the night.

Another home treatment is taking your child outside into the cold night air (assuming it is cold outdoors!). The point is to try the opposite of hot steam, if the steam wasn't working for her. You can also put a cool mist vaporizer into your child's room.

If a croup attack is very severe, your child can't breathe despite home treatments, or is looking quite pale, bluish, or lethargic, you should go to the emergency room. There your child can receive breathing treatments (to temporarily open the airway), oxygen (if required), and steroids (to reduce swelling in the airway). Remember, however, that croup can look and sound much worse than it really is--so if your child is happy and playful, able to nurse or drink from a bottle or sippy cup pretty well, it's unlikely that you need to go to the emergency room for croup.

If you make it through the night, but had a rough time getting to morning (needing recurring steam or outdoor treatments) you should bring your child to the office the next morning. Symptoms may appear to be gone in the daytime, but croup comes back each night for a few nights before it turns into a regular cold.

After a few days of the croupy stage the cough will change into a phlegmy, wet cough. This almost always happens with croup, and is a sign that the croup is starting to clear up. However, when the cough changes into something else, every parent worries that it is turning into something more serious. When it changes, watch your child closely. If she is sleeping better, is more playful, more hungry, and the fever is mostly gone, then your child IS improving and you can handle the rest of the croup illness at home, like you would for the average cold virus.

Croup is contagious in the way a regular cold is contagious. It is spread by respiratory droplets (mucous, cough, sneezing), and is most contagious in the first 2 to 3 days of the illness. If there is no fever, and the child is sleeping pretty well at night, croup is not a reason to keep kids out of daycare or school.

As always, my blog is designed to give you general information about your child's health and illness. One of the main reasons I posted this topic is to provide the links to videos of a croupy cough and stridor. My advice here is not meant to replace the more personal advice you can receive from your child's own pediatrician.

Lots of information about croup is available on the web. Here are some possible links, if you want more information:

http://www.askdrsears.com/html/8/t084200.asp

http://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/Croup-Treatment.aspx

Post updated 1/26/2014 (a new video added to replace one no longer available, two links replaced with embedded videos).

The Great Outdoors versus Turtle Salmonella

For me growing up and playing outside was all about seeing what was out there. We caught fireflies, minnows, toads (remember that warm wet feeling on your hand?), beetles, ants, frogs, and turtles. Today the emphasis is trying to get kids "back to nature." Get them playing outdoors, in nature, whenever possible. Give them free time to just play, make daisy chains and houses for fairies, use a dandelion to make wishes or check to see if you like butter (rub the yellow dandelion on someone's chin, if their chin turns yellow, they like butter), gather acorns and make houses for the acorn family, find bird nests with evidence that chicks have hatched (or have the mama bird swoop at you and scold you to keep away from her babies).

We are also told by health authorities that we shouldn't have our kids touch these animals (especially turtles) because they could be carriers of salmonella. Salmonella is a nasty gastrointestinal illness, and definitely worth avoiding. However, didn't anyone ever think of washing your hands? I think we should tell our children to go ahead and observe and even carefully catch turtles, frogs, toads, and garter snakes! It's exciting to do this and it makes nature more real. Kids can learn about nature and how to be kind to animals by creating their own relationship with them. They can learn about habitats and lifecycles. Protecting the environment becomes more important when we see who lives in the marsh, or even on the side of the road. What is all the trash we just picked up on the lakeshore doing to these animals? And it's all more real because of "Fenton and Frieda" (the frogs in the pictures), or Snakey the garter snake, or Percy the turtle--who all became "pets" for a few minutes before they were gently let go (and the child washed her hands).