Staphylococcus aureus, is a bacterial strain that has become quite famous – rightly or wrongly depending on the context. In this post, I will share a pediatric infectious diseases specialist’s perspective on the fact and fiction surrounding this germ.

What is MRSA?

MRSA is a particular subtype of Staph aureus bacteria. Staph aureus is everywhere and many people are “colonized” with Staph aureus. In other words, the bacteria live happily on our skin with all the other bacteria, minding their own business. Sometimes, if a person is colonized with Staph aureus, and there is a break in the skin from a cut or other injury, the Staph aureus can cause an infection. This can happen even if a person is not colonized with Staph aureus, because the bacteria are everywhere – in the environment on surfaces, on other people, etc. On people, Staph aureus like to live in the nose and other warm moist places like the armpits and groin area. MRSA is just like regular Staph aureus in where it lives and how it spreads – the major difference between the two is that the antibiotic choices for treating an infection caused by MRSA are more limited because MRSA is resistant to more antibiotics.

Isn’t MRSA rare?

No. In the Philadelphia area where I trained, at least half of skin infections tested are caused by MRSA. In other words, a child having a MRSA skin infection is not a unique event for a community. MRSA is more prevalent than most people realize. In addition to colonization, which you would never know from just looking at someone, many people have minor skin infections for which they never see their doctors because the infection comes and goes on its own with no treatment, or maybe with a little antibiotic ointment. Because samples from these infections are not tested for bacteria, we will never know what caused them and many could be caused by MRSA.

Rarely, a child can have a severe illness as a result of MRSA. This does happen, and appears to be happening more frequently now compared with 10 or 20 years ago, but far more common are simple skin infections caused by MRSA, and the vast majority of these do not progress to serious illnesses.

My grandmother was in a nursing home and died of MRSA. Now my child’s friend had a skin infection caused by MRSA – is this the same thing?

No. MRSA infections that people acquire in hospitals are different from community-associated (CA-MRSA) in a few ways. First, people in hospitals are there because they are ill, often with conditions that make it difficult to fight infections, like being elderly or getting cancer treatment. Second, people in hospitals often have devices that allow entry of bacteria into their bodies more easily, like IV lines or breathing tubes. Third, the strains of MRSA found in hospitals often have different characteristics from those found in the community. In hospitals, MRSA tend to be resistant to more antibiotics and have different properties that make the bacteria more harmful. Also, MRSA infections people get in hospitals are usually not the simple skin infections that children in the community get. Most children who get MRSA skin infections, even recurrent ones, don’t seem to go on to develop other more invasive infections caused by MRSA.

My child was diagnosed with a MRSA skin infection. Will it happen again?

Maybe. If you’ve been told your child has MRSA, don’t panic! In many cases, a single infection caused by MRSA is a one-time occurrence. Some children have recurrent infections with MRSA, but this is far more likely to be an annoyance and inconvenience rather than a serious illness. Recurrent MRSA infections can occur for a period of time, and then not happen again. Some of the time, changes in hygiene practices can stop the cycle of recurrent infection. If your child has recurrent infections, ask your doctor for more information about strategies to try. One important thing to keep in mind is that having MRSA, and even having recurrent MRSA infections, does not mean something is wrong with your child or her immune system – it is just bad luck.

Does someone have MRSA forever?

Maybe, but probably not. As I mentioned above, a significant proportion of the population is colonized with MRSA. The bacteria that colonize our bodies change over time due to a variety of factors, like age, antibiotic use, and environmental exposures. A person could be colonized with MRSA for a period of time, and then never again or not again for years.

Should the school be closed and decontaminated if there is a child with a MRSA infection?

No. Schools should be cleaned as they normally are to reduce bacteria and viruses on surfaces. MRSA and other Staph aureus predominantly live on people, in the nose and other moist body areas, so unless people are decontaminated (not advised!) MRSA can’t be eliminated.

Should kids with MRSA be excluded from school?

Absolutely not. For every one child with a diagnosed MRSA infection there are many more who are colonized with the bacteria, so it does not make sense to exclude a child on the basis of a diagnosis. A child with a MRSA skin infection is not a danger to other children or adults. As with any skin infection, open wounds should be covered. MRSA, while it can in some cases be more harmful than regular Staph aureus, is not any more contagious than regular Staph aureus. A much better strategy than exclusion is to teach children to wash their hands well and to avoid nose-picking, as these interventions will protect them against hundreds of diseases.

Can my child play with his friend who has MRSA?

Yes! As discussed above, a MRSA diagnosis does not say anything about a person’s overall health or make them more likely to transmit disease. Also, your child could very well be colonized with MRSA too and you wouldn’t know it. The best way to prevent the spread of MRSA is to encourage routine hand washing and to discourage nose-picking. Also, avoid sharing towels and sharing sports equipment that rubs against the skin, such as soccer shin guards and football pads. Remember, your child is much more likely to catch a cold or stomach virus from a friend than they are to catch a MRSA infection.

Amanda Paschke, MD, MSCE

©2013 Two Peds in a Pod®

Parents ask us about fever more than any other topic, so here is what every parent needs to know:

Fever is a sign of illness. Your body makes a fever in effort to heat up and kill germs without harming your body.

Here is what fever is NOT:

· Fever is NOT an illness or disease.
· Fever does NOT cause brain damage.
· Fever does NOT cause your blood to boil.
· Unlike in the movies and popular media, fever is NOT a cause for hysteria or ice baths.
· Fever is NOT a sign of teething.

Here is what fever IS:

· In many medical books, fever is a body temperature equal to or higher than 100.4 degrees Farenheit.
· Many pediatricians, consider 101 degrees Farenheit or higher as the definition of fever once your child is over 2 months of age.
· Fever is a great defense against disease, and thus is a SIGN, or symptom, of an illness.

To understand fever, you need to understand how the immune system works.

Your body encounters a germ, usually in the form of a virus or bacteria, that it perceives to be harmful. Your brain sends a message to your body to HEAT UP, that is, make a fever, to kill the germs. Your body will never let the fever get high enough to harm itself or to cause brain damage. Only if your child is experiencing Heat Stroke (locked in a hot car in July, for example), or if your child already a specific kind of brain damage or nervous system damage (rare) can your child get hot enough to cause death.

When your body has succeeded in fighting the germ, the fever will go away. A fever reducing agent such as acetaminophen (e.g. Tylenol) or ibuprofen (e.g. Motrin) will decrease temperature temporarily but fever WILL COME BACK if your body still needs to kill off more germs.

Symptoms of fever include: feeling very cold, feeling very hot, suffering from muscle aches, headaches, and/or shaking/shivering. Fever often suppresses appetite, but thirst should remain intact: drinking is very important with a fever.

Fever may be a sign of any illness. Your child may develop fever with cold viruses, the flu, stomach viruses, pneumonia, sinusitis, meningitis, appendicitis, measles, and countless other illnesses. The trick is knowing how to tell if your child is VERY ill or just having a simple illness with fever.

Here is how to tell if your child is VERY ill with fever vs not very ill:

Any temperature in your infant younger than 8 weeks old that is 100.4 (rectal temp) degrees or higher is a fever that needs immediate attention by a health care provider, even if your infant appears relatively well. For kids over 2 months of age, take the temperature anyway you’d like, just let your pediatricians know how you took it.

Any fever that is accompanied by moderate or severe pain, change in mental state (thinking), dehydration (not drinking enough, not urinating because of not drinking enough), increased work of breathing/shortness of breath, or new rash is a fever that NEEDS TO BE EVALUATED by your child’s doctor. In addition, a fever that lasts more than three to five days in a row, even if your child appears well, should prompt you to call your child’s health care provider. Recurring fevers should also be evaluated.

Should you treat fever? As we explained, fever is an important part of fighting germs. Therefore, we do NOT advocate treating fever UNLESS the side effects of the fever are causing harm. Reduce fever if it prevents your child from drinking or sleeping, or if body aches or headaches from fever are causing discomfort. If your child is drinking well, resting comfortably or playing, or sleeping soundly, then he is handling his fever just fine and does not need a fever reducing agent just for the sake of lowering the fever.

A note about febrile seizures (seizures with fever): Some unlucky children are prone to seizures with sudden temperature fluctuations. These are called febrile seizures. This tendency often runs in families and usually occurs between the ages of 6 months to 6 years. Febrile seizures last fewer than two minutes. They usually occur with the first temperature spike of an illness (before parents even realize a fever is present) and while scary to witness, do not cause brain damage. No study has shown that giving preventative fever reducer medicine decreases the risk of having a febrile seizure. As with any first time seizure, your child should be examined by a health care provider, even if you think your child had a simple febrile seizure.

Please see our “How sick is sick?” blog post for further information about how to tell when to call your child’s health care provider for illness.

Julie Kardos, MD and Naline Lai, MD

rev © 2015 Two Peds in a Pod®

Happy 2013! Time start those new year resolutions. If you are like many families, your kids are up early anyway so you might as well get started (or maybe they never went to bed). To jump start your list, we’re sharing a list of New Year’s health resolutions we’ve come up for our own families over the years.

1- I will make sure my child is up to date on her vaccines, including the yearly flu vaccine (there’s still time).

2- I will start to sleep train (if older than 6 months old).

3- I resolve to wean the bottle if my baby is older than one year.

4- I will read aloud to my child every day, even after he is old enough to read to himself.

5- I resolve to go through the medicine closet, dispose of out-of-date medications, and renew important rescue-type medicines such as epi-pens and albuterol.

6- I resolve to check to see that my child’s bike helmet still fits (consider putting name and contact telephone number on outside…just in case something were to happen) and tuck emergency phone numbers into her backpack.

7- I will start to read my child’s facebook page and phone texts. I’ll look for signs of bullying and signs of mental distress from my child’s friends as well as from my child. I will take action to address any problems.

8- I will remember to praise my child for acts of kindness and for working hard on school assignments.

9- I’ll get to know my kid’s friends and their families. I will start by getting out of the car to say hello when I drop my kid off at someone’s house.

10- I plan to encourage more self-sufficiency in my child. I’ll stop doing household tasks for my child when he shirks his duties. 

11-I will turn off my cell phone while I am doing an activity with my child.

12- I will listen carefully to my child’s own New Year’s Resolutions.

Have a wonderful, healthy 2013,

Drs. Kardos and Lai

©2013 Two Peds in a Pod®

Many times parents bring their children with sore throats to our office to “check if it’s strep.” Some are disappointed to find out that their child does NOT have strep. Moms and Dads lament, “But what can I do for him if he can’t have an antibiotic? At least strep is treatable.”

Take heart. Strep or no strep, there are many ways to soothe your child’s sore throat:

• Give  pain medication such as acetaminophen (Brand name Tylenol) or ibuprofen (brand names Advil or Motrin).  Do not withhold  pain medicine before you bring her in to see her pediatrician. Too many times we hear “We wanted you to see how much pain she is in.” No need for this! Pediatricians are all in favor of treating pain as quickly and effectively as possible. Pain medicine will not interfere with physical exam findings nor will it interfere with strep test results.
• Give lots to drink. Some kids prefer very cold beverages, others like warm tea or milk. Avoid citrus juices since they sometimes sting sore throats.  Frozen Slurpies on the other hand feel great on sore throats. Tell your child that the first three sips of a drink may hurt, but then the liquid will start to soothe the throat. Watch for signs of dehydration including dry lips and mouth, no tears on crying, urination less than every 6 hours and  lethargy.
  
• Provide soft foods if your child is hungry. For example, noodles feel better than a hamburger on a sore throat. And ice-cream or sherbet therapy is effective as well.
• Try honey (if your child is older than one year) – one to two teaspoons three times a day. Not only can it soothe a sore throat but also it might quiet the cough that often accompanies a sore throat virus. Give it alone or mix it into milk or tea.
  
• Kids older than three years who don‘t choke easily can suck on lozenges containing pectin or menthol for relief. Warning: kids sucking on lozenges may dupe themselves into thinking they are hydrating themselves. They still need to drink and stay hydrated.
  
• Salt water gargles are an age-old remedy.  Mix 1 teaspoon of salt in 6 ounces of warm water and have your kid gargle three times a day.
  
• Magic mouthwash: For those older than 2 years of age, mix 1/2 teaspoon of liquid diphenhydramine (brand name Benadryl 12.5mg/5ml) with 1/2 teaspoon of Maalox Advanced Regular Strength Liquid (ingredients: aluminum hydroxide, magnesium hydroxide 200 mg, and simethicone) and give a couple time a day to coat the back fo the throat prior to meals. Do not use the Maalox formulation which contains bismuth subsalicylate. Bismuth subsalicylate is an aspirin derivative and aspirin is linked to Reye’s syndrome.
  
• For kids three years and older, try throat sprays containing phenol (brand name Baker’s P&S and Chloraseptic® Spray for Kids). Use as directed.
  

Strep throat does not cause cough, runny nose, ulcers in the throat, or laryngitis. If your child has these other symptoms in addition to her sore throat, you can be fairly sure that she does NOT have strep. For a better understanding of strep throat see our posts: “Strep throat Part 1: what is it, who gets it and why do we care about it” and “Strep throat Part 2: diagnosis, treatment, and when to worry.”

Any sore throat that prevents swallowing or prevents your child from opening his mouth fully, pain that is not alleviated with the above measures, fever of 101F or higher for more than 3-4 days, or a new rash all merit a prompt visit to your child’s doctor for further evaluation. Please see our prior post on how to tell if you need to call your child’s doctor for illness.

Julie Kardos, MD and Naline Lai, MD

©2012 Two Peds in a Pod®

Photo by Lexi Logan

Picture the Mission Impossible theme song in your head… da da da DUM DUM da da da DUM DUM dadada…dadada…dadada…DA DA! Keep this background music playing as you read.

Recently, Two Peds in a Pod® went undercover as two unsuspecting moms surveying the scene on the shelves of a local chain pharmacy, seeking to uncover what medicines, ointments, and therapies avail themselves to the unsuspecting consumer. Today we break open the case.

All medication labels have an “active ingredient” list. This list contains the actual medicine that acts on your child’s body to hide symptoms or cure a condition.  Read this list carefully so that you know what you are actually giving your child. For example, Flu-Be-Gone claims it “cures the aches and cough of flu and helps your child sleep better.” In order to know just what is actually in Flu-Be-Gone, you need to read the active ingredients. Included might be acetaminophen (brand name Tylenol), a fever reducer and pain reliever, and diphenhydramine (brand name Benadryl), allergy medicine that has the common side effect of causing drowsiness and has some mild anti-cough properties. Notice neither active ingredient actually kills the flu germ. Additionally, you may already have these two medications in your medicine cabinet, or you might have already given your child diphenhydramine recently and giving Flu-Be-Gone would overdose your child.

Also note, diphenhydramine is everywhere. If you see the word “sleep” or “PM” in the name of a product, you will usually find diphenhydramine in the active ingredient list.

Now, let’s hone in on your choices for the anti-itch therapy, hydrocortisone. When your child’s health care provider advises treating an itchy bug bite, poison ivy, or allergic rash with hydrocortisone, make sure that the ACTIVE INGREDIENT in the product is “hydrocortisone 1%.” Hydrocortisone comes as a cream, ointment, spray, or stick (looks like a glue stick) and can have aloe, menthol, or other ingredients thrown in as well. Don’t bother with anything less than maximum strength. Regular strength is 0.5% and is generally ineffective.  Also, keep in mind that while ointment is absorbed a bit better, it is more greasy/messy than cream.

Don’t be fooled into thinking products with the same brand name contain similar active ingredients. Also, do not depend on your doctor to necessarily know the difference between the all the formulations. We noticed that the same brand name pain reliever, such as Midol, can have different active ingredients depending on which one you choose. Midol Teen contains acetaminophen, Midol liquid gels contains ibuprofen, and Midol PM contains acetaminophen and diphenhydramine.

Let’s talk bellyache. Did you know that kids should not take adult pepto bismol because it has a form of aspirin in it? Aspirin may cause Reye’s syndrome, a fatal liver disorder. However, we did see a product called Children’s Pepto Bismol and guess what the active ingredient is? It is calcium carbonate, which is the SAME active ingredient as in Tums, and is safe to give kids. However, watch your wallet: the children’s pepto bismol that we found cost $6.00 for a box of 24 tablets. The TUMS that we found cost $4.50 for a bottle of 150 tablets of the same stuff, just in slightly higher dose. Check with your child’s doctor but in most cases, the kids can take the adult dose.

Also, be aware that cold and cough medicine have not been shown to treat colds successfully or even to actually relieve symptoms in most kids. In fact these medicines have potential for harmful side effects, accidental overdose, or accidental ingestion and are just not worth giving your children. However, we found tons of cold and cough medicines marketed for children. Here are the three most commonly used active ingredients:

• If you see “suppressant” you will likely find “dextromethoraphan” in the active ingredient list.
• If you see “expectorant” you will likely find “guaifenesin” in the active ingredient list.
• If you see “decongestant” you will likely find “phenylephrine” in the active ingredient list.

Many products combine two or all three of the above. We ask, even if these ingredients did work well in kids and were not potentially dangerous, what is the POINT of combining a cough suppressant with an expectorant? Can you really have it both ways? (Remember, that Mission Impossible theme is still playing in the background.)

A few other tidbits. “Dramamine,” used for motion sickness, gets broken down in the body to diphenhydramine, that allergy medicine that we already talked about. So look at cost differences when choosing a motion sickness medicine. Both have the same side effect: sleepiness.

Many cough drops contain corn syrup and sugar. This is the same stuff lollipops are made of, so just call a candy a candy and keep your child’s throat wet with the cheaper choice, if you choose to do so.

Finally, we found one “natural children’s cough medicine” which claimed that it is superior because of its “all natural ingredients.” The first active ingredient listed? Belladonna. Sure it’s natural because it comes from a plant. So does marijuana. Just because it’s “natural” doesn’t mean it’s safe. Belladonna can cause delirium, hallucinations, and death and in fact has been used in high doses as a poison! Leave the cough medicine on the store shelf, and read our post about other ways to soothe a cough and cold symptoms.

Bottom line:  remember always to check the “active ingredient” list when buying any over-the-counter medication for your children.

As we were wrapping up our mission, one of the pharmacy employees came over to us, raised an eyebrow at our clipboard, and asked, “Can I help you ladies with anything?” We were tempted to answer “YES, can you help us take notes?”  but we just smiled and said “No, we’re fine, thanks. Just checking out what’s available.”

So now, we will don our stethoscopes and come out of hiding, go back into our offices and onto our website. Thanks for tuning in to this episode of Two Peds in a Pod®…. Da da da, DUM DUM da da da, DUM DUM dadada…dadada…dadada…DA DA!!!

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

As we head into this year’s cold and flu season, we re-release this post in response to recent questions  about “the best cold medicine for my kid.” Originally posted May 27, 2011

“DaDu.”

That’s how my oldest used to say “Thank you” when he was about two years old. Now that he is thirteen I find myself still reminding him to say “thank you” when he goes to a friend’s house or to a birthday party or when a friend’s parent drives him to school.

From Two Peds in a Pod®:  We are thankful for our readers, our facebook friends, and our subscribers for continuing to send us ideas and for telling parents around the world about our down-home source of “sound pediatric advice for parents on the go”. We’ll keep writing as long as you all keep reading. 

Today, may you enjoy cramming in folding chairs to your dining room table, the sleepy post Thanksgiving feast lull, and the sight of heaps of children piled onto a tiny couch.

Dadu and Happy Thanksgiving, 

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

It’s gift-giving season. Yes, we could write a soppy post about how the best gifts in life are not material. Or that you should donate money to charity in a child’s name. However, sometimes you just want to buy something. To help you find a perfect gift, or at least one a kid will play with this season, we present a review of child development and a corresponding set of gift ideas.

0-3 months: Babies this age have perfect hearing and enjoy looking at faces and objects with contrasting colors. Music, mobiles, and bright posters are some age appropriate gift ideas.

3-6 months:  Babies start to reach and grab at objects, so they enjoy rattles and toys that are big enough to hold onto and safe enough to put in their mouths- try bright colored teething rings and large plastic “keys.” Because babies learn by mouthing objects, buy your niece some first books made of cloth or vinyl knowing they will be heavily drooled on.

6-12 months: Around six months, babies begin to sit alone or sit propped. Intellectually, they begin to understand “cause and effect.” Good choices of gifts include toys with large buttons that make things happen with light pressure.  Toys which make sounds, play music, or cause Elmo to pop up will be a hit. For a nine-month-old old just starting to pull up to standing, a water or sand table will provide hours of entertainment in the upcoming year. Right now you can bring winter inside and fill it with a mound of snow. Buy some inexpensive measuring cups and later in the summer your toddler will enjoy standing outside splashing in the water.

12-18 months: This is the age kids learn to stand and walk. They enjoy things they can push while walking such as bubble blowers, plastic lawn mowers or plastic “poppers” that have little balls inside that pop around when pushed.

18-24 months: Kids this age still like to push toys while walking, and although kids can not pedal, they enjoy riding on toys such as big wheels “Fred Flintstone” style. Dexterous enough to drink out of a cup and use a spoon and fork, toddlers can always use another place setting. Toddlers are also able to manipulate shape sorters and toys where they put a plastic ball into the top and the ball goes down a short maze/slide. They also love containers to collect things, dump out, then collect again.

2-3 years: To encourage motor skills, offer tricycles, balls, bubbles, boxes to crawl into and out of. Go with crayons over markers because crayons require a child to exert pressure and therefore develop hand strength. Dolls, cars, and sand boxes all foster imagination. Don’t forget those indestructible board books so kids can “read” to themselves.

3-4 years: Now kids engage in elaborate imaginary play. They enjoy “dress up” clothes to create characters- super heroes, dancers, princesses, kings, queens, animals. They become adept at pedaling tricycles or even riding small training-wheeled bikes. Other gift ideas include crayons, paint, markers, Play-doh®, or side-walk chalk. Children this age understand rules and turn-taking and can be taught simple card games such as “go fish,” “war,” and “matching.”  Three-year-olds know colors but can’t read- so they can finally play the classic board game Candyland®, and they can rote count in order to play the sequential numbers game Chutes and Ladders®.

5-year-olds: Since 5-year-olds can hop on one foot games like Twister® will be fun. Kids this age start to understand time. In our world of digital clocks, get your nephew an analog clock with numbers and a minute hand… they are hard to come by. Five-year-olds also begin to understand charts— a calendar will also cause delight. They can also work jig-saw puzzles with somewhat large pieces.

8 years old: Kids at this point should be able to perform self help skills such as teeth brushing. Help them out with stocking stuffers such as toothbrushes with timers. They also start to understand the value of money. The kids will appreciate gifts such as a wallet or piggy bank.  Eight-year-olds engage in rough and tumble play and can play outdoor games with rules. Think balls, balls, balls- soccer balls, kickballs, baseballs, tennis balls, footballs. Basic sports equipment of any sort will be a hit.

10-year-olds: Fine motor skills are quite developed and intricate arts and crafts such as weaving kits can be manipulated. Also ten-year-olds value organization in their world and want to be more independent. Therefore, a watch makes a good gift at this age. And don’t forget about books: reading skills are more advanced at this age. They can read chapter books or books about subjects of interest to them.

Tweens: Your child now has a longer attention span (30-40 minutes) so building projects such as K’nex® models will be of interest to her, as well as puzzles with hundreds of pieces. This is a time when group identity becomes more important. Sleepovers and scouting trips are common at this age so sleeping bags make great gifts. Tweens value their privacy – consider a present of a journal with a lock or a doorbell for her room.

Teens:  If you look at factors which build a teen into a resilient adult, you will see that adult involvement in a child’s life is important. Create opportunities for one-on-one interaction by giving gifts such as a day of shopping with her aunt, tickets to a show with her uncle, or two hours at the rock climbing gym with dad. Teens usually have enough “stuff” anyway.

However, if you want to give “stuff,” here are some suggestions:

Since it’s best for kids back to carry the weight of school books on two shoulders (see our post about backpack safety), find your teen a cool backpack.

Encourage physical activity. Sports equipment is always pricey for a teen to purchase- give the fancy sports bag he’s been eying and encourage physical activity with a gym membership.

Hunched over the computer is not an ergonomically correct way to study.  Prevent your kids from growing into adults with strained necks and backs by getting a key board and chair set which is kind to their bodies.

Happy shopping.

Naline Lai, MD and Julie Kardos, MD

©2012 Two Peds in a Pod®

A decade ago, we wondered if arsenic was in pressurized wood-containing playground equipment . Then we worried about the toxin turning up in apple juice . Now recent reports say arsenic is in the US rice supply .

Uh oh.

As an Asian-American I often cook rice for my family, so I emailed my toxicologist sister when the reports of arsenic in rice first surfaced.

“It’s okay,” my sister emailed back, “Just wash/rinse the rice several times. It’s not like we’re drinking water in Bangladesh.”

“That’s it?” I thought to myself and decided to call her. After all, I figured she is one of a small number of board certified medical toxicologists and an author of a paper on arsenic.

“What is arsenic anyway?” I asked when I got her on the line.

“It’s a naturally occurring element,” she said. To be more precise, it’s number 33 on the periodic table. Like other elements such as iron, lead or calcium, arsenic is found in the earth’s crust.

Here’s what  I learned about arsenic:

Why did my sister reference Bangladesh in her email? In the 1970’s drinking water
was in short supply in Bangladesh. Contamination of water by sewage and
monsoons lead to diarreheal illness and high infant mortality rates.
Hundreds of thousands of wells were drilled in order by well meaning aid
organizations. Unfortunately, unbeknownst to the drillers, Bangladesh
sits over a pocket of arsenic rich soil. As a result, some estimate one
in five of the drilled wells is contaminated with arsenic.

How does arsenic affect humans?

Organic arsenic is not toxic and is found in seafood. The inorganic form of arsenic, however, interferes with Adenosine–Tri- Phosphate (ATP), which is a building block for cellular energy. When a large amount is ingested at one time, the body goes haywire, causing many vital organs in the body to shut down.

Chronic effects of low amounts of poisoning are more subtle. Exposures to low levels over time are linked to some cancers such as bladder and skin cancer.

How does arsenic enter the body?

By eating or drinking of tainted substances. Rarely, arsenic is inhaled. Absorption of arsenic will not occur via touch.

Can I tell if something is tainted?

No. Arsenic is colorless and tasteless when dissolved in water. In fact, arsenic’s nick name is “Inheritance Powder” because it was used to speed up royal inheritances in medieval and renaissance Europe.

Should I run out and have my kids tested?

No. Arsenic does not accumulate in the body. It moves in and out quickly. A spot test is not meaningful. Think of eating trace amounts of arsenic like eating the charred part of a piece of steak.

To lower arsenic levels or any other potential contaminant on food, wash, wash, wash:

-Wash your hands before you prepare food.

– Wash your child’s hands before she eats.

–Wash your produce (meat does not need to be washed).

Also, serve a variety of foods to minimize the chances your family will be exposed to a large quantity of any potential toxin found in one food source.

What about rice cereal? Is it safe for my baby?

The jury is still out. For now, limit the amount of rice cereal you give to your baby. For details and the latest updates www.aap.org

Tonight my family will be eating ribs and rice…just hold the arsenic.

Naline Lai, MD with Julie Kardos, MD

With thanks to Melisa Lai Becker, MD, director of medical toxicology of the Cambridge Health Alliance

©2012 Two Peds in a Pod®

We can tell from this past week at the office that croup season has started. DON’T PANIC! Read on to learn what to look for and what to worry about. Please also listen to our podcast on this same subject.

You wake up in the middle of the night to the sound of a seal barking…inside your house. More specifically, from inside a crib or toddler bed. Unless you actually have a pet seal, that sound is likely the sound of your child with croup.

“Croup” is the lay term for any viral illness causing swelling of the voice box (larynx)  which produces a seal-like cough. The actual medical term is “laryngotracheobronchitis.”  In adults, the same viruses may cause laryngitis and hoarseness, but minimal cough. In children the narrowest part of a child’s airway is his voice box. So not only does the child with croup sound hoarse when he talks and cries, but since he breathes through a much narrower opening, when he forces air out with a cough, he will sound like a barking seal. When a kid with croup breathes in, he may produce a weird guttural noise, called “stridor.”

Many viruses  cause croup, including  flu (influenza) viruses. Therefore, a flu vaccine can protect against croup. While no antibiotic or other medicine can kill the croup causing viruses, here are some ways to help your child feel better.

What to do when your child has croup:

Stay calm. The noisy breathing and barky cough frighten children and their parents alike. It’s easier for the child to breathe when he is calm rather than anxious and crying. So, even if you are scared, try to act calmly since children take their cues from their parents.

Try steam. Run the shower high and hot, close the bathroom door and sit down on the bathroom rug with your child and sing a song or read a book or just rock him gently. The steam in the bathroom can help shrink the swelling in your child’s voice box and calm his breathing.

Go outside. For some reason, cool air also helps croup. The more misty the better. In fact, many a parent in the middle of the night has herded their barking, noisy breathing  child outside and into the cold car to drive to the hospital. Once in the emergency room, the parents are surprised to find a happily sleeping, or  wide awake, chatty child, “cured” by the cold night ride.

Run a humidifier. A cool-mist humidifier running in your child’s room will also help. Make her room feel like a rain forest, or the weather on a  really bad hair day, and often the croupy cough will subside. Cool-mist humidifiers in the child’s room are safer than hot air vaporizers because vaporizers pose a burn risk. It’s the mist that helps, not the temperature of the mist.

Offer ibuprofen or acetaminophen. Your child may cough, and then cry, because her throat is sore. Pain relief will make her more comfortable and allow her to get back to sleep.

Who needs further treatment?

Most kids, more than 95%, who come down with croup, get better on their own at home. Typically, croup causes up to three nights of misery punctuated by trips into the cold night air or steam treatments. During the day, kids can seem quite well, with perhaps a slightly hoarse voice as the only reminder of the night’s tribulations. Why croup is worse at night and much better during the daytime hours remains a medical mystery. One theory is, just like ankles swell after one is upright all day, swelling in the voice box increases when people lie down. After the three nights, your child usually just exhibits typical cold symptoms with runny nose, a regular sounding cough, watery eyes, and a possible ear infection at the end. Then brace yourself for next time—kids predisposed to croup tend to get croup the next time a croup causing virus blows into town. But take heart, most kids outgrow the disposition for croup around six years of age.

Some kids do develop severe breathing difficulties. If your child shows any of these symptoms, get emergency medical care:

Turns pale or blue with coughing. Turning red in the face with coughing is not as dangerous.

Seems unable to swallow/unable to stop drooling.

Breathing fails to improve after steam, cool air, humidity, or breathing seems labored– nostrils flare with every breath or chest heaves with every breath—pull up their night shirts to check for this. See this link for an example of labored breathing.

Mental state is altered: your child does not recognize you or becomes inconsolable.

Child is unimmunized and has a high fever and drooling along with his croup symptoms: he may not have croup but rather epiglottitis, most commonly caused by a vaccine-preventable bacteria. This is a separate illness that can be fatal and requires airway management as well as antibiotics in a hospital.

We searched the internet for a good example of what the “seal bark” cough of croup. The best imitation we found is actually the sound of a sea lion. We will have to ask a veterinarian sometime if seals and sea lions get croup. If so, what do they sound like?

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®