A mom wrinkles her brow and  hands me a bulging bag of inhalers. “Which medicine is the ‘quick fix’ inhaler? And which medicine is the ‘controller’ inhaler?” she asks.

Perfecting a treatment regimen for a child with asthma initially can be tricky and confusing for parents. But don’t panic. There are simple medication schedules and environmental changes which not only thwart asthma flare ups, but also keep lungs calm between episodes. The goal is to abolish all symptoms of asthma. Here are some commonly used measures used in non-hospitalized patients:

For asthma flares

Albuterol (brand  names Proair, Proventil, Ventolin). When inhaled, this medicine works directly on the lungs by opening up the millions of tiny airways constricted during an attack. Albuterol is given via nebulizer or inhaler. A nebulizer machine areosolizes albuterol  and pipes a mist of medicine into a child’s lungs through a mask or mouth piece.

For kids who use inhalers, we provide a spacer, a clear plastic tube about the size of a toilet paper tube which suspends the medication and gives the child time to slowly breathe in the medication. Without a spacer, the administration technique can be tricky and even adults use inhalers incorrectly. Albuterol in a drinkable form does exist but is less effective and has more side effects.

Prednisone (brand names include Prelone, Prednisolone, Orapred): Given orally in the form of pills or liquid, this steroid medicine acts to decrease inflammation inside the lungs. The kind of steroid given is not the same kind used illegally in athletics. While steroids in the short term can cause side effects such as belly pain and behavior changes, if needed, the advantages of improving breathing greatly outweigh these temporary and reversable side effects. However, if your child has received a couple rounds of steroids in the past year, talk to your pediatrician about preventative measures to avoid the long term side effects of continual steroid use. 

Quick environmental changes One winter a few years ago, a new live Christmas tree triggered an asthma attack in my patient. The only way he felt comfortable breathing in his own home was for the family to get rid of the dusty tree. Smoke and perfume can also spasm lungs. If you know Aunt Mildred smells like a flower factory, run away from her suffocating hug. Kids should avoid smoking and avoid being around others who smoke.

For asthma prevention

Taking preventative, or controller medicines for asthma is like taking a vitamin. They are not “quick fixes” but they can calm lungs and prevent asthma symptoms when used over time.

Inhaled steroids (brand names Flovent or Pulmicort, for example) work directly on lungs and do not cause the side effects of oral steroids because they are not absorbed into the rest of the body. These medicines work over time to stop mucus buildup inside the lungs so that the lungs are not as sensitive to triggers such as cold viruses. 

Monteleukoclast (brand name Singulair)  also used to treat nasal allergies, limits the number and severity of asthma attacks as well by decreasing inflammation at a different point than steroids. It comes as a tiny pill kids chew or swallow daily.

Avoid allergy triggers  (see our allergy post ) and respiratory irritants such as smoke. Even if you smoke a cigarette outside, smoke clings to clothing and your child can be affected.

Treat acid reflux appropriately. Sometimes asthma is triggered by reflux, or heartburn. If stomach acid refluxes back up into the food pipe (esophagus), that acid could tickle your child’s airways which lie next to the esophagus.

Avoid Respiratory Viruses and the flu. Teach your child good hand washing techniques and get yearly flu shots. Parents should schedule their children’s flu vaccines as soon as the vaccines are availiable.

Use Peak flow meters. Peak flow meters are small, hand-held devices that measure how well your child’s lungs are functioning and can detect an impending asthma flair before the cough or symptoms are obvious. The child blows as hard as he can into the small plastic air chamber and gets a number score. Baseline scores depend mostly on a child’s height, and the meters come with charts to guide what your child’s best score on a good day should be. The child tracks his scores daily until his baseline is well established. Then, if the child starts with a runny nose, he begins using his peak flow meter. If the number drops from baseline, treatment medicine (albuterol) is started. An asthma attack may be prevented because the attack is treated before symptoms get bad. 

Some parents are familiar with asthma because they grew up with the condition themselves, but these parents should know that health care providers treat asthma in kids differently than in adults. For example, asthma is one of the few examples where medicine such as albuterol can be dosed higher in young children than in adults. Also some treatment guidelines have been improved upon recently and may differ from how parents recall their own asthma was managed as children.  A doctor friend now in his 50’s said his parent used to give him a substance to induce vomiting. After vomiting, the adrenaline rush would open up his airways.

Don’t do that. We can do better so that both you and your child can breathe easy about asthma.

Julie Kardos, MD with Naline Lai, MD
©2010 Two Peds in a Pod℠

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Last week a nurse in my office rushed a one year old girl back to one of my exam rooms. She was sitting in her mom’s lap, anxious and breathing hard. Her nostrils flared with every breath she took, and when I had her mom pull up the child’s shirt, I could see her ribs every time she inhaled because she was using extra muscles in her chest to breathe.  Her belly was moving in and out as well. Her breathing had just become labored an hour before the office visit.  The child had similar experiences in the past and now carries the diagnosis of asthma.

Asthma. Parents initially cringe at the diagnosis. But what is it? Most children with asthma never show up in the office with an attack as severe as the child I described above.

Asthma is a condition where the millions of airway tubes (called bronchioles) throughout the lungs get clogged with mucus (inflammation) and also get narrower (constrict) and thus become harder to breathe through. Medicine reverses the effects of asthma. Think of asthma as sensitive airways.  A nasty cold virus or the billowing dust cloud from cleaning the garage makes everyone’s airway spasm. In kids with asthma, the spasm may be more severe, resulting in more cough or airway tightening.

Asthma is the most common on-going illness in children. Many babies and toddlers who have asthma have a good likelihood of outgrowing it by age three. Another subset of children, again especially below age three, have ONE episode that looks for all the world like asthma, but then they never have another episode.  Other kids have asthma that stays and these kids and their families must proactively manage their asthma long term.

Asthma symptoms can start at any point, from infancy through the teen years. Adults can be diagnosed with asthma for the first time at age fifty.  Dr. Lai has had symptoms of asthma since childhood but Dr. Kardos first had symptoms of asthma when she turned thirty.

The tendency to develop asthma is genetic, but there are environmental triggers in kids who carry the asthma gene. The most common triggers of asthma flares are cold viruses, cigarette smoke, and environmental allergies (animals, pollen, etc). Also, air pollution, exercise, and very strong scents (new house paint or perfume, for example) can trigger an asthma attack. It is also common for someone with asthma to have allergies and/or eczema (excessively dry, irritated skin).

How do you know your child has asthma? No one test can definitively identify asthma.  Chest x-rays cannot show asthma. Sometimes Pulmonary Function Testing  in older children helps doctors diagnose asthma, but younger kids often have a hard time performing the test.

Pediatricians diagnose asthma by studying the past experiences of the child.  Not every child is out of breath like the patient I saw in the office. The most common symptom of asthma is cough.  Watch for the following symptoms:

1. Night time cough most nights of the week, usually starting somewhere after midnight. The child may or may not wake up because of the cough.
2. Cough that shows up with exercise, usually after several minutes of running, swimming, jumping, even laughing.
3. Cough with a common cold virus that lasts much longer than what is typical—longer than two weeks after the onset of a cold when most other kids or siblings with the same cold are better.
4. Cough that is accompanied by increased work of breathing. Your child’s nostrils may flare in and out with each breath, or her ribs might stick out with each breath, or her breathing rate is much higher than baseline as if she were just running hard even when she is just resting. She might not be able to talk in complete sentences, drink, or eat because she is too short of breath.
5. A wheeze— a high pitched sound heard during exhalation. The sound is not the strange, hoarse sound heard during inhalation (e.g. in a child with croup) nor is it the mucus/rumble you hear from the back of the throat of most kids with a cold.
6. Cough triggered by cold: eating an ice pop or breathing cold, winter air, for example.

Don’t worry about labeling your child with the diagnosis of asthma.  Gone is the stereotype of a child with asthma as a sickly kid who sits in the corner and is told not to participate in sports.  A large percentage of Olympic athletes have asthma.  The diagnosis of asthma will open up a world of medication and lifestyles which can soothe your child’s irritated airways.

Stay tuned for Understanding Asthma, part 2: the treatment of asthma.

Julie Kardos, MD and Naline Lai, MD
©2010 Two Peds in a Pod℠

Panic.

Off to the mall today with my children. Everyone was strapped in the minivan ready to go.  But where were the gift certificates the kids just got for Christmas from the relatives? I was perplexed and scuttled back into the house. Inside, I recreated in my head the scene at grandma and grandpa’s where I had last seen the gift certificates. At their house, after the children had properly said their thank yous, I remembered carefully folding the certificates in tissue paper and tucking them into the sparkly blue gift bag which was to go to my parents on behalf of my in-laws.  As an added guarantee that they would not be forgotten, I deliberately placed the blue bag with the other presents we had received. Where could they be? After all, they were safely in the big black trash bag with all of the other presents.

The trash bag? Oh dear.

Suddenly I remembered arriving home from my in-laws to a family room cluttered with gifts from Santa. I told the kids to clear everything out. When the dust settled I saw a big black trash bag in the center of the room. I grabbed it and threw it in the garage. Then a Christmas miracle happened.  In the midst of holiday hub-bub, my husband remembered that it was trash pickup day and took out the trash.

Gone were the gift certificates. Gone were my in-law’s presents to my parents. Gone was the plug in Star Wars game module. Gone was the “last copy” of a book of Chinese folk tales lovingly picked out for my daughter. And gone was the silly Bop- it game, a crazy game of Simon Says where one of the commands is to “bop” the toy against your tummy.

For a brief moment I contemplated running down to the dump and trolling through the garbage. After all, there were probably only a couple thousand black garbage bags. If I started now, I could be done by next Christmas.

Laughing (what else could I do?), I made my way back to the car where I broke the news to my kids. I too was disappointed, but I couldn’t go back and undo the event.  I had no choice but to laugh.

Together, between the tears, we stepped through lessons learned.

Lesson #1 Be more careful with our things

Lesson #2  Forgiveness is hard but essential for moving forward

Lesson #3 We were happy two days ago and that was before the presents arrived

Lesson #4  Let your kids play with their new toys the moment they get them- you never know when they will disappear

And the most important lesson #5 Use clear trash bags

My oldest smiled slowly and pointed out that I had declared to the kids, “Any presents not cleared out of the family room and put away in your own rooms will be thrown out.” I had unknowingly carried out my threat. Gradually, murmurs of disappointment gave way to laughter as we all imagined a scruffy bearded hobo going through the garbage picking up gift certificates from the girly stores Justice and Abercrombie.  Somewhere there is a stylin’ hobo with a scruffy beard in a fur trimmed hooded puffy coat and tank top, hopping up and down, playing Bop-it.

The minivan shook with laughter.”Oh, mommy, I’m laughing so hard my stomach hurts,” my daughter said. “Mine too,” my other two moaned between giggles.

The cost of “the stuff”:

A lot.

Making kids laugh so hard that their stomachs hurt:

Priceless.

Naline Lai, MD
©Two Peds in a Pod℠

Kids are noisy. A noisy child is usually a healthy child, so we pediatricians welcome noise. Today we give you Top Ten Sounds we are grateful for this Thanksgiving:

10. The sound of a six-month-old baby’s belly laugh.

 9. The sound of a two year old trying to say “gobble, gobble, gobble.”

 8. The sound of a three year old saying “why?” about 100 times a day.

 7. The sound of a chatty first grader who tells you about her favorite part of her day in one gigantic run-on sentence.

 6. The sound of a grade school orchestra concert (as heard through ear plugs).

 5. The sound of a high school orchestra concert played by the same students you remember playing in their grade school concert.

 4. The sound of a teenager confiding something very important during a check up and then answering “yes” to the question “Do your parents know about this?”

 3. The sound of a high school senior saying he got into his first choice college.

 2. The sound of children (and their pets) breathing as they sleep.

 1. The sound of a child’s small voice at Thanksgiving dinner leading her family in thanks.  

Wishing you all a noisy Thanksgiving.

Julie Kardos, MD and Naline Lai, MD

©2010 Two Peds in a Pod℠

Although the American Congress of Obstetricians and Gynecologists recommends a first gynecological visit between 13 and 15 years of age, a teen usually does not need to have an internal pelvic exam at the first visit unless she is having problems or unless there is a need to screen for certain sexually transmitted diseases.

For more information, please visit  http://www.acog.org/publications/patient_education/bp150.cfm.

Julie Kardos, MD and Naline Lai, MD

The American Congress of Obstetricians and Gynecologists in June recommended adolescent girls have their first visit with an ob-gyn between the ages of 13 and 15 to help set the stage for optimal gynecologic health. This visit does not necessarily include an internal pelvic exam. Last month the American Academy of Pediatrics released a policy statement outlining when teenage girls may stay with their pediatrician for routine care. Our guest blogger today, pediatrician Dr. Carly Wilbur, illustrates for us the guidelines.

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Last week, I saw a 14-year-old young lady who suffered painful menstrual cramps.  Her mother wanted her to see a gynecologist, but my patient was reluctant.  At my office, we have a room that is dedicated to providing gynecologic care, including pelvic exams, that contains a proper exam table with stirrups.  The patient, her mother, and I discussed reasons that some adolescents can have their gynecologic health managed in the pediatrician’s office and some teenagers get referred to gynecologists. 

Many pediatricians can handle:

• Routine/annual gynecological exams, including a Pap test,  in sexually active patients
• Vaginal/cervical cultures used to diagnose new conditions (some general pediatric offices are even equipped with a microscope to aid in their evaluations)
• Acute gynecologic concerns such as vaginal discharge, itching, or a change in menstrual flow

Reasons for a referral to a gynecologist include:

• The patient has pelvic pain and needs further evaluation of her ovaries, fallopian tubes, or uterus
• Patient and pediatrician have failed to find a birth control pill that is acceptable (too many side effects or unacceptable side effects) and thus require expert opinion of a gynecologist regarding oral contraceptive pills
• The patient engages in high-risk sexual activity
• Pediatrician does not provide gynecologic services
• The patient becomes pregnant

This family opted to have me perform my patient’s first pelvic exam since I was familiar to her and this brought her some comfort. 

Carly W. Wilbur, MD, FAAP

Suburban Pediatrics, Inc.

Rainbow Babies and Children’s Hospital

Cleveland, Ohio

© 2010 Two Peds in a Pod℠
Revised 9:15pm 10/25/10

Lately my office staff has taken to giving out Sillybandz as rewards for kids who bravely endure the sting of vaccines , cooperate during exams, or just behave well while along for the ride at a sibling’s doctor visit. The kids LOVE them. Better than stickers. Healthier than lollipops.

Parents can become frustrated when searching for effective therapeutic treatment for childhood anxiety. Parents want to know what works and what their child will experience. Cognitive behavioral therapy is one type of therapy for children which directly addresses the behaviors kids exhibit. When anxiety starts, CBT gives kids concrete strategies to employ. Today psychologist and mom, Dr. Leah Murphy gives us an example of cognitive behavioral therapy treatment and how it involves the patient’s family and community.

Naline Lai, MD and Julie Kardos, MD

We all experience anxiety at times; anxiety can help us get things done (e.g., study for a test, finish a project, complete things in time for deadlines) and inform us that something is wrong. However, frequent, moderate to high levels of childhood anxiety both prevent, and interfere with, enjoyment and success in the school, home, and social arenas, resulting in a poorer quality of life. Wanting to improve your child’s anxiety and stress without “pushing them” much? You could have a look about at what summer activities for kids might be able to help manage their anxieties.

The experience of Connor, an 11 year-old boy, is a good example of how children can experience and show social and separation anxiety, as well as of how psychologists help children with anxiety.

Connor constantly worried. When he came to school Connor clung to his mother. At bedtime, Connor was unable to fall asleep without a parent staying with him, and he would often wake up and go into his parents’ room in the middle of the night. He even felt uncomfortable talking to other children. He constantly worried that kids would not like him and that he would “do something” that would cause the other children to tease him. He would avoid other children, and as a result, he had very few friends. He felt sad and lonely. Connor’s social and separation anxiety also manifested in physical symptoms. He felt nauseous, tired, suffered headaches and stomach aches, and experienced panic attacks in social situations. At school, Connor failed to concentrate on his work. Anger ensued when he felt pressure to perform anxiety provoking acts.

To help Conner, his pediatrician determined Conner had anxiety but no other medical condition and referred Conner to us for therapy. Our initial therapy sessions focused on teaching him how to to identify and express his feelings. During these sessions he created a feelings dictionary book and a feelings collage.

During the next set of sessions, Connor learned relaxation skills (deep breathing and muscle relaxation), positive coping thinking (“I can do this, the chance of something bad happening is very small, the chance of something good happening is very big”), and problem solving skills to help him to identify and implement solutions to the problems that made him nervous. Most sessions were conducted individually, but his parents participated in these sessions at times to learn the skills and to establish a plan for practicing and using these skills outside of our sessions. Also, I conducted parent-only and family meetings helped his parents cope with their own stress and anxiety about Connor’s difficulties.

During the last part of the skills based therapy, Connor used his skills in the situations which made him anxious. Starting with the least anxiety provoking situations, he gradually worked into more anxiety provoking situations. He practiced asking a teacher for a pencil, asking a waiter for a napkin/straw, introducing himself to a new peer, giving answers in class, asking a teacher for help, and going to swim lessons/baseball. We made a list of coping strategies (think positive, deep breathing, muscle relaxation, use problem solving steps, ask an adult for support/help) that he could use when overcoming anxiety provoking situations. He hung this list in his room and sometimes took it with him in his pocket or backpack. Apparently it was a lot of help to him.

Connor’s parents and school/camp staff prompted and reinforced his use of these skills in anxiety provoking situations. Connor had a point chart in which he earned points for using his skills and doing anxiety provoking activities. When he earned a sufficient number of points, he would pick a privilege from the privilege list that he created with his parents. Parent-only meetings during this time further assisted his parents cope with the discomfort and distress that they experienced when Connor began engaging in situations that caused him anxiety.

Additionally, Connor participated in a social skills group for children experiencing anxiety. Therapy groups are a great way for children to practice social skills while in a small group setting under supervision. The group practiced relaxation skills, as well as introduction/greeting and conversation skills. The group also learned skills to make friends.

In response to the therapy, all of Connor’s anxiety symptoms stopped over the course of 9-12 months, and his mood changed from anxious and fearful to calm and happy much of the time. He successfully attended school, participated in camp and after school programs, participated in social and recreational activities with children, and established friendships.

Sometimes, other strategies are needed to alleviate anxiety, including medication. Your pediatrician is able to provide information about medication options.

Leah Murphy, Psy.D.

Center for Psychology and Counseling www.psychologyandcounseling.com

© 2010 Two Peds in a Pod

(introduction modified 10:48a.m. October 13, 2010)

She’s eyeing your lip gloss and won’t wear clothes with animals or hearts on them anymore. She’s begging you for a Facebook account, but still talks to her dolls and holds her dad’s hand in public. Yes, your daughter is on the edge of puberty and you’ve been talking to her about her upcoming body changes and getting her period. But your own memory of early adolescence from a couple of decades ago is a little fuzzy. Beyond the basic anatomical changes, did you cover everything?  Here is a smattering of questions about menstruation which may not have occurred to you, but we hear in the office:

From the girls: Does a period hurt just like when I cut myself?

In a kid’s experience, blood is associated with an injury and therefore pain. Reassure your daughter that bleeding during a period is not like the bleeding of a cut. Yes, you can mention that she may feel cramps, but usually not initially.

From the moms: When can she wear a tampon?

At any point. Several manufacturers make tampons especially designed for teens. Do not worry; even for a virgin, a tampon will not cause any injury. Just like you’ve taught her everything, you may need to teach her how to insert and take out a tampon.Warning—do not teach her five minutes before she leaves for the beach during her period. For some girls, removing the tampon is more difficult than inserting it. Teach her/ talk it through when she is not menstruating. Remind her to change tampons frequently- young girls in particular are more vulnerable to Toxic Shock Syndrome.

From both: It’s been months, how long until her period is regular?

It can take around two years for periods to come regularly. Once they are regular, the average frequency is every 28 days, but can vary from 21 to 36 days.

From the girls: Will I know when I get my period?

Let your girls know that when they see their first period it may not be a bright red blotch of blood on their underpants. Explain that dried blood looks like brownish streaks; they may confuse it with stool.

From both: In this age of skinny jeans and jeggings, where to hide a pad or tampon during school?

If she doesn’t carry a purse, then have your daughter try inside the cuff of a sock or tucked in the waistband of pants. I have seen a thin pad hidden under the tongue of a sneaker.

From the girls: Do I go to the nurse’s office if I get my period for the first time during school?

Not necessarily, unless you are looking for pads. This is not an illness.

Remind your tween to let you know when she starts getting her period and that you will keep it private. One girl told me she did not tell her mother for months. The reason? Her neighbor’s mother had given her neighbor a “Red” party in honor of her neighbor’s first period. Everyone wore red to the party and there was even a red cake. My patient was appalled at the attention and avoided telling her own mother until well after her menstrual cycle was well established.

Also, you can help your tween track how heavy her flow is by checking her supply of pads and tampons. Excessively heavy periods cause anemia from blood loss and young girls can be unaware how much blood loss is normal. Remind her that if she has to change a pad once an hour, or if her period drags on over a week (average is three to seven days) she needs to tell you about it. Even without excessive blood loss, make sure she eats iron containing foods (eg. spinach, lean red meats) to help prevent anemia.

If you get overwhelmed by all the facts about menstruation which need to be explained, keep in mind this conversation I once had during a check-up. During the visit I gave a young teen a moment alone to ask questions privately. As the door closed behind her mother, I asked the girl if she had any questions about adolescence.

“No questions,” she declared.” I wear a bra… I bleed every month. There’s nothing else to know.”

Wish everything about the teenage years could be so simple.

Naline Lai, MD with Julie Kardos, MD

© 2010, revised 2017 Two Peds in a Pod®

Two Peds in a Pod turns today to guest blogger Dr. Alan Woolf, Director of the Pediatric Environmental Health Center at Children’s Hospital Boston and president-elect  of the American Academy of Clinical Toxicology, to tackle the question, “Should you feed your kids organic fruits and vegetables?”

Nutritionists are urging parents to feed kids one and one-half cups of fruit and two and one-half cups of vegetables daily and the American Academy of Pediatrics suggests whole fruit rather than juice to meet most of the daily fruit requirements. 

 Are they worth it? Will non-organic produce harm your kid? No easy answers here. American consumers demand a bountiful supply of blemish-free, perfect fruits and vegetables. We want unspotted shiny red apples, brightly colored large oranges and arrow-straight asparagus. Farmers want to give us just that. Since pests attack crops causing blemishes, worms, blight, and other forms of costly crop damage, farmers have been using pesticides for years to increase crop yield, profit, and visual marketability. 

The US Dept of Agriculture (USDA) regulates the agricultural procedures and labeling that use the buzz word organic. Obviously every business wants to put that word on their product if it means consumers will run out and buy it. The USDA will certify farms that use organic methods. But even the USDA’s definition of organic allows a percentage of synthetic chemicals to be added to products labeled organic. Also organic does not mean that the food contains increased amounts of essential minerals and vitamins or is more nutritious for you. And remember that organic produce doesn’t necessarily come from small, cuddly, local, family-run farms. Most large, international agribusinesses are touting organic foods for sale these days.

That being said, you still need to be cautious. In pediatrics we often invoke the “precautionary principle.” The idea is that if you don’t exactly know what a chemical will do to a child’s health because there aren’t enough scientific studies out there, then you assume that what it is capable of is bad and so, if possible, try not to expose them, just as a precaution. 

When you can, buy from local farms or stands where you can ask them their growing practices, or else just grow your own. If you decide to buy organic foods, you should eat them right away. They may not stay edible as long without preservatives. Again, no matter what type of food you buy, wash, wash, wash.

Finally, alternative “greener” farming techniques, integrated pest management (IPM), and more resistant varieties of plants have increased crop yields, in many cases without using as much pesticide. That’s good news for all of us. Breeding of genetically-engineered plants require less use of pesticides, but they may not be acceptable to most consumers. That’s a whole column in itself!

The bottom line: My wife and I will try to buy organic foods when we think of it, but we don’t obsess over it when we forget. 

Alan Woolf, MD, MPH, FAACT, FAAP

Director, Pediatric Environmental Health Center, Children’s Hospital Boston

© 2010 Two Peds in a Pod®