New American Academy of Pediatric recommendations include a booster vaccine against the cause of meningococcal disease  (Neisseria meningitidis) for older teens in addition to the one routinely given to tweens. Olga Pasick, mom of a teen who died of meningococcal disease, shares her personal experience and talks about the updated guidelines.

I wish I had known the importance of vaccination for meningococcal disease before it was too late for my son. Back in September of 2004, David was a happy, healthy 13 year old, who came down with flu-like symptoms one evening. He first felt cold, then spiked a high fever, and vomited throughout the night. In the morning we called the pediatrician to have him seen. Everything ached, and he needed help getting dressed. That’s when I noticed purplish spots on his chest and arms. I didn’t know how serious that symptom was. As soon as the doctors saw him, they knew he had meningococcal disease. He was rushed to the ER for a spinal tap and treatment. Unfortunately, the disease spread quickly and his organs failed. David died within 24 hours of first developing those flu-like symptoms from a potentially vaccine-preventable disease. Unbelievable… and heartbreaking.

Meningococcal disease is spread through respiratory droplets, such as coughing or sneezing, or through direct contact with an infected person, such as kissing. About 1 in 10 people are carriers, and don’t even know it. It doesn’t affect everyone. It is difficult to diagnose because symptoms are similar to the flu, and include high fever, headache, stiff neck, nausea, vomiting, exhaustion and a blotchy rash. The disease spreads quickly and within hours can cause organ failure, brain damage, amputations of limbs, and death.

The CDC (Centers for Disease Control and Prevention) and the AAP (American Academy of Pediatrics) recommend meningococcal vaccination for all 11-18 year olds. If vaccinated at age 11-12, a booster at age 16 is recommended. If vaccinated at age 13-15, a booster is recommended at age 16-18. No vaccine is 100% effective, but it is the best preventative measure we can take. Since the vaccine only covers four of the five major strains of the disease, continue to be aware of the symptoms.

Because of my experience, I became a member of the National Meningitis Association’s (NMA) Moms on Meningitis (M.O.M.s) program. We are a coalition of more than 50 mothers from across the country whose children’s lives were drastically affected by this disease, and are dedicated to supporting meningococcal prevention.

Visit the NMA website for more information and to view powerful personal stories of those affected.  Talk to your doctor about vaccination. It could save a life. How I wish those recommendations were in place six years ago.

Olga Pasick
Wall, New Jersey

© 2011 Two Peds in a Pod®

The bad news is that influenza is now circulating in all 50 states. The good news is that according to the Centers for Disease Control, the vaccine covers all currently circulating strains. 

A mom recently wrote to us about her grade school aged child’s bedtime creeping later while her wake up time stayed the same. She wondered how to reclaim the earlier bedtime.

Many parents notice as their kids get older, they seem to take longer to fall asleep at night or push their parents for a later bedtime. This trend is largely biological— the older kids get, the less sleep they need. Also as kids age, their body clocks naturally signal them to stay up later at night and sleep later in the morning. Sometimes children are worried about something and this stress prevents them from falling asleep. Parents should ask their kids what they think about while lying in bed at night. However, many times the child is just fine emotionally but begins shifting sleep patterns anyway.

According to sleep experts, adults function best on 7-8 or more hours of sleep per night. In kids and teens, a wide variation exists for how much sleep is sufficient for any individual. In general, if your child is easy to awaken in the morning, cheerful, able to concentrate during the day, easily completes school work and homework and is not having emotional outbursts, then she is sleeping enough. So, when your grade school child transitions from getting 11-12 hours of sleep per night to getting 10, if her days are still rosy, then this sleep shift is okay. Some people just don’t need very much sleep.

If your child needs more sleep, it’s tough to simply move his bedtime up earlier. To him, the sudden change will feel like he flew from California to New York. A gradual approach works best. Put your child to bed first very near the time that he is already falling asleep, even if that seems inappropriately late.

For instance, if your child won’t fall asleep until 11:00 pm, establish a soothing night time routine that ends with reading in bed or listening to soothing music for a few minutes, and turn out the lights out at 10:45 pm. Avoid television within an hour of sleep time because this can interfere with falling asleep. No matter how late he fell asleep, even on weekends, make sure he wakes up at the same time every morning. Once he falls asleep consistently within a few minutes of lights out, move the bedtime another fifteen minutes earlier.  Continue to do this until the daytime sleep-deprivation symptoms have resolved. A child may still need an alarm to wake up in the morning but if he is well rested, he should wake easily.

Be sure to limit or avoid caffeine (found in soda, tea, coffee, some sports drinks, and chocolate) because caffeine stays in the body 24 hours and hinders falling asleep. Also, make weekend sleep routines, including wake up times, as similar to weekdays as possible. If you allow a child to sleep until noon on Saturday and Sunday, he will never be able to fall asleep early on Sunday night and he will start the school week sleep deprived.

Time to end this post. I’ve got to go put my kids to bed. Sweet dreams.

Julie Kardos, MD and Naline Lai, MD
©2011 Two Peds in a Pod®

Take a look at the February 2011 issue of Real Simple magazine. We are two of the experts cited on page 124. The good news is that some of our thoughts on the essentials of a medicine cabinet were integrated into a photo-essay piece. The bad news is that children’s cough medicine is listed as a component of the medical cabinet.  While the other contributors to the piece may encourage use of over-the-counter cold and cough medications, we discourage use.

Of concern, safety and effectiveness of cough and cold medicine has never been fully demonstrated in children.  In fact, in 2007 an advisory panel including American Academy of Pediatrics physicians, Poison Control representatives, and Baltimore Department of Public Health representatives recommended to the U.S. Food and Drug Administration (FDA) to stop use of cold and cough medications under six years of age.

Thousands of  children under twelve years of age go to emergency rooms each year after over dosing on cough and cold medicines according to a 2008 study in Pediatrics . Having these medicines around the house increases the chances of accidental overdosing. Cold medications do not kill germs and will not help your child get better faster. Between 1985 and 2007, six studies showed cold medications didn’t have significant effect over placebo.  

So why are children’s cough and cold medicines still around? A year after the advisory panel published their recommendations, FDA advised  against using these medications in children younger than two years but data about these medications in older children is still rolling in.   FDA continues to advise caution with these medications. The producers of cold medicines said at that point they would launch new studies on the safety of medication for those two to twelve years of age. In the meantime pharmaceutical companies stopped manufacturing cold medicine products for those under two years of age and changed the labels to read “for four years old and above.”

Yes, watching your child suffer from a cold is tough. But why give something that doesn’t help her get better and has potential side effects?  There is plenty to do besides reach for cold medicine.  Give honey for her cough  if she is over one year of age. Run a cool mist humidifier in her bedroom, use saline nose spray or washes, have her take a shower with you, and teach her how to blow her nose. Break up that mucous by hydrating her well- give her a bit more than she normally drinks.

If you have young children and want to make your medicine cabinet truly “real simple” then take out the over the counter cough and cold medication. 

Naline Lai, MD and Julie Kardos, MD
©2011 Two Peds in a Pod®

We know the first time your child rides a two wheel bike or loses a tooth is a momentous occasion. In honor of January first, we’ve compiled a list of some of our favorite, lesser known, firsts. Have we missed any of your favorites? Please add to this list.

First time he tries peas

First time she walks on sand or grass in bare feet

First time he sees snow

First time she explains to you how to work your computer

First time she sleeps through the night (if ever)

First he calls grandpa on the telephone

First poop in potty- remember saving it to show your spouse?

First time she buckles herself into the car, with no help from you

First time she sleeps over someone else’s house

First time he gives you a handmade gift

First time finding the restroom by himself in a restaurant, and you allow him to “got it alone”

First time you leave her home alone to babysit herself

First time he is too old to qualify for the restaurant’s kids menu

First time she shaves her legs or first time he shaves his face

First time your teen drives herself to a sports practice

First day your youngest starts kindergarten

We wish you a year filled with many successful “firsts.”

Naline Lai, MD and Julie Kardos, MD with mommy of three Steffie MacDonald 
©2010 Two Peds in a Pod℠

Fa-la-la-la-la, THUD.

It’s the sound of junior high bands and choir students practicing during this holiday season. That thud is the sound of a kid fainting mid-way through a long, sweltering rehearsal. Last night Dr. Lai was on the edge of her seat wondering which child would faint during her daughter’s chorus concert. In the past couple of weeks, we had a patient who fell off the stage during a musical performance and several others falling over during choir practice.  Today we discuss causes of fainting and ways you can prevent the most common reasons to faint … Just in time for pageant rehearsals.

Why do people faint? The quick answer is people faint when their brains don’t have enough blood flow. Fainting causes people to fall down. When this happens, their heads become level with their hearts, and thus the body has an easier time getting blood (and oxygen) to the brain. So then the fainted person “wakes up.”

Dehydration and anxiety are two relatively common causes of fainting. So are standing up in place for a long time, sudden pain, and underlying illness. We have had teenagers faint after they received a vaccine which they were dreading. We have seen a high school athlete play an entire soccer game, then faint while standing with her team as her coach gave information about the next practice. Another patient faints every time she suffers an injury that causes her to see her own blood, whether it is a skinned knee or a small paper cut.

Kids who faint in this way usually feel weird before they go down. They can tell that something strange is happening to their bodies. They might feel suddenly very hot and sweaty, or dizzy, or feel like their vision is blurred or sounds are coming from far away. If your child feels this way but hasn’t passed out yet, the best thing to do is have him lie down. Lying down increases blood flow to the brain and can prevent fainting.

Some fainting signals that your child has an abnormal heart or other abnormality in the body. Fainting during exercise can be caused by a heart problem. So can fainting “without warning” or without any obvious inciting event. Fainting with accompanying body shaking or rhythmic movements of arms or legs can be a seizure rather than a faint. Weakness in an arm or leg, difficulty talking or thinking after a faint are all abnormal. Staying unconscious for more than a few seconds also can be a sign of underlying problems. Vomiting, severe headache, or any persistent symptoms such as altered mental state warrant medical attention promptly.  Remember that a child who faints might hit his head when he falls and may also sustain a brain injury.

If your child faints, especially if it is the first time he faints, you should call his health care provider. Some kids need a physical exam, some need an EKG (electrocardiogram), some need blood work, and some need further workup by a specialist.

Fainting should never be ignored, but it is not always a reason for panic. Again, if your child faints, lie him down so his head is level with his heart. You can even raise his legs a few inches to make blood flow to his head even easier. Make sure he is breathing (watch for chest rise and fall, watch to see that his lips stay pink and do not turn blue). When he “comes to,” try to treat the underlying problem (give fluids if your child is dehydrated). And call your child’s health care provider to see what the next step should be.

Just hydrate your child well before his choir concert and tell him not to stand with his knees locked. Then sit back and enjoy the music.

Fa-la-la-la-la!

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

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℠