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Saturday, October 15, 2016

Great News About the HPV Vaccine!

The HPV vaccine has been a controversial vaccine on social media, but anyone who knows me knows that I agree with the recommendations and wholeheartedly endorse it for the reasons given in my favorite HPV Vaccine article.

Photo Source: Jan Christian via Wikimedia

To add to the confusion and misinformation that circulates regarding the safety of the vaccine (which I don't have room to go into here, but is discussed herehere, here, and visually here), the vaccine itself has changed (covering 9 strains now compared to the initial 4 strains) and the dosing schedule is changing.

Don't presume the change in vaccine schedule is to answer the calls of the anti-HPV vaccine crowd. That isn't needed because their claims have been debunked (see all the articles referenced above).

Dosing schedule ~ Happy News!

HPV vaccines were initially approved to be administered as a 3-dose series: dose #2 given two months after the first and the 3rd dose at least 4 months after the second. Giving doses later is acceptable, but they cannot be given too early.

There is research that supports giving just two doses at least 6 months apartA two dose schedule was approved earlier in Europe and this week was approved by the FDA in the US for children 9 to 14 years of age. The two doses should be given 6-12 months apart, which means for most kids they can get the vaccine at two regularly scheduled well visits (such as the 11 year exam and the 12 year exam) and not have to come in for additional visits.

The data support continuing a 3 dose series in those 15 years and up. This means they can get the 2nd dose 2 months after the 1st dose and then a 3rd dose at least 4 months after the 2nd dose and 6 months after the 1st dose.

The official ACIP Meeting Information is not yet available, but will be posed within 90 days of the October 19-20 meeting. (Note: I originally stated this was an October 11 meeting.)

I know that the two dose series will make many kids happy ~ one less shot for the same protection!

If two doses have already been given at less than 6 months apart or if the teen is 15 years and older, the third dose will still be needed.


I don't want to confuse everyone... the FDA has approved a new schedule, but the Advisory Committee on Immunization Practices (ACIP) will need to give their input before the schedule actually changes. That will be decided at their October 19-20 meeting.

One last addendum:

The ACIP approved the changes! Talk to your doctor about your child's vaccine needs. In short, the new recommendations state:
  • Kids who get the first HPV vaccine before their 15th birthday need two doses 6-12 months apart.
  • Kids who have turned 15 years old before the first dose should use the 3 dose series.
  • Kids who have gotten a 2nd dose less than 6 months after the first (regardless of age) need the 3rd dose.

Sunday, September 25, 2016

Fevers: How High is Too High?

Despite having fever information on our website and blogging about it many times, including here and here and here, parents often call in or bring their child in with excessive concern for fevers. (Note: paracetamol is the same as acetaminophen and Tylenol in the linked article.)

The information here is only for infants and children over 3 months who are otherwise healthy and vaccinated. If those criteria are not met, the child is in a higher risk category.

Fever is one of the biggest anxiety inducers in parents, and I want that to change. Yes, we should care for our children when they're sick, but we don't need to worry about the numbers on the thermometer.

Maybe one time I'll explain fever in a way that hits home so parents can stop focusing on the number and more on the child. Parents often tell us in detail what the temperatures are at various points of the day but omit how the child looks and acts. I care more about the child's behaviors than the thermometer's reading.

photosource: Shutterstock

I know fever is scary. Kids are miserable. But the temperature itself is not what we treat. Treat the symptoms!

What is a fever?

The number on the thermometer can be confusing to parents. How the temperature is taken is as important as the number itself to determine if it is a fever. A fever is often defined as a temperature over:
  • 100.4 °F (38 °C) rectally
  • 99.5 °F (37.5 °C) in the mouth
  • 99 °F (37.2 °C) under the arm
Those are simply the minimum temperatures that are no longer considered normal. The American Academy of Pediatrics doesn't recommend treating fevers until the temperature is over 102°F unless the child is uncomfortable. Thermometers are not very accurate, so when you worry more about a temperature that is 0.5 degree higher than another temperature, it might not even be a significant difference. You could take the temperature twice in a row and get different readings. If your child is playful and the thermometer reads 101.5°F that is a very different story than if your child is barely moving, whimpering, and breathing fast with a temperature of 101.5°F. I wouldn't recommend any fever reducers for the first, but I would recommend the second get evaluated by a pediatrician or other medical provider.

Why do we care about fevers?

I think medical professionals help to foster this fear of fevers because we ask about them. It can be helpful to know the actual temperature because many kids are warm but not really running a fever.

  • We are more contagious during a fever, which is why schools and daycares won't let kids stay if they have a fever. 
  • The height of the fever doesn't indicate if the child has an infection requiring antibiotics or not, but it can cause increasing discomfort as it rises above 102°F. 
  • The height of a fever does not cause fever seizures, but a rapid change in temperature can cause a seizure in a child that is susceptible to them.
  • If a true fever lasts more than 3-5 days or is accompanied by other concerning symptoms, the child should be seen to look for a source. 

So how high is too high?

Fevers higher than 106°F (41°C) might be the answer parents are asking when they want to know what temperature is too high. It is at this point that brain damage from the temperature itself can occur due to hyperpyrexia (heat stroke). This is not common from a simple infection and other symptoms will be present, such as change in consciousness, vomiting, flushed skin, headache, rapid breathing, and very rapid heart rate. Emergent medical attention and cooling the body is important with hyperpyrexia, which differs from fever.

If your child does not appear very ill and the thermometer reads very high, it is likely the thermometer is in error.

What if the temperature doesn't go down to normal after using a fever reducer?

When parents give a fever reducer, they often worry that the temperature doesn't go back to normal. Returning to normal doesn't mean it isn't a serious infection and not returning to normal doesn't mean that it is a serious infection. Studies show the temperature tends to decrease by 1.8 to 3.6°F. Acetaminophen begins to work in 30 - 60 minutes and has its peak effect in 3-4 hours. The duration of action is 4-6 hours. Ibuprofen begins to work in under 60 minutes and has its peak effect in 3-4 hours. The duration of action is 6-8 hours. The goal should be to make a child more comfortable though, not to get the temperature to normal.

My personal opinion is that most children won't need their temperature taken to verify that they are better. They should be more comfortable. If they aren't, then it is wise to have a medical professional look at them.

Wednesday, September 21, 2016

Flu Vaccine Recommendations for 2016-2017 Season

Flu vaccine recommendations change from year to year. Here's this year's summary:

  • Everyone over 6 months should get a flu vaccine. This includes children, teens, adults, pregnant women, the elderly, and most people with chronic diseases.
  • The vaccine can be used as soon as it is available. (Note: the elderly might benefit from waiting until October due to potentially shorter duration of protection.) Preferably vaccination will happen by November, but vaccination can be done any time the vaccine is available. Illness from influenza can occur at any time in the year, but is most common in the winter and early spring, so vaccinating throughout the season is appropriate if it has not already been done.
  • The nasal spray is not recommended this year.
  • People with egg allergies can get the flu vaccine and don't have to be monitored for 30 minutes afterwards unless they have a history of severe reactions to egg (not just hives). The amounts of egg protein in the flu vaccines are so low that an allergic reaction is not likely.
  • Kids under 9 years of age who have previously received two or more total doses of any influenza vaccine only need one dose of flu vaccine this season. The big difference from previous recommendations is that the two doses don't need to have been given during the same season or even in consecutive seasons - any two flu vaccines count.
  • Different brands of flu vaccine are approved for use in various age groups, but they all include the same strains of viruses. This year’s strains are:

    o A/California/7/2009 (H1N1)pdm09-like virus
    o A/Hong Kong/4801/2014 (H3N2)-like virus
    o B/Brisbane/60/2008-like virus (B/Victoria lineage)
    o B/Phuket/3073/2013-like virus (B/Yamagata lineage) (quadrivalent vaccines only)

The flu shot is not going to give you the flu. 

I got mine! 

It might cause a sore arm, low grade fever, and headache, but that is brief and doesn't limit activities. I have heard many times that people were sick after getting the shot, but most often they were sick with whatever virus was going around town, not the flu. If they did get the flu that season, they were generally not as sick as those who got the flu without previously being vaccinated. (People who had the FluMist at times did get very sick with the flu, which is one of the reasons it is not being used this year.)

Influenza disease causes significant illness that usually improves within 2 weeks, but can lead to severe complications (including death). The majority of people who get the flu do not develop the severe complications, but they do miss a significant amount of work or school. Save yourself (and your family) and get the shot!

Related blogs

Vaccines don't have to hurt as much as some fear Tamiflu: Guest blogger Dr. Mark Helm

Tuesday, September 13, 2016

Vaccines don't have to hurt as much as some fear

Many kids are scared of shots. Some even fight parents and nurses when it's time to get shots. The more they fight and worry, the worse it gets. But it doesn't have to be that way.

Photo source: Wikimedia

In general there are some things that increase anxiety about shots or just make them seem bad. Lying about shots or threatening them as a punishment are never a healthy approach to the situation.
  • Never tell kids they won't get a shot at the doctor's office. They might be due for one (or more) and if they were specifically told they won't get one, they are usually more upset.
  • Do not threaten kids with shots if they misbehave. This makes kids see shots as a negative.
  • Siblings can increase anxiety with their teasing. Don't share the need for shots with siblings and if it's possible to leave siblings at home when one child will need shots, that might work best. 
  • Some kids worry more because parents are worried or presume the child will be worried. When the parent starts talking about shots in a worrisome manner it feeds into the fear. Try to be factual. Don't start telling them it's okay and not to worry. That tells them there's something to worry about.
Oh, no!

Just kidding. It's not bad getting my flu shot!

Some kids do best if they don't know shots are coming. If they ask if they'll get shots at an upcoming visit, you can say you don't know. If you think your child will lose sleep for days worrying about the shots, this is often the best way to handle it. Then the doctor and nurse at the office can deliver the news and it isn't your fault.

Some kids do better with advance warning. If you want to prepare your kids before bringing them in for shots or if you just need some help when you're at the office, follow these tips:

  • Do not tell kids it won't hurt. Shots can hurt. Lying doesn't help. It just minimizes their fear and makes things worse. It might hurt, but how much is variable. Pain is a very individualized feeling. You can describe it as a pinch. 
  • I often ask kids if they've ever gotten hurt playing outside. They usually say yes. Then I ask if they still wanted to play outside again. They usually say yes. I might sound surprised that even though they know that they can get hurt, they still want to play, but then I "realize" that it was because the benefit (playing) outweighs the risk (getting hurt). Then we talk about the benefits of the shot are so much more than the quick poke and a little pinch feeling. This works really well for the middle school shots because they're old enough to get the connection.
  • Don't pre-treat with an oral pain reliever. Studies have shown that acetaminophen and ibuprofen decrease the immune response, which might make the vaccines less effective.
  • Don't tell kids to not cry. It's okay to be scared and to feel pain. Let them know what is and is not okay. If they cry it's okay. It is not okay to kick, hit, run, or do anything that can harm others or themselves.
  • Educate kids about how vaccines help us. There are many resources available. When they understand why the shots are good for them, it helps them to accept them.
  • Practice what happens when we get shots. Have them practice sitting still and making their arms loose. Wipe the arm with a tissue as you explain the person giving the shot will clean the area with a very cold wet tissue to clean the area. (I avoid the term alcohol swab because the term alcohol confuses younger kids who learn about drug prevention in school.) Pinch the arm to show them there will be a small pinching feeling. Put a bandaid on the area if they like or just explain that they can get a bandaid when it's over. (If your child hates bandaids, tell the person giving shots that they prefer to not have them.) Let them practice giving you a "shot" too. 
  • Let kids know that the poke will be fast and they can move their arms up and down afterwards to make the sting go away. 
  • Bring a comfort item from home, such as a stuffed animal or blankie.
  • There is evidence that blowing out or coughing during the injection helps decrease the pain. We often recommend this for kids old enough to blow or cough. Sometimes we'll entice preschoolers with bubbles or pinwheels. It really helps!
  • Other forms of distraction can help too. Telling stories, reading books, or watching a video on a smart phone or tablet are great distractions. 
  • Studies have shown that allowing kids to sit (rather than force laying down) during shots is perceived as less painful. The less restraining the child needs, the better. It makes sense that if they need to be held down they will be more scared and it will be perceived as more painful.
  • Ask the person giving the vaccines to save the most painful vaccine for last, if applicable. (Our nurses do this routinely.)
  • Our office sometimes uses Buzzy when kids are especially afraid of shot pain. As long as the child isn't overly worked up and they aren't opposed to the coldness of the ice, Buzzy works fantastically! If kids have worked themselves into a frenzy it isn't sufficient to distract in this way.  
  • I used to think bribery was not a good parenting technique... until I had kids. It can be very effective. If you can promise a reward for being brave, such as stopping for a smoothie or getting a favorite treat, that can work wonders. 

Help with anxieties in general (great for life worries, not just shots!):

  • After kids do things that they were afraid of, congratulate them for the attempt. Remind them that even though they were scared they did it. This helps set the pattern that they can be brave when faced with any fear. They can even keep a list of things that they did despite being scared to try. They can use the list whenever a new fear pops up to see how many things they've already done and how brave they really are.
  • Use a meditation app, such as Stop, Breathe & Think. It's free and helps with general anxieties as well as mindfulness. Download it and use it at home several times to let them get comfortable using it. 
  • Some great articles: 


Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline

Vaccines are a pain: What to do about it (This includes a link to this parent tip sheet.)

Monday, September 5, 2016

Over and Under Supply of Breast Milk

New moms often worry that they won't have enough milk for baby. Most moms have plenty of milk, but working with nurses or doctors who have been trained to help with lactation and following weights of your baby is important until breastfeeding is well established. In some instances we also check blood sugars and other indicators of hydration. I always try to support breastfeeding, but there are some instances where a baby will require a supplemental formula to avoid further medical complications.

photo source: Shutterstock

It is normal to lose weight the first week of life. Babies are born with excess water weight, making them look a bit puffy, but this allows them to stay hydrated until milk comes in. Most babies lose between 6 and 8% of their birth weight, but there are normal variances. A great resource to see if they are within the acceptable weight loss is the Newborn Weight Tool. Once they start gaining, they tend to gain 15-30 grams per day until about 4 months of age.

How much milk is there?

Once milk supply is established, it is constantly being made. The breasts are never completely empty. It is common for one breast to make more milk than the other. This does not indicate over or under supply as long as the combined amount is sufficient for baby to grow. In general the more a baby feeds, the more milk is made. It is not recommended to wait longer between feedings to have more milk per feed. This actually backfires because your breasts sense that baby doesn't need to eat as much, so will make less overall milk.

Initially there is only a few milliliters of colostrum for each feed. Once milk comes in, there will be a couple ounces total. This increases as baby feeds more, such as during growth spurts. Your body should respond to baby's needs.

Peeing and pooping

We monitor urine to be sure babies stay hydrated. I use the 1, 2, 3 rule.

  • 1. The first 24 hours of life baby should pee once. 
  • 2. The 2nd 24 hours baby should pee twice.
  • 3. The 3rd 24 hours baby should pee three times.
  • By the 4th day milk should come in and the wet diapers will increase. Most babies will need to be changed with each feeding.
  • Disposable diapers have super absorbent gel that make it really difficult to see small amounts of urine. (When older babies have a soaked diaper you might notice these gels look like crystals - some parents worry about kidney stones when they see these. Nope. Just super absorbent gel crystals that escape the diaper!) If you're having a hard time telling if there is urine in the diaper during the first few days, put a piece of toilet paper in the diaper. Don't count on the color indicator strip (found on some diapers) to know if the diaper is wet or dirty - there's often not enough wetness to make these work initially. 
Stools change quite a bit during the first week of life and then again over the initial months.
  • Meconium (thick, black tar like stools) is common the first few days. If baby doesn't have a meconium stool within the first 24 hours of life talk to baby's doctor.
  • Once all the meconium is out, some babies don't poop for a day or two. It takes time for the milk to go through. This is fine as long as breastfeeding is otherwise going well!
  • Green stools are common during the transition from meconium to breastfeeding stools.
  • Breastfeeding stools look like yellow cottage cheese - watery with flecks of solid pieces (this is why they are called seedy). Many parents think it looks like diarrhea, but it's normal. 
  • Breast fed babies often stool multiple times a day initially, but then can develop a pattern that they only stool once a week (sometimes even less often). As long as the stools are soft when they come out, it is okay. 
  • Most babies grunt and groan during bowel movements. Some even get red in the face. This is not constipation. They are just learning to bear down and poop. 


When milk first comes in the breasts often feel hard and swollen. This is normal and typically improves over time. It does not indicate that there is too much milk. Breasts must adjust to milk production, so can feel very full when they are not. You can get relief from warm compresses for 5 minutes before each feed, feeding frequently, changing baby's position with each feed, and massaging breast tissue during feeds. Some women like to use cold compresses between feeds for 20 minutes at a time. You can also take ibuprofen for pain. Briefly hand expressing milk or pumping before breastfeeding can be helpful. Excessive pumping can lead to more milk production, so use this only to soften the tissues to allow for a better latch when feeding unless you're trying to increase milk supply or begin storing milk.

Is it normal to feed so often?

Most newborns will feed 8-12 times in a 24 hour period. Since feedings and the associated diaper changes, burping, and everything else can take an hour or so initially, it does seem like they are constantly feeding. Many babies will cluster feed, which is when they stack feedings closely together at a particular time of day. This is often in the evening and can help them sleep longer stretches at night. 

How do I know when milk comes in?

The first few days there is colustrum to nourish baby. This is usually sufficient until milk comes in, typically when baby is 3-5 days old.

When milk comes in some mother's feel their breasts harden and swell, but not all mothers feel this. You might feel baby sucking and hear swallowing in a different pattern once milk comes in. The amount of urine baby makes will increase when milk is in, both in the number of wet diapers and the volume in each diaper.

Nipple Confusion

A lot of lactation experts warn about nipple confusion, but I don't find that it causes problems in most babies if they use artificial nipples, especially pacifiers.

Pacifiers, AKA binkies, can help soothe a fussy baby between feeds. They have been shown to reduce the risk of SIDS, though it is not known how. Studies are inconclusive as to whether or not they affect breastfeeding success. The suck on a pacifier and the suck on mother's nipples are very different, but I have not seen many babies get confused when offered both. If baby has a good latch and breastfeeds effectively, there is no reason to avoid pacifiers in my opinion - which is shared by others. (This differs from the American Academy of Pediatrics position to wait until 3-4 weeks of age.) Babies are seen to suck on fingers and arms while still in the womb... if they need to suck, it is okay for them to suck. If a pacifier helps between feeds to give mom's nipples a break, great! I actually find that this break helps mom want to breastfeed and not give up as easily. Don't use the pacifier to delay a feed though - if baby's hungry, feed him! Of course, if the use of a pacifier seems to affect their feedings, then stop their use until breastfeeding is well established.

Bottles are a means of nutrition. Most breastfeeding babies won't need to take a bottle until breastfeeding is established, but if a baby is failing to get sufficient hydration or nutrition from the breast supplemental nutrition is important. I do see some issues with latch and biting if baby gets used to biting on a bottle's nipple, though not every baby has problems. Many can go back and forth from breast to bottle easily. If you're worried about nipple confusion and your baby needs supplemental nutrition, you can spoon feed or use a syringe to put the milk into baby's mouth. Some mother's will use a supplemental nursing system provided by a lactation nurse. If you are using a bottle for nutrition, it is important to pump so that the breasts are stimulated to make milk for baby.

On the flip side, if breastfeeding is going well, don't forget to start a bottle between 3 and 6 weeks. Mothers who wait longer often find that baby won't take a bottle at all, which makes returning to work or leaving baby for more than an hour or two difficult.

Overproduction of Milk

I always say that too much breast milk is a good problem to have. It's good because it's often easier to handle than too little milk, but it's still a problem.

Too much milk can lead to baby not emptying the breast sufficiently, which can lead to clogged milk ducts and mastitis. You might notice a firm area in the breast that didn't empty during a feed. If this becomes red, painful, or is accompanied with fever or flu like symptoms, see your doctor.

It can also allow them to fill up on fore milk, which is lower in fat than hind milk (which means fewer calories per ounce), so baby can be well hydrated but under nourished.

There also can be increased lactose in fore milk, which can lead to gas, fussiness, and even more watery than normal stools. Many people see more green in the stool, but stool color can also vary with mother's diet.

These babies often only need to feed for a short period of time, but more often than other babies because they fill up quickly, but the low calorie content of the milk leaves them hungry in a short period of time.

Because there is oversupply, these babies may choke when feeding if the milk comes out fast. They may pull off or clamp down. To help with this, try side lying position of feeding or sit in a reclined position during feeds.

Working with your pediatrician and a lactation specialist to ensure adequate weight gain is important with overproduction because baby is feeding well and satisfied after each feeding so it is difficult to be sure the calories he is getting is sufficient. 

Tips and tricks used:

  • Express 1/2-1 oz of milk before the feed to allow baby to get some hind milk. (Store this in the freezer for future use!)
  • Feed only from one breast per feed to decrease overall supply. Usually within a week supply will begin to decrease, and you might need to feed the second side if baby shows hunger cues after eating from the first side.
  • Pumping about an hour before the next feeding can remove some of the excess milk. 
  • Sometimes hormone therapy (birth control pills) or other medicines are used to decrease supply.

Low Milk Supply

It is very common for mothers to worry about not having enough milk for their baby. The first few days most babies only need a teaspoon or so of colostrum per feed. Most babies do not need to supplement with formula until milk comes in. 

Breastfeeding 8-12 times per 24 hours will help establish healthy milk supply. Feed from one breast completely before changing to the other side, and alternate which side you start each feeding. The more you feed (or stimulate the breast with pumping), the more milk you'll make. You can pump between feedings or for 5 minutes after each feed. Feed baby anything you pump if he's still hungry after breastfeeding! See "Nipple Confusion" section above for information on giving expressed milk.

Milk supply can be affected if you have had medical complications of pregnancy, are excessively tired, are not properly nourished, start hormonal birth control or have certain medical conditions. Some medications (especially for cough and cold)  and some herbs can decrease milk supply. Talk with both your obstetrician and baby's pediatrician about any milk production concerns. 

In general you will need about 500 calories per day more than your baseline to make milk. You will also need to drink plenty of water -- keep your urine pale, not too yellow! 

Sleep helps! I know it is difficult to get enough sleep when baby eats every 2 hours, but nap throughout the day as much as possible. 

Galactagogues are compounds that boost milk supply. Many are sold over the counter but should only be used if other means of increasing milk have not worked well enough. Talk with your OB and pediatrician if you are using any of these:

  • Fenugreek (do not use if diabetic or allergic to chick peas or peanuts): 
  • Tea - 1 cup three times daily
  • Capsules 1500- 2000 mg three times daily 

  • Blessed thistle or Milk thistle (can be used with fenugreek but is very bitter)
  • Tea - 1-2 tsp in cup of tea three times daily
  • Capsules 800-1000 mg three times daily

  •  Alfalfa  
  • Tea - 1-2 tsp in cup of tea three times daily
  • Capsules 2000 mg three times daily

  •  Anise
  • Tea - 1-2 tsp in cup of tea three times daily

  • Oats (you can do this one regardless of milk production since it can be part of a healthy breakfast)
  • One bowl oatmeal a day (avoid the little packets with added sugars)

  •  Goat's Rue

  • Tea - 1 tsp in cup of tea three times daily

    • For more information:

      Kelly Mom is a fantastic breastfeeding resource. You might have noticed that I linked several of their pages above.

      Saturday, August 27, 2016

      7 Concussion Myths

      As the country is focusing more on concussions, I've seen a lot more kids come in after head injuries, many of which are concussions. Even some kids who went to an ER after a head injury get incorrect information about return to play sometimes.

      Source: CDC Heads Up

      Common myths and misinformation about concussions:

      1. A normal head CT means no concussion and a full return to play is okay.
      Concussions are not diagnosed by CT. Brain bleeds and masses can be seen on CT, but the damage done to the brain during a concussion is not seen on a CT. Concussions are diagnosed based on symptoms, such as headache, confusion, lack of coordination, memory loss, nausea, vomiting, dizziness, ringing in the ears, sleepiness, and excessive fatigue. Not all symptoms need to be present to make the diagnosis. Some symptoms develop over time and are not present at the time of injury.
      A CT scan is usually not needed with head injuries. They involve radiation so are not without risk themselves. Unless there are signs of a possible bleed in the brain, skull fracture, or the type of injury suggests the need for a CT, a CT scan is not needed in the evaluation for concussion.
      2. A minor hit to the head never causes concussions.
      The force of a hit does not determine the severity of the injury. Some people with more significant problems initially also seem to heal more quickly than others with more mild injury. It is very hard to predict how long it will be until all symptoms are resolved. The most important thing is that if you have symptoms of a concussion, your brain needs rest.

      3. After two weeks you can return to play without further testing.
      Sadly I've had more than one patient who was given this advice from a medical professional, whether on the sideline at a game or in an emergency room or urgent care. Although most concussions resolve within 2 weeks, not all do and returning to play before the brain is healed can lead to a more serious condition called "second impact syndrome." Second impact syndrome is a very rare condition in which a second concussion occurs before a first concussion has properly healed, causing rapid and severe brain swelling and often catastrophic results, including death.
      After a concussion clearance to return to play should only happen when the child, teen, or adult is re-examined and found to be symptom free. Returning to play is done in a stepwise fashion, with each step lasting at least one day and only progressing to the next step if symptoms don't resume. This starts with light exercise when there are no symptoms at rest, then progresses to moderate activity followed by heavy activity without contact, then full practice with contact (if the sport is a contact sport) and finally full competitive play if each step can be done without return of symptoms. If symptoms return, you back up to lighter activity.
      Returning to play too quickly can prolong healing time and even lead to long term consequences. Do not return to any activity that causes symptoms to worsen!
      4. If a coach doesn't recognize the concussion, it's minor enough to return to play.
      Coaches cannot see everything that happens on a field. If you had a head injury, tell your coach. Even if you are the star player. Really. You will do your team a favor if you take time to heal and can play again versus stay in the game and get more severely injured and are out for good. See these real stories of concussion survivors.
      Someone who is trained in concussion evaluation should do a sideline evaluation. If there is any chance of concussion, you should not return to play at all that day or until you are cleared by a doctor who understands concussions.

      5. IMPACT testing is necessary.
      IMPACT testing is a computerized test that measures neurocognitive functioning. Ideally a baseline is done prior to the season (or at least every 2 years) and then testing is repeated if a concussion is suspected. The results of the current test are compared to the person's baseline and can be repeated at intervals until the person is back to baseline and able to be cleared to return to play. It is one tool to help manage concussions and determine when it is safe to return to play, but at this time concussions are diagnosed based on symptoms and physical exam.
      6. Complete bed rest until all symptoms are gone is best.

      Bed rest for the first day or two can help enforce brain rest and allow healing, but may not be required and prolonged bed rest is specifically not recommended. Prolonged bed rest can increase stress in children who miss substantial amounts of school. This stress is thought to possibly prolong healing. Depression is more common if bed rest is enforced beyond 48 hours. Socialization with friends and family can help provide emotional benefits that aid in healing. This does not mean that people should participate in all social settings. They will likely need relative quiet, so even going to a sporting event to watch can lead to return of symptoms.
      7. Concussions only impact sports.
      Concussions take kids out of play, but other activities should also be limited until they are tolerated. Lights, sounds and even smells can trigger symptoms after a concussion. If anything leads to worsening of symptoms, it should be avoided. Things that take focus or a lot of brain work may cause symptoms to worsen. These include reading, watching television, or playing video games. Initially a child might need total restriction from these activities, and then can slowly add them back in small increments as tolerated. Many kids need to have breaks during school, a decreased work load, and shouldn't take standardized tests until they can focus for a prolonged time. If computers are used for school, it might be necessary to use paper books and worksheets and to limit computer use until it can be tolerated.

      For more information:

      • Heads Up is a free resource for parents, athletes, coaches, and medical professionals
      • Acute Concussion Evaluation (ACE) Care Plan has all the typical symptoms of a concussion, general guidelines to healing, plus return to school and sport templates
      • Dr. Mike Evans has two great concussion videos:

      Saturday, July 30, 2016

      Cholesterol - something to watch in childhood

      Since our office has adopted new screening protocols based on the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, we have seen many questions and resistance. I suspect the resistance is due to the fact that kids hate needles and parents aren't sure if insurance will cover the cost of labs. Some families simply have a difficult time taking kids to a draw station.

      These guidelines cover additional topics, such as blood pressure and tobacco exposure, but I will only discuss the most common questions specific to the cholesterol measurements here. A lipid panel includes the total cholesterol, triglyceride level, high density lipoproteins (HDL, "good" cholesterol), and low density lipoproteins (LDL, "bad" cholesterol). Some labs include other types of lipids.

      My office website discusses the basics of cholesterol.

      The dietary advice is summarized nicely in CHILD-1 Diet and Nutrition Recommendations -Childhood Nutrition Basics.

      Preparing for the lab draw

      If your child hates needles, I understand. But some things are important, and in pediatrics we focus on prevention. If we can prevent heart attacks, strokes, and other consequences of unknown risks of heart disease, we should.

      Kids can be prepared before going to the lab. NEVER say it won't hurt. Everyone perceives pain differently, but if they know it might pinch or feel like a poke they will be prepared. Remind them it only pokes for a very short time usually and holding still helps it go faster. Tell them there will be a big rubber band called a tourniquet that will squeeze the top of their arm to help make it easier for the needle to find the right spot.

      Let them watch this video on lab draws.  (Warning, this video does show a blood vial being filled... some people get queasy just seeing things like this.)

      You can practice at home by letting them show you how they will hold still with their arm out. They can look away and take big breaths with a strong forceful blow out each time. You can wipe the arm with a cotton ball or tissue and talk about how that part tickles. Maybe they can pretend they're blowing out candles or they can blow on a pinwheel.

      Make sure they are well hydrated with water before going to the lab. Remind the phlebotomist (who draws the blood) that studies show blowing out upon the insertion of the needle has been shown to decrease pain with injections, and I suspect also with lab draws. You can also use a video on your smartphone or tablet to distract during the draw.

      What affects when you should take a child for the lab?

      A child should be on his or her regular diet for 4-6 weeks before testing to reflect the child's true levels. If a child vacationed and ate fast food for a week but typically eats a healthier diet, the levels will be skewed toward the more recently eaten foods. If they often eat poorly, do not alter the diet for the purpose of the lab. Get a baseline that is accurate to their lifestyle.

      Illness can also affect lipid levels, so ideally children will be overall healthy when the lab is drawn. If there was a recent significant illness, waiting 4-6 weeks to draw the lab is ideal. Significant illness would be one that requires hospitalization or surgery. If oral steroids were given, it would be best to wait at least 4 weeks. An upper respiratory infection, cough, or typical short term illness should simply be resolved before the draw. You would not need to wait 4-6 weeks for these common illnesses. If you are uncertain if an illness is significant, ask your doctor.

      Fasting does not affect the total cholesterol significantly, but it does affect the triglycerides. It is recommended to fast 8-12 hours before having the triglycerides checked. This is most easily done by having children drink water in the morning without food or other drinks. Take them to the lab for the lab draw and then let them eat breakfast.

      If it is not possible to take kids to the lab when they have fasted, be sure the lab knows that it is a non-fasting level. They will include this with the report so the doctor can evaluate the lab values with that important information. In general I do not enforce fasting if it is too inconvenient unless there is a history of a previous elevated triglyceride. If the triglyceride level has been high on a previous lab, it is important to do a fasting level to see if it is a real risk or due to a recent meal.

      Why do we need to check cholesterol in children- isn't heart disease an adult problem?

      We know that obesity increases the risk of having a high cholesterol and atherosclerosis.
      Elevated triglyceride levels and obesity are associated with Type 2 diabetes. Children with obesity need routine monitoring of their cholesterol along with other chronic disease indicators.

      Multiple studies show that parents often perceive their children to be a healthy weight, but in reality their diet and exercise are not healthy and their height and weight do not indicate health.
      We know that a family history of people with high cholesterol or certain heart conditions increases the risk. Tobacco exposure increases the risk. Certain chronic diseases increase the risk of cardiac problems. All of these can be risks in otherwise healthy appearing children.

      There are a significant number of children who have no known risk factors yet have an elevated lipid level. This can put them at risk for cardiovascular disease, but if it is known, steps can be done to lower that risk.

      The simple answer is atherosclerosis (clogging of arteries) can begin in childhood, but has no symptoms at the early stages when treatment is most effective. There are some people who have a genetic predisposition to this despite healthy habits and an outward appearance of health.

      Screening recommendations are done by age and risk.

      Many things can alter the risk of cardiovascular disease, including genetics, recent illness, puberty, obesity, blood pressure and tobacco exposure. Guidelines take into account these factors to help determine when testing should be done. If risk factors are identified, a lipid panel should be done. All children, regardless of risks should be checked at 9-11 years and again at 17-21 years of age. If the levels are normal, a lipid panel should be repeated in 5 years. If abnormal or if risk factors change, the level will need to be repeated sooner, depending on risk.

      From page 8 of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Summary Report 

      What are you going to do with the results?

      Many parents are frustrated if we find an elevated level but then "don't do anything about it." We are doing something. We just don't start with medicines because medicines are not the best answer. We recommend a healthy diet and daily exercise. Those two things are more important than many parents realize. They can make changes that benefit your child for life. But they must be done. Making healthy changes for the entire family benefits everyone and makes it easier for a child to comply with recommendations.

      Repeat levels will be required to see if the diet and exercise changes make an impact. If the results are consistently elevated or significantly elevated to require medication, a referral to a pediatric lipid specialist is indicated.

      See page 53 of the guidelines

      See page 54 of the guidelines

      If you have questions about cholesterol screening for your child, please talk to your child's doctor. 

      Other Resources:

      Pediatric Lipid Disorders in Clinical Practice Workup, Henry J Rohrs, III, MD et al