Follow by Email

Sunday, April 23, 2017

Itchy, sneezy, puffy - All signs of allergy. What can you do?

It's allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors. This is an update to a previous blog I wrote on the subject, since there are many more medicines now available over the counter.

Symptoms of Allergies: 

Allergies can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes. Some kids get a crease across their nose from wiping. Others get purple circles under their eyes called allergic shiners. These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!


It is best to treat before the symptoms get bad. It is easy to monitor pollen counts online to know what's out there and start treatment before symptoms make you (or your child) miserable. Treatments include medicines and limiting exposure.


I don't want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help. Types of medicines:
  • Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others. In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits. You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help. Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. Insurance companies rarely cover the cost of antihistamines these days.
  • Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn't needed. If you need a decongestant initially, you can use one with your usual antihistamine. Most decongestants on the market are ineffective. If you ask the pharmacist for pseudoephedrine, it is available behind the counter. It was replaced by phenylephrine years ago due to concerns of methamphetamine production, but works a little better than phenylephrine. Decongestants do NOT fix a cold, they only dry up some of the mucus. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age. 
  • Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better. Most insurance companies don't cover prescription allergy eye drops well, so you might want to check your formulary before asking for a prescription. This is usually available on your insurance website after you log in. Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye. 
  • Singulair (Montelukast) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. Once a person has been on montelukast for a couple weeks, they usually don't need an antihistamine any longer. It is available only by prescription, so make an appointment to discuss this if your child might benefit.
  • Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

  • Wash hair, eyelashes, and nose after exposures -- especially before sleep. They all trap allergens and increase the time your body reacts to them. I have found the information and videos on very helpful to teach kids as young as 2 years to wash their noses. (Note: I have no financial ties to Nasopure... I just love the product and website!)
  • Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.
  • Wash towels and sheets weekly in hot water.  
  • Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting. 
  • Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them. 
  • There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners. 
  • Keep the windows closed. Sorry to those who love the "fresh air" in the house. For those who suffer from allergies, this is just too much exposure!  
  • Keep pets out of bedrooms. If you know a family member is allergic to an animal, don't get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal. 
  • If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts. 
  • Keep smoke away. Smoke is an airway irritant and can exacerbate allergy symptoms. Remember that the smoke dust remaining on hair, clothing, upholstery, and other surfaces can cause problems too, so kids can be affected even if you don't smoke near them.  

What if all of the above isn't helping?
  • Maybe it's really not allergies. 
  • Allergies to things other than foods are rare before 2 years of age.
  • Viruses can cause very similar symptoms to allergies. 
  • Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don't find it very helpful for environmental allergens because you can't avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn't take long to see patterns. Testing is important if allergy shots are being considered.   
  • Need help tracking allergy symptoms? There's an app for that! Here's one review I found of allergy apps. I don't have any personal experience of any, so please put your favorite in the comments below to help others!
  • Wrong medicine or wrong dose. 
  • Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.
  • Some kids outgrow a dose and simply need a higher dose of medicine as they grow. 
  • Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment to discuss if this is an option for your allergy sufferer.

Wednesday, March 15, 2017

Hearing Loss

Most of us associate hearing loss with old age, but it is increasingly common for children and teens to suffer from mild to moderate hearing loss. Nearly 15% of kids have hearing loss according to the CDC. Hearing loss can be due to many things that are difficult to control, such as heredity, infection, and medications. In kids and teens it is oven due to a preventable cause: noise.

Where does the excessive noise come from?

Even young children are exposed to more loud noises through toys, television, and gaming devices than children of years past.

Widespread use of ear buds for prolonged periods can take its toll on hearing. Unlike the bulky headphones used when I was a child, earbuds deliver sound directly into the ear canal without any sound buffering in between. Most often the earbuds are used with iPods and other mp3 players are low to mediocre quality, so they are unable to transit the bass as effectively. Many kids turn the music up to hear the bass. If others can hear the music coming from ear buds, they are too loud!

Loud concerts or sporting events can also expose our ears to excessive volumes for a prolonged period of time.

Not all excessive noise is from kids being undisciplined - some kids are helping out the family or trying to earn extra cash by mowing lawns or using power tools, which puts them at increased risk.

How much is too much?

According to the Centers for Disease Control and Prevention (CDC), being exposed to more than 85 decibels (dB) of sound for eight hours can damage your hearing. At 105 dB, hearing loss is possible after a mere 5 minutes.

If you're like me, that means nothing because how much is 85 dB? There is a great chart of common sounds and how loud they are on this page from the CDC. There are also several free apps available for download on smartphones and tablets - search "sound meter" or "decibel" and read reviews before downloading. Take advantage of these -- and because it's in the phone, kids might actually have fun playing around with them and learning about their environmental risks at the same time!

Signs of hearing loss

One early sign of excessive noise is ringing in the ears, but most people with hearing loss never realize it's happening because it's slowly progressive. If you notice your child asking "what" more often or complaining that the television is too quiet when others hear it well, it is a good idea to have their hearing tested.

Consequences of hearing loss 

There are many potential consequences to hearing loss:

  • Learning - you have to be able to hear the lecture. 
  • Behaviors - if directions and instructions are missed, a child might incorrectly be seen as misbehaving. 
  • Friendships and social skills - if a child can't follow a conversation they aren't easy to talk to or play with.
  • Job availability - many jobs require hearing at a certain level. 


Talk to your kids about the risks of their habits that involve loud sounds. Unfortunately kids won't always take parental advice to heart because they have a feeling of invincibility, but studies show if they learn about hearing loss they are more likely to use protection. Even more so, what their friends are doing alters their behavior. Teach not only your kids, but also their friends. If they're all going to a loud event, consider giving them all ear plugs. Once hearing is damaged they can't gain the hearing back, so prevention is key.

Ways to protect include:
  • Wear hearing protection (earplugs) when mowing the grass and attending loud events, such as concerts or sporting events.
  • Turn down your music! Some music players have alerts when the volume goes too loud, but those can be ignored if the child doesn't understand why it's important to lower the volume. If others can hear the music you're listening to through earbuds, turn it down.
  • Lower the maximum volume setting on your iPod or mp3 player. To do this, go to "Settings" and select "Volume Limit" under Music. Set it at about 60% of the full volume, that way you can't accidentally turn your music too high.
  • Use big headphones instead of earbuds. They offer more external noise cancelling, which allows the music to be heard better at lower volumes. They are also physically further from your eardrum, which helps.
  • If you must use earbuds, use high quality buds that transmit bass if you are tempted to turn music up to hear the bass.
  • Follow the 60/60 rule: No more than 60 minutes of listening at a time, and no higher than 60 percent of maximum volume. If you go under "settings," you can actually set your iPod for maximum volume setting of 60 percent, so you can't accidentally turn your music up too loud.
  • Higher pitched sounds have greater potential to damage your ears than lower pitched sounds. Turn down the volume when a high-pitched song comes on.
  • Try not to fall asleep with earbuds or headphones on. The time of exposure matters and why waste sleep time damaging your ears? 
  • If you need "white noise" to fall to sleep, put together a playlist of soft songs or sounds and have it play at a low volume from a speaker on your bedside table. Use your clock's "sleep" function, which will automatically turn off your music after a set amount of time to ensure the music doesn't end up playing all night long, which saves energy in addition to your hearing.
  • As always: model these behaviors for your children. If they see you mowing the grass with loud music blaring in your ears, they will grow up to do the same. If you wear ear buds many hours of the day, they will see that as a normal and acceptable behavior. 

What happens that hurts our hearing?

Keep the volume down – Too loud and too long can damage your hearing shows a man listening to music. Below it the music soundtrack and volume levels are shown. The video then breaks to showing what happens to the hair cells in our ear with these volumes, which makes the damage more understandable because you can see it happening. 


CDC's Hearing Loss main page

Sunday, February 19, 2017

Flat heads in babies

We have significantly decreased the risk of SIDS by placing babies on their backs to sleep, but have seen a rise in flat heads due to their positioning. Prevention of the flatness involves several positioning strategies.
Supervise tummy time when Baby's awake!

It's important for babies to sleep on their back, but they tend to have their head facing one direction or another. They should alternate which side they face, but many babies have a stiff neck and favor looking to one side. Think of when you wake with a stiff neck - probably from positioning overnight. Many babies are in the same position for quite awhile at the end of pregnancy - of course they're stiff!

If Baby's neck is stiff, you can massage his or her neck and shoulder muscles gently and then slowly move the head right and left (chin to each shoulder) and side to side (ear to shoulder). Don't quickly force the head movement, but think of what you do if you have a stiff and sore neck. The more frequently you stretch it out, the better it feels, right? I recommend stretching Baby's neck with each diaper change (before the change or after you wash your hands!) until it isn't stiff for several days and Baby moves his or her head easily without your help.

Start supervised tummy time early on - the longer you wait to start, the more Baby might resist it. I see so many parents who are hesitant to put Baby on his or her stomach. Concerns range from the umbilical cord stump still being on and bothering the baby (it won't) to spitting up will worsen (test it out, for many babies it's actually better) to "I thought babies should never be on their stomachs" (only when sleeping or not supervised).

Tummy time is an important time for baby to develop muscle strength. It needs to be supervised, but it can be a fun time to interact with Baby. Lay face to face and talk to Baby, encouraging him or her to look up. Grab a brightly colored object and move it around for Baby to watch. Enjoy your play time.

For more information on issues related to stiff necks in babies and how to treat the stiffness, see this Torticollis information.

AAP article on how to prevent flat heads in babies.

Saturday, February 4, 2017

Rashes in kids... a few case studies for parents

I am not a dermatologist, but I see rashes all the time. Some are easy to identify, others I'm not sure what the cause is. In general physicians are taught to treat the symptoms of a rash. The standard dermatology lecture in a nutshell is: If it's wet, dry it. If it's dry, wet it. If it itches, use steroids. If it's infected, use antibiotics.

I'll go over a few made up case studies -- each one is a conglomeration of kids I've seen.

Case 1

Parents bring Itchy in for a well visit but mention that her skin has rashes on her elbow creases and behind her knees. Sometimes she scratches them to the point where they bleed. They've tried applying a pink fragrant lotion that they got as a baby gift, but she says it burns and didn't help.

Advice for this family would not include which of the following?

  1. Use the lotion more often since the skin is dry
  2. Stop the lotion because fragrant lotions can worsen this condition
  3. This type of dry skin can be related to allergies and asthma, having one makes it more likely to have another
  4. Controlling the itch is important because scratching worsens the rash

The answer is #1. This rash is most likely eczema, a fancy term for dry skin. It often develops in infants but improves as a child gets older. It is more common in kids with allergies and/or asthma. It can worsen with exposure to irritants (such as a fragranced lotion or soap) and allergens (food allergies and seasonal allergies). I've often heard this called "the itch that rashes". Scratching damages the skin, which allows water to escape, which dries the skin more, leading to more itching. This itch/scratch cycle worsens the rash and can lead to secondary infections. This can be a very frustrating condition because it will come and go for years in some kids. It's important to avoid irritants and use proper skin care. For more treatment, visit Dry Skin / Eczema / Atopic Dermatitis.

Case 2

Parents bring their infant in for her well visit and ask about a rash that's been there "for awhile" but doesn't seem to bother Baby. They aren't sure when it started. They can't recall any new soaps, lotions, foods, or other potential triggers. They describe it as red spots and they aren't sure if they're changing over time. Baby is eating well, gaining weight well, sleeping well, and not fussy. On exam, they show me the rash on the abdomen and arm, but I cannot see any red spots. 

What further questions might I ask and what advice might I give?

  1. If this rash would be on your own skin, how would you treat it?
  2. Treatment of the rash should be based on symptoms, and since there are no symptoms, no treatment is needed
  3. Monitor for signs of itching, fussiness, fever, poor feeding, and other concerns
  4. All of the above

The answer is #4 and yes, I see this non-existent rash all the time. It's not just my old eyes that can't see it -- I hear from pediatrician friends about this phantom rash too. I know parents worry more about their children than they worry about themselves, but sometimes they can realize the unfounded concern when I simply ask what they would do if this rash was on their own skin. Most say they wouldn't worry about it. Enough said. 

Case 3

Parents ask about a rash that appears sometimes after their school aged child showers. It doesn't itch or hurt. It is always on the chest and abdomen and sometimes on the legs. It looks like red splotches. They've tried various soaps and shampoos, but changing them doesn't seem to affect the rash. It isn't present on exam because it only happens after showers and lasts less than 30 minutes. They are concerned because it returns so frequently.

My advice to parents includes which the following?

  1. Treatment of a rash should be based on symptoms, and since there are no symptoms, no treatment is needed
  2. Use only cleansing products made for babies since your child is obviously sensitive to something
  3. Turn down the temperature of the water in the shower to see if the rash "resolves"
  4. 1 and 3
The answer is # 4. Again, I've been asked this type of question more than once. It also falls into the category of "What would you do if you had this rash?" Most parents would admit they wouldn't do anything since it didn't cause any problems and was brief. If they really think about it, they probably have had this "rash" after a hot shower. It's just flushed skin. If you enjoy a hot shower, it's okay if your skin flushes a bit.

Case 4

Mom brings Kiddo in because her nails are growing "funny." They have a horizontal crack and the tips are peeling off. They don't seem to hurt or bother Kiddo.

What further information would be important to know?
  1. Was there any trauma to the nails?
  2. Has your child been sick in the past 2 months?
  3. Does kiddo use nail polish or fake nails?
  4. Does your child pick at her nails regularly?
  5. All of the above.
The answer is #5. The answer is usually in the patient history with this one. I've seen a number of kids with peeling nails recently because we had hand, foot, and mouth in the area about a month ago. Not all kids with that infection lose their nails, but it can happen. For more on this, including pictures, see Four Cases of Onychomadesis after Hand-Foot-Mouth Disease. Other causes of peeling nails include trauma and nail picking, nutritional deficiencies, nail products, chemical irritants, certain medications, infections, and chronic diseases. 

Case 5

Mom brings Snotty in because he's had a runny nose all week. On exam, he's found to have what mom thought was dried mucus under his nose, but the underlying skin is red and it's actually more of a crusting, not mucus. 

Treatment of this includes all except:
  1. Using rubbing alcohol to rub off the crust
  2. Antibiotic ointment
  3. Washing the area
  4. Avoid touching the area
  5. Oral antibiotics
The answer is #1. That would hurt! This is a classic case of impetigo. Impetigo is a bacterial skin infection. It often happens when the skin is damaged (in this case from Snotty wiping his nose constantly) and if bacteria from the nose or mouth get into the skin. It can be treated with prescription topical antibiotic ointment in most cases, but some cases require oral (by mouth) antibiotics. Wash the area gently and soak crusts with warm wet cloths to help remove the crust. Complete removal of the crust isn't necessary though - that will happen naturally as the infection resolves. Touching the area can spread the infection, so avoid touching it and wash hands well after touching it!

Tuesday, January 31, 2017

Cough 'til you puke...

This is the time of year it seems everyone's coughing. I've heard from more than one worried parent that their child coughs to the point of vomiting. In the medical world, we call this post-tussive emesis.

Post = after, tussive = cough, emesis = vomit

Kids tend to have a very active gag reflex, so they sometimes gag themselves and vomit with cough. This can be good, since it gets the mucus out of the back of the throat. You can try to teach older kids to hack and spit it out, cough and spit it out, gargle with salt water, and rinse mucus out of the nose.

Of course it's not fun to vomit after coughing because everything in the stomach comes up and makes a huge mess. Sometimes the vomit comes out of the nose, which can burn from the stomach acid. And vomiting can be very scary to kids.

Are there serious concerns when kids vomit from coughing? 

Yes. In medical school I learned that when kids cough to the point of vomiting we should consider whooping cough, pneumonia and asthma. In reality, I find that many kids with regular cough and colds can gag from cough, but I always consider the more serious options.

What should I do if my child vomits from a cough?

First, keep your cool. If a parent starts to get flustered, it makes the child more worried, which never helps.

Make sure your child's breathing is okay. Obviously he is coughing, but between coughs if the breathing rate is too fast or labored, he should be evaluated ASAP.

Rinse out your child's mouth (and nose if needed- saline drops or rinses work well for this). Vomit is just nasty tasting and can burn in the nose.

Treat the cough. If your child has asthma, give a breathing treatment or their rescue inhaler. If your child is over a year of age, you can use honey to help a cough. A tsp usually does the trick. Humidify the air with a vaporizer or humidifier. For more treatments see Cough Medicine: Which one's best.

When should my child be seen?

If your infant is under a year of age or your child has not had the whooping cough vaccines, he should be evaluated. Some babies with whooping cough stop breathing so many are hospitalized to monitor for complications. 

After a single episode of vomiting if your child's breathing is comfortable, just continue to manage at home.

If your child develops difficulty breathing or dehydration, he should be seen as soon as possible.

If your child continues to vomit after coughing but is comfortable between episodes, he should be seen during normal business hours at his regular doctor's office.