Breast is Best... Unless it's Not

We've all heard the well-intentioned slogan "Breast Is Best" in reference to supporting breastfeeding. Breastmilk is made just for our babies, so yes, it is a great source of nutrition. But it isn't the only option and there are many reasons mothers give formula and even with exclusive breastfeeding there comes a time that infants need additional sources of nutrition.

I decided to write on this topic because I see so many mothers struggle to feed their baby and they feel like a failure if they don't exclusively breastfeed. And then to top it off I saw a blog that encouraged exclusive breastfeeding without any foods or supplements until one year of age. I knew someone had to counter that thought before it becomes popular. It shouldn't be a badge of honor to breastfeed to the point of potential harm to the infant, and some ultra-crunchy moms are bragging about it as if it is.

You're not a failure if you feed your baby, regardless of what you feed your baby as long as it's age appropriate. Your baby needs nutrition and hydration. While most babies under 6 months of age can get all their nutrition from breastmilk, some need a boost, especially at the beginning of life. If you’re not producing enough milk, you’ll need to give your baby some formula as well (or use a milk donor). Usually this is temporary - just until your own milk supply increases or until your baby starts enough solid foods that the supplement isn’t needed. I'm not suggesting that every newborn who struggles at the breast should be supplemented, but if your doctor says the baby's blood sugar is low or the baby is losing too much weight, it's not only okay, but it's necessary to supplement.

Benefits of Breast Milk

Most of us have heard by now the many benefits of breastfeeding for the baby, including:

• Immune system benefits. (Which means fewer infections, meaning not only helping babies stay healthy, but also leading to fewer lost work days for working parents and fewer sleepless nights for all parents.)
• Decreased risk of Sudden Infant Death Syndrome.
• Decreased risk of asthma in a child who has breastfed.
• Decreased risk of diabetes when the baby grows up.
• Decreased risk of obesity as the baby grows up.
• Decreased risk of certain cancers in the child, such as leukemia.
• Improved cognitive development of the child.

Benefits for mothers include:

• Less bleeding, both in the immediate postpartum period from contracting the uterus after birth, and fewer menstrual cycles during breastfeeding. 
• Decreased risk of getting pregnant while breastfeeding - though this is not 100% effective! If you're not wanting to get pregnant don't rely on breastfeeding alone.
• Easier return to pre-pregnancy weight.
• Decreased risk of ovarian and breast cancers.
• Decreased risk of Type II diabetes.
• Decreased risk of postpartum depression.
• Decreased risk of heart disease.
• Less missed work (see immune system benefits above).
• Cost - breastmilk is free and formula is expensive. Breast pumps should be covered by insurance. 

When Breast Milk Isn't Enough, Isn't Desired, or Isn't Safe

Despite the benefits, breastfeeding not always possible or desired. In the US, 8 out of 10 mothers start breastfeeding during the newborn period. Only half are still nursing at 6 months, and less than a third are still nursing at 12 months.

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months, followed by continued breastfeeding for 1 year or longer, as mutually desired by mother and child. Some AAP sources indicate starting foods at 4-6 months. The American Academy of Allergy, Asthma & Immunology (AAAAI) recommends introducing foods between 4 and 6 months to prevent certain allergies.


There are very few contraindications to breastfeeding:

• Classic galactosemia. Classic galactosemia is a rare genetic condition in which a baby is unable to metabolize galactose. It is one of the conditions we screen on the newborn screen. Galactose is the sugar made from the lactose in milk. When galactose is not metabolized, it will reach high levels in the blood and become toxic, causing cataracts in the eyes, damage to the liver and kidneys, and brain damage. The galactosemic baby will fail to thrive on breast milk or formula based on cow's milk. The treatment for this condition is to remove all sources of lactose from the baby's diet and give soy formula.
• HIV. Mothers who have HIV and are able to feed formula made with safe water should not breastfeed according to current guidelines. However, there is growing evidence that HIV positive mothers who take proper medications can safely breastfeed.
• Untreated active tuberculosis.
• Chemotherapy or radiation treatment.
• Certain drugs. Most medications are compatible with breastfeeding. You can look on Lactmed to learn if a particular medicine is safe or what other options are recommended. 

Some mothers do not want to breastfeed for various reasons. That's okay. It isn't for everyone. No one should say things that make these mothers feel guilty. They brought new life into the world. That alone is an amazing feat. As long as the baby is fed age-appropriate and formula that has been approved for use in infants, it is great.

Babies can thrive on formula. Just be careful of the many alternate formulas and milks that are advertised online. Discuss with your child's pediatrician if you plan on making your own formula or giving another alternative milk. There are many concerns with these, as discussed in Please Don’t Feed Your Baby Homemade Formula!

Some mothers really want to exclusively breastfeed but they have problems. Working with a lactation consultant and physicians (both mother's and baby's doctors) might help if there is a correctable condition, such as

• insufficient breastfeeding attempts per 24 hours - not feeding frequently decreases supply
• tongue tie treatment can improve latch and milk transfer from the breast into baby
• jaundice, which makes baby sleepy and not feed as effectively
• identifying and treating hormonal problems in mother
• identifying and stopping medicines or herbs that might be inhibiting milk supply
• stopping nipple shields as soon as possible - the use of nipple shields can decrease breast stimulation and lower supply
• avoid unnecessary supplements - supplementing with formula can decrease supply overall because the mother's breast makes milk based on how much is used (This does not mean you should avoid formula if it is medically necessary.)

Even when breastfeeding goes well for both Mother and Baby, it is not sufficient to be the sole source of nutrition for the entire first year of life. There are some mom blogs that support exclusive breastfeeding for the first year of life, and that is not safe. I'm not linking any of them here because I don't want to promote them, but if you don't believe me just do a quick search and you will find some.

While breast milk is fantastic for young infants, it does not have the nutritional components to exclusively feed for the second half of the first year. Feeding with food from fingers or a spoon also encourages healthy development of fine motor skills.

It is important for older infants to learn to eat from a developmental standpoint. Once they can sit fairly well, turn away from food or open their mouth in response to food, they are showing signs that they are ready to start eating. They don't need teeth to move foods around in their mouth and make chewing motions. 

They are much less averse to new things typically when they're younger, so if babies are delayed past a year they are much more likely to be picky eaters and not get the nutrition they need during childhood.

Then there's the research that shows that delaying certain foods past a year increases the risk of allergy. If you've ever seen a child with anaphylaxis to peanuts, you won't want to increase this risk for your child! See the AAP's guidance on introduction of high-risk allergenic foods. 

Babies need a source of iron after about 4-6 months of age. If they are not eating foods rich in iron (meats, legumes, egg yolk, leafy greens) they will need an iron supplement. Many of the bloggers who support exclusive breastfeeding do not want any supplements at all. Just breast milk. It simply isn't enough to support the older infant's growing brain and body. 

Vitamin D is important for us all, but it is not passed through breast milk well unless a mother is taking at least 6400 IU/day. Historically we could make vitamin D with the help of the sun, but we now know that sun damages our skin so it is safer to protect against excessive sun exposure. This puts us at risk for vitamin D deficiency. The AAP recommends that newborns begin supplementing with 400 IU/day of vitamin D soon after birth, and increase to 600 IU/day at 6 months of age. The supplement should continue even if they transition to Vitamin D fortified cow's milk at 1 year of age.

Any problems feeding should be discussed with your child's doctor

If your baby struggles with feeding, whether it's breastfeeding, formula feeding, or eating foods, please discuss it with your child's doctor. There are many reasons feeding might not go well, and we need to insure that your baby is being adequately fed. We will look at your baby's overall growth and development in addition to discussing the specific details of the problems. 

Resources

Breastfeeding landing page for the American Academy of Pediatrics
Vitamin D & Iron Supplements for Babies: AAP Recommendations

Related Blogs on Quest for Health

Over and Under Supply of Breast Milk

Feeding Your Newborn

Breastfeeding: Easier for Working Moms with New Insurance Rules

New SIDS Prevention Guidelines

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Car Seats for Safety

It's been years since I've written about car seat safety and since September 17-23, 2017, is Child Passenger Safety Week I thought I'd take a moment to review car seat safety basics and share some of my favorite car seat safety links.

Most parents are now aware that all infants must be in a rear facing car seat, but many turn their toddlers around too early or let older kids move to the next level too soon.

I tell kids all the time that the state law is the bare minimum, but it isn't necessarily the safest way to ride. I use the example that in my state an adult can ride a motorcycle without a helmet, but that's not safe. They usually agree, and I think it helps them understand that just because it's legal to do something, it doesn't make it safe to do.

Kids learn from the behaviors they see their parents display, so all parents should buckle up for safety!

When looking for a car seat or booster seat, don't assume spending more money will buy a better seat. You need to be sure it fits your vehicle and your child.

Infants and children under 2 years should ride rear facing unless they are bigger than the height or weight maximum for the seat. Children over 2 years who still fit in the height and weight requirements of the rear facing car seat can still ride rear facing safely. Young children often fall asleep in the car. If sleep deprived (no parent is ever really well rested) and in a hurry, even the best parent can be distracted and forget about the sleeping baby. There are many tips to follow to be sure you don't leave your baby unattended in the car.

Children who are 2 years old or older (and those less than 2 years but larger than the rear facing car seat maximum height or weight) should use a forward facing car seat with a 5 point harness until they are capable of staying seated during the duration of the drive and meet the minimum height and weight requirements for a booster seat. Learn to use the tether properly with your forward facing car seat.

Children should remain in a booster seat until the vehicle's lap and shoulder seat belt fits them properly. This is generally between 10 and 12 years of age and about 4 foot 9 inches, but varies based on the size of the vehicle's seat. Everyone should always use the vehicle's seat belt (or car seat harness) when riding. Have your kids take the 5 Step Test to see if kids can safely ride without a booster.

Only teens and adults should sit in the front seat. It's always safer in the back seat. If you look at the sticker on the passenger side visor, it will say something to the effect that children 12 and under are safer in the back seat. That means wait until 13 years of age to sit up front. Airbags can be dangerous if a passenger is too short for it to hit properly in the chest. The force of the airbag can cause significant injury to the face or neck. If the airbag is turned off, the passenger is at risk of hitting the dashboard or being ejected from the car. Even big kids don't have the muscle or bone strength to be safe up front. They aren't mini-adults.

In the winter months it's important to avoid over bundling infants and children in car seats. The added layers and padding of clothing can increase the amount a child can move in the force of a crash or sudden stop. The Car Seat Lady has great tips to keep kids warm and safe in the cold weather.

Don't use car seat attachments and accessories that were not sold with the seat. They may look cute or seem to make your child more comfortable, but if they haven't been tested with the seat they may not be safe - even if they claim to be safety tested. This includes neck rolls, shoulder pads, winter covers that go between the child and the seat, dangling toys, and more. If you're in an accident and have these additions they might void the warranty of the seat.

Do you have a Houdini? If your toddler or preschooler is able to weasel out of the car seat harness, try this button down shirt trick.

Take your kids to a certified car seat installer to see if they're buckled in properly. Car Seats for the Littles has information about how to find an installer near you.

Register your car seats so you can be alerted if they are recalled.

Car Seat Stickers are a great way to notify first responders who to call if you've been in an accident and aren't able to communicate. I recommend putting them under the cloth part of infant seats so they aren't visible when you're carrying the seat in public. You can put a small sticker on the handle to let emergency personnel know to look under the padding for emergency contact information. Once kids are out of the infant seat you can put the sticker on the outside of the seat, just not over any important information (such as the height/weight max information). My office gives stickers from the W.H.A.L.E. Program to patients, but you can print your own at home and attach them to your seat with wide clear tape. Information to include would be:

• Child's name, birth date, address, allergies, important health history, medications
• Parent's names and phone numbers (cell and work)
• One emergency contact name and phone number (not a parent) 
• Doctor's name and number
• Childcare provider name and number if applicable 

Remember that if you're in an accident, your car seats might need to be replaced. Talk to your insurance company.

Used and borrowed seats cautions: 

• Be sure to know when your seats expire. The seats typically expire about 6 years after manufacturing due to unseen breakdown in the materials used to make the seat. 
• Never buy a used seat from someone you do not know. A friend or family member should verify that it hasn't been in an accident and it's not expired before you use it. 
• Don't just throw your old car seat away. Someone might try to use it past its expiration date. You can break it down into pieces to make it unusable or you can see if you can recycle it. 

For more information:

• National Highway Traffic Safety Administration
• The Car Seat Lady
• Car Seats for the Littles
• Safe Kids Car Seat Information
• Safe Kids Booster Seat Information
• LATCH information from The Car Seat Lady, Safe Kids, and Car Seats for the Littles
• HealthyChildren.org
• Car seats for obese children
• 2017 Car Seat List

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HPV vaccine concerns

The large majority of the parents who bring their children to my office want their children to be vaccinated against any disease we can protect them against. The HPV vaccine is one exception. While most of my patients are given the Gardasil at their 11 or 12 year check up, some parents still "want to do their research" or "have heard things" so they decline to protect their kids at those visits. Sadly they often return year after year and say that they still haven't done their research, so their child remains unprotected. Sometimes they'll say that they will let their child decide at 18 years of age. Sadly, by that age many will have already been infected.

I recently had a parent share HPV Vaccine: Panacea or Pandora’s Box? The Costs and Deceptiveness of the New Technology with me. She had concerns based on the information in this article. The first thing I noted was that it is from 2011. This is outdated, since we have learned so much in the six years since it was published, yet like many anti-vax articles, it continues to circulate online.

 The first argument is that it won’t last long enough. 

It is therefore possible that the protective effects of the vaccination will wane at the time when women are most susceptible to the oncogenic effects of the virus (those over 30), providing protection to those who do not need it (adolescents) and failing to provide protection to those who do (women over 30).

Studies show protection lasts 10 years and hasn’t dropped by that time. If future studies show a booster is needed, we can add that. That in no way should mean to not give protection for the years it is really needed – adolescence and young adult life. I cannot agree with the statement that providing protection "to those who do not need it (adolescents)" at all. Yes teens need protection. I'll get more into their risks below. And the fact that women over 30 are more likely to develop the cancer does not mean that is when they come into contact with the virus. It's kind of like saying that kids don't need to brush their teeth because they don't have cavities. If you wait for the cavities to develop, it's too late!

The second argument is based on old version of the vaccine. We now use the 9 valent variety, which covers the large majority of cancer causing strains. Again, even if there are other strains, why not protect against what we have?

The argument that natural immunity will last longer than the vaccine immunity is not a valid argument. Natural immunity can wane with some diseases too, and if we can protect against the disease, it is preferable. Boosters for many vaccines are needed when we know immunity wanes. That’s okay. Some parents advocate to not vaccinate and get the real disease. When their kids get whooping cough they’re miserable. Many are hospitalized. Some even die. I’d rather do boosters! (This may be a bad example because I don’t think our booster for whooping cough lasts long enough and there are complications with giving boosters more often, but ongoing surveillance and research will continue and hopefully improve the situation.)

The cost issue is interesting. If it was not cost effective in the long run, insurance companies wouldn’t pay for it. It’s that simple. They’ve done the math. Australia is a great example. Their cancer rates are down because HPV is a mandatory vaccine. 

The risks listed have all been shown to not be as risky as once shown.

• HPV Vaccine Not Linked To Autoimmune Disorders, Study
• Questioning Whether To Get Your Child the HPV Vaccine? Read This
• Is The HPV Vaccine Safe? v 2.0
• Gardasil HPV Vaccine Safety Assessed In Most Comprehensive Study To Date

The article also alludes to this being a sexually transmitted disease so we can just teach abstinence until marriage. There are so many things wrong with this. First, this virus can spread through non-intercourse activities, which can be part of a normal and healthy teen relationship. Second, even if your child is a virgin at marriage, their spouse might not be. Or the spouse could die and they remarry. Or there could be infidelity in marriage. There may not be signs of this virus during an infection. Testing for HPV is recommended for women over 30 years of age, but is not available for men at any age, so teens and young adults will not know if they have the virus or not. And we know that abstinence only teaching fails. Some people raised in strict Christian households have sex outside of marriage. Teaching kids to protect themselves is much more effective to prevent many sexually transmitted infections, but condoms don't always protect against HPV transmission.  And there’s always rape. One out of four women has been sexually assaulted. One in four! What a horrible thing to be raped. Then to find out you get cancer from that…

They argue it hasn’t been tested in males. It has. And it cuts cancer rates in men too. They’re not just vectors as stated in the article.

This article is several years old. It didn’t yet know that the cancer rates in Australia would fall like we now know. We’ve learned much more information than they knew in 2011 when it was written. We know the HPV vaccine is safe. It is best given before the teen years to induce the best immune response and to get kids protected before the risk of catching the virus becomes more likely. It isn’t a lifestyle choice to get this virus, as it seems the author claims. People have sex. This virus and other infections can spread through sex. But this virus is also spread without intercourse (such as through oral sex or skin to skin contact without sex), which is why 80% of the adult population has had the virus at some point.

Someone You Love is a documentary that follows several women with HPV related cancer. If you still think the vaccine isn't worth it for your child, watch it. I am not paid in any way to recommend this. It simply is a powerful documentary that shows the devastation of HPV disease and you should see that before saying your child doesn't need protection.

I strongly feel this is a safe and effective vaccine. So much so that my own teens received three doses of the original Gardasil and one dose of Gardasil 9 despite no official recommendations for this booster. I want to protect them in any way that I can. If I had any concerns about its safety I would not have given it to my own children. I don't think I can list any study or give any argument stronger than that.

Tamiflu status downgraded!

Those of you who follow my blog or are my patients know that I've never been a fan of Tamiflu. I've written To Tamiflu or Not To Tamiflu and I've posted Tamiflu from guest blogger, Dr. Mark Helm. Despite the CDC's recommendation to use Tamiflu frequently, I rarely prescribe it. And when I do, I often find that the whole course isn't completed because the kids don't tolerate it well - usually vomiting, but occasionally they've had scary hallucinations. I haven't seen very much benefit, especially given the cost (and often the difficulty of finding it during peak flu season).

The World Health Organization (WHO) has recently downgraded the status of Tamiflu. The CDC and FDA will have to chime in for the US recommendations, but the WHO is a respected source of medical guidelines and I look forward to a response from the CDC.

As I've said before, Tamiflu doesn't seem to work as well as needed and it has significant side effects. Not all studies done on Tamiflu were published. Only studies showing a little benefit and minimal side effects were considered in making the recommendations to use it. If many studies show no benefit but aren't published, it makes it seem better than it is. Most studies are done in adults, but studies in children for prevention of flu and treatment of flu also fail to show much benefit.

A 2013 review of all the studies done in adults found only a 20.7 hour reduction in symptoms (yes, less than one day). In the elderly and those with chronic diseases (among the highest risk adults) no reduction was found. They also found no evidence of decreasing the risks of pneumonia, hospital admission, or complications requiring an antibiotic. This same review also showed more side effects than commonly reported. Nausea, vomiting, and psychiatric side effects are common.

I hope that the CDC reviews its recommendations for antiviral use before the influenza season hits this year. Until then, plan on getting your family protected with the flu vaccine. It isn't perfect, but it does help keep us from getting sick and it can help save lives!

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It's Back to School Time, Time to Think Safety!

Walking to school is wonderful for kids because they get exercise, which can help with focus at school and their overall health. It can be also be a time to talk with friends or family and build community bonds.

But it also can pose dangers, especially if drivers are distracted talking to their own children or texting. Please stop texting and driving. Don't touch your phone at all while driving. Calls and texts can wait. If they can't, pull over and check the message while parked. Really.

Talk to your kids about safety.

• Kids should walk with an adult until they show the maturity to walk safely without direct supervision. The specific age will depend on the area as well as the child's maturity. Are there safe sidewalks? Are there busy roads to cross? Are there other kids walking the same route? Are there homes along the way they can go to in case of emergency? How long is the walk?
• Find the safest route: Choose sidewalks wherever possible, even if that means the trip will be longer. If there are no sidewalks, walk as far from vehicles as possible, on the side of the street facing traffic. If possible, avoid areas near high schools, where there are more teen drivers.
• Cross streets safely. If there are crossing guards, use those intersections. If there are street lights, wait until the "walk" symbol appears. Never cross in the middle of a block, use intersections. Look both ways twice before crossing. Do not text or play games when in the street. 
• Remind kids that if they are crossing a street, they should make eye contact with a stopped driver before crossing, even if there's a "walk" symbol. Drivers turning right might turn on red and not notice small pedestrians.
• Teach kids to use the same route every day or discuss which route they will take each day if they use different routes. If they don't arrive to school or home as planned, you know the route to search. Walk the routes with them until they know how to safely navigate each.
• Have kids stay in groups or with a walking buddy as much as possible. 
• Avoid distractions. Listening to music (especially with earbuds), playing video games, watching videos, and texting all keep kids from paying attention to their surroundings. Even talking on the phone is distracting, so don't assume they are safer if they talk to you all the way home when you're at work. They are more likely to trip and fall, step into a street without looking first, or not notice that they're being followed if they're distracted. They should be aware of their surroundings at all times.
• Remind kids to never accept a ride from anyone unless you pre-plan it. Rain, snow, and cold weather make it tempting to hop in a car, so have kids dress appropriately for the weather and arrange safe rides as needed. 
• Have kids keep important contact information in their backpacks in case of emergency. At least two people should be on this list. People on the list could include a parent, grandparent, or trusted adult friend/neighbor. Names and phone numbers should be included.
• Related: If they are riding a bike, scooter, or skateboard to school, they should follow the rules of the road and proper safety.

See if your school can help arrange walking buses, where kids all walk the same route to school with adult walk leaders.

Suggestions for adults:

• Be extra cautious when driving in the before and after school times, especially near schools and in neighborhoods.
• Be nice and don't use your sprinklers in the before and after school times so kids can stay on the sidewalks and not wander into the street to avoid getting wet.
• Never text and drive. Put your phone on silent and in a place you can't reach it while driving. Texts can wait.
• If kids are in your car, make sure they are properly buckled. Only teens and adults should be in the front seat. Use an appropriate car seat or booster seat. Kids shouldn't wear their backpack in the car, nor should they unbuckle while in a drop off line to get their backpack on before the car is stopped. 
• If your kids will carpool with other families, be sure they are in proper seats at all times. It's tempting to not use boosters for short drives, but it's never safe to have kids improperly restrained. Find boosters that are easy to move between cars.

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Neutropenia... What?

It is recommended to screen for anemia (low red blood cell levels) around one year of age. Our office orders a complete blood count (CBC), which checks for red blood cells, white blood cells, and platelets - the main components of our blood.

One relatively frequent abnormal lab we see (especially during the winter months) is a low absolute neutrophil count (ANC). Neutrophils are a type of white blood cells that fights bacterial infections. When their numbers get too low, it can increase the risk of serious bacterial infections. While some people have low ANCs that cause significant immune deficiencies and can lead to infection, the most commonly seen low ANC we see are brief dips after a viral infection. A low ANC is called neutropenia.

Photo source: Wikimedia. Blausen.

The large majority of kids with neutropenia have only mild drops in their ANC and are not at significant risk of illness. In general the more severe the drop, the more significant the infection risk.

Most causes of neutropenia are due to infection, drugs, severe malnutrition or immune disorders. The most common cause of neutropenia we see is after an infection. In most cases this type of neutropenia quickly resolves without any treatment. Some viruses, such as hepatitis B, Epstein-Barr, and HIV, are associated with prolonged neutropenias. The drugs that can cause neutropenia are not commonly used medications and routine testing for neutropenia would be done when those medications are used. Vitamin B12, folate, and copper deficiencies are very uncommon in children, but can lead to abnormal blood counts.

There are three levels of neutropenia:

Mild neutropenia: The ANC ranges between 1000-1500/μL

Moderate neutropenia: The ANC ranges between 500-1000/μL

Severe neutropenia: The ANC is less than 500/μL

• Mild: ANC 1000-1500
• Moderate: ANC 500-1000
• Severe: ANC less than 500

Mild neutropenia: The ANC ranges between 1000-1500/μL

Moderate neutropenia: The ANC ranges between 500-1000/μL

Severe neutropenia: The ANC is less than 500/μL

Since most mild cases of neutropenia self-resolve, it is not usually anything for parents to worry about. I used to recheck all of these, but found that many kids needed several rechecks because they always had a mild viral infection and they never got significantly sick. I have changed my personal protocol because if kids start getting sick, they will end up being rechecked and if they're healthy, there was no need to recheck.

• If a child is overall healthy and growing well, the level is only mildly low (above 1000) I do not recheck the level -- though if your doctor wants to recheck it (or if you want it rechecked), that is appropriate to do.
• If the level is in the mid-range (500-1000) or if the child has had problems with recurrent infections or growth, I will usually recommend a confirmation (repeat test) and possible further evaluation. 
• If the level is in the severe range (less than 500), it should be rechecked and the child should be closely monitored due to high risk of severe bacterial infections.
• Some physicians recommend repeating a blood count with any fever for a year in kids who have had any degree of neutropenia, so you'll have to talk to your child's doctor for a plan.

What symptoms might happen if the ANC is low?

Most children with a temporarily and mildly low ANC will have no symptoms and need no treatment. Children with chronically low ANCs will have more infections that require antibiotics, such as pneumonia, skin infections (abscesses, cellulitis) and lymph node infections. They might also have chronic gum disease, mouth sores, or vaginal or rectal ulcers. A common cold or cough is NOT from a low ANC, since these are viral illnesses and a different type of white blood cell targets viruses.

Frequent infections

Serious respiratory infections, including pneumonia or sinus infections

Skin infections (e.g. cellulitis, abscesses)

Multiple serious infections (e.g. meningitis, bone infections)

Lymph node infections

Gum disease

Mouth sores/ulcers

Vaginal, urethral rectal ulcers

When do we worry?

The level of ANC as well as the cause both determine the risk level of an overwhelming infection. An example would be when people are immune suppressed from chemotherapy, they are at very high risk of bacterial infections. On the other hand, an otherwise healthy person with a mildly low ANC is not more likely to get a bacterial infection than another person with a normal ANC.

We are concerned if the child has recurrent infections, poor growth, or a very low level. Each case must be evaluated by the person who ordered the test and who has recently seen your child.

What treatment is done for a low ANC?

Most children do not need any specific treatment. They are monitored for recurrent infections, especially infections that require antibiotics. They are also monitored for growth, since if a body is chronically sick, it often doesn't grow well.

Each infection that requires antibiotics is treated and blood counts might be checked to see how low they are at the time.

In children who have a chronically low ANC, I usually refer them to a hematologist (blood specialist) to evaluate why they have it and if it requires a special treatment that stimulates the bone marrow to make more neutrophils.

For more information:

Benign familial leukopenia and neutropenia in different ethnic groups.

Pediatric Autoimmune and Chronic Benign Neutropenia

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Dry Drowning - What Parents Need To Know

I thought about titling this one "We're drowning in dry drowning phone calls" because we are getting many worried calls about dry drowning, but that's overly dramatic and I hate headlines that make things seem like the sky is falling...

I had never heard of dry drowning until social media picked it up a couple of summers ago. Maybe I did as a resident, but since I've never seen it, I'd forgotten the term. Either way, it isn't very common at all, but it is an emergency when it happens, so it's good that we all know that it can happen. People also use the term secondary drowning and some experts differentiate the two by whether or not water actually gets into the lungs, causing swelling of the lung tissue, or if water irritates the vocal cords, causing them to spasm and close off. Either situation is potentially life threatening and they have similar symptoms. Note: Please see the addendum at the bottom. Several articles have emerged since the original writing of this post that clearly indicate there is no such thing as dry drowning.

One of the reasons I think so many parents are worried is that it is common for kids to go under water: in the tub and in the pool. Many get water in their mouth or complain that it went up their nose. Few actually get any into their lungs, which is where it can cause problems. How can you know when you need to worry?

Most of us recall a time we coughed briefly after inhaling liquid, and we were fine. So when is it worrisome? It's when the water that gets into the lungs causes inflammation within the next day or two. This inflammation makes it hard for the lungs to work - the air tubes are swollen, so air can't get through. Treatment is giving oxygen, sometimes with a ventilator (breathing tube and machine) until the inflammation goes down.

Symptoms you need to recognize and act upon by taking your child to an ER:

• Cough: If your child has coughing for a minute or more after being in water, he's at risk. This indicates that the child is trying to clear the airways. If water got down there and they cough most up, some can remain behind and lead to inflammation over time. Watching your child carefully for the next 3-4 days is important. This can be hard to recognize initially, so a complete evaluation is important if any other symptoms develop.
• Difficulty breathing: Anyone who is struggling to breathe needs further evaluation. Signs can be rapid breathing, sucking in the ribs or the stomach, difficulty talking, or even a look of fear from difficult breathing.
• Near drowning: If your child had to be pulled out of the water, he should be evaluated in an ER. Even if he seems fine afterwards. The reaction is delayed, so they can seem to be 100% better and then go downhill.
• Behavior changes or confusion: If a child is confused, lethargic** or has a change in ability to recognize people, he should go to the ER. Serious illnesses can present with a change in mental status, including significant infections, concussion, heat exhaustion, brain tumors, and drowning. The ER doctor will ask what else has been going on to help identify the cause of confusion.  **Many people misuse the term lethargic. Lethargic isn't the same thing as being tired after a long day. The medical definition is "Relatively mild impairment of consciousness resulting in reduced alertness and awareness; this condition has many causes but is ultimately due to generalized brain dysfunction."
• Vomiting: Vomiting after a day at the pool can be due to infection (from swallowing contaminated pool water), food poisoning (from food left in the heat too long) or dry drowning. It's best to check it out in the ER.

What will happen in the ER?

Many parents don't want to go to the ER because of high co-pays. We try to keep kids out of the ER as much as possible. But some issues are better taken care of in an ER. Most offices don't have the equipment or staff to manage these issues well. Dry drowning can be life threatening, and the evaluation and treatment should start in the ER. I cannot say exactly what the doctor will do, since that will depend on your child's symptoms and exam. There is no specific treatment for this, only supporting your child's airway and breathing as the swelling goes down.

• If the doctor thinks your child may have swelling of the airways, he might order a chest x-ray to look for pulmonary edema (lung tissue swelling). 
• An iv might be started to be able to give adequate fluids, since your child might not be up to drinking well. 
• Oxygen levels will be monitored and extra oxygen might be given. 
• Since the swelling worsens before it gets better, if there is a strong suspicion of dry drowning your child will be admitted for further observation.
• Some kids need help breathing and are put on a ventilator (breathing machine) until the swelling goes down.

Prevention is important!

As with many things, we should do all we can to be sure our kids are safe around water. This includes the bathtub and toilet as well as swimming pools, lakes, and ponds. 

• Childproof your home when you have little ones who might play in a pet water bowl or the toilet. 
• Teach your kids water safety. Swimming lessons can help them learn skills. Tell them to never try to dunk each other. They shouldn't pretend they're drowning because it might distract a lifeguard from a true emergency. 
• Learn infant and child CPR.
• If you have a pool or pond at home, be sure there is a fence limiting access from your house.
• Watch your kids closely and keep them within reach when they're in water until they are strong swimmers. When they are strong swimmers you can let them swim outside your reach as long as lifeguards are present. 
• Learn what distress in the water looks like. The movie depiction of drowning with a lot of yelling and thrashing around is not what usually happens. If someone can verbalize that they're okay, they probably are. Drowning victims can't ask for help. There is a video linked to this page of what to look for with drowning that shows an actual rescue. From this site, signs of drowning:

• Head low in the water, mouth at water level

• Head tilted back with mouth open

• Eyes glassy and empty, unable to focus

• Eyes closed

• Hair over forehead or eyes

• Not using legs – Vertical

• Hyperventilating or gasping

• Trying to swim in a particular direction but not making headway

• Trying to roll over on the back

• Appear to be climbing an invisible ladder

Addendum:

I just read this post that gives references regarding drowning definitions. It appears I didn't forget learning about dry drowning in medical school. It isn't really a thing. The symptoms listed above that I recommend getting evaluated are still concerning symptoms, but they might be from another cause. Check this out: On "Dry Drowning"

Another: Drowning in a Sea of Misinformation: Dry Drowning and Secondary Drowning

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