Updated Sinusitis Guidelines

photo source: Shutterstock

This month the American Academy of Pediatrics updated the guidelines for management of sinus infections in children (1-18 years of age) in the June edition of Pediatrics, available online.

Many parents bring kids in to the doctor for green or yellow runny noses because they're worried about bacterial sinusitis. Sinuses can be infected with viruses or produce mucus from allergies, so not all sinus infections are bacterial. Most of these kids do not need antibiotics to get better, but the guidelines help determine who might benefit from them and when to change an antibiotic if not improving. The guidelines are based on duration of symptoms and severity, not the color of the drainage, how much drainage there is, or fancy testing. Only infections caused by bacteria need antibiotics. Overuse of antibiotics can lead to resistance (so when there is a severe infection it becomes more difficult to treat), side effects (such as diarrhea), or allergic responses.

Unfortunately, a physical exam is not helpful in distinguishing a simple viral cold and cough from a bacterial sinus infection, but is needed to identify other problems that might complicate the picture, such as pneumonia or an ear infection. The inside of the nose can be swollen and various shades of pink, red or blue in sinus infections from bacteria or other causes. How often have I palpated those sinuses to see if tender, yet I know from personal experience that mine hurt when my allergies flare-- certainly not a reason for antibiotics!

I wish there was a simple test, but nose swabs for culture have not been found to be accurate in predicting bacterial cause of the infection. Imaging studies are not needed to help diagnose sinusitis because the inflammation seen in pictures can be from other causes, not just bacterial.

Most cases of runny nose, fever, and/or cough are due to a viral illness. The nasal discharge usually starts clear, but can become thick and discolor over time for several days. It often goes back to a thinner, clear color before resolving without antibiotics. Fever in a typical viral illness tends to be the first several days, and may precede the other symptoms. Fever usually resolves by day 3, when the nasal discharge and cough tend to worsen.  Symptoms tend to peak between the 3rd and 6th day, then resolve after about 10 days. (Though some studies show longer.) Back to back infections are common in kids, especially during the winter months, which can be confused with one prolonged sinus infection.

Guidelines to diagnose and treat acute bacterial sinusitis in a nutshell:

• Symptoms in a child with upper respiratory infection suggest acute bacterial sinusitis if: 

• there is persistent illness (nasal discharge or daytime cough) of 10 days without improvement. This persistence can be difficult to distinguish from back to back viral illnesses, so a careful review of symptoms is important.

 or

• there are worsening symptoms (nasal discharge, cough, fever) after initial improvement. (New in the 2013 guidelines.)

or

• there is severe onset (fever over 102.2F and discolored nasal discharge for at least 3 consecutive days). Several viral infections, notably influenza, can cause severe onset of symptoms, but a clue to the bacterial nature is the combination of fever with mucus in the initial days, since the fever usually comes before the mucus in many viral illnesses. 

• Observation without antibiotic is acceptable with a persistent infection over 10 days for another 3 days if there was not a severe onset or worsening of symptoms. (This differs from the 2001 guidelines to use an antibiotic for symptoms of 10 days.)
• Imaging is not recommended to diagnose routine sinusitis. Plain x-rays, computed tomography (CT), magnetic imaging (MRI), and ultrasounds (US) cannot distinguish between viral, bacterial, or allergic nature of the inflammation. 
• If there is a suspicion of extension of the infection outside of the sinus cavities, such as into the eye orbit or central nervous system, a contrast-enhanced CT scan is indicated. These might be suspected if the eyelid is swollen and the mobility of the eye is decreased, sensitivity to light, severe headache, seizures, or other neurologic changes. 
• When antibiotics are indicated, amoxicillin or amoxicillin with clavulanate (Augmentin) is the first line choice unless there are documented allergies to penicillins. If there are allergies or failure to respond to the amoxicillin, a cephalosporin may be used. There are other good choices, but studies do not show that azithromycin (Zithromax) or trimethoprim sulfamethoxazole (Bactrim) are good choices because they aren't effective against the most common bacteria of bacterial sinus infections. The duration to take an antibiotic is not well identified. Recommendations vary from 10 to 28 days, or 7 days from the time symptoms go away. This will vary by prescriber's preference and experience.
• If there are worsening of symptoms or failure to improve within 72 hours of initial visit, a repeat evaluation is recommended. If no other source of symptoms is found on physical exam, adding an antibiotic (if not previously initiated during the observation period) or changing the antibiotic is recommended. 
• There was not enough evidence to support other treatments, such as decongestants, antihistamines, nasal corticosteroids, or saline rinses. More studies in children are needed to validate whether these are effective or not. There's always more to learn!

Bicycle Safety

I like the simplicity of picture blogs. They make it easy to share a lot of information in an easy to see format, so when I decided to do a blog on bicycle safety, it was an obvious choice.

Bicycle Safety Tips

Teach kids to use hand signals to alert others where they are going:

From: http://www.nhtsa.gov/Bicycles

Use a properly fitted helmet:

From: http://www.nhtsa.gov/Bicycles

Help your kids learn about bike safety with these fun activities from the National Highway Traffic  Safety Administration.

Swimmer's Ear

Summer's here and that means we will soon start seeing a lot of older kids with earaches.

Swimmer's ear differs from a middle ear infection. It is an inflammation of the skin lining the ear canal and is most common in older children and teens. Middle ear infections (otitis media) are caused by pus behind the eardrum and are most common in infants and younger children.

Swimmer's ear (AKA otitis externa) gets its name because it is commonly caused by water in the ear canal making a good environment for bacteria to grow, causing an infection of the skin. Water can come from many sources, including lakes, pools, bath tubs, and even sweat, so not only swimmers get swimmer's ear.

Anything that damages the skin lining the ear canal can predispose to a secondary infection, much like having a scraped knee can lead to an infection of the skin on your knee. Avoid putting anything in your ears, since it can scratch the skin of the ear canal. This includes anything solid to clean wax out of the ear. Excess earwax can trap water, so cleaning with a safe method can help prevent infection. A little wax is good though -- it actually helps prevent bacterial growth. For more on earwax, please see Ear Wax: Both Good and Bad.

Swimmer's ear can cause intense pain. Sometimes it starts as a mild irritation or itch, but pain worsens if untreated. It typically hurts more if the ear is pulled back or if the little bump at the front of the ear canal is pushed down toward the canal. Ear buds (for a music player) or hearing aides can be very uncomfortable (and increase the risk of getting swimmer's ear due to canal irritation). Sometimes there is drainage of clear fluid or pus from the canal. If the canal swells significantly or if pus fills the canal, hearing will be affected. More severe cases can cause redness extending to the outer ear, fever, and swollen lymph nodes (glands) in the neck. Swimmer's ear can lead to dizziness or ringing in the ear.

Prevention of swimmer's ear is possible for most people.

• If your child has excessive wax buildup, talk with his doctor about how often to clean the wax. (Wax does help keep your ears clean, so you don't want to clear it too much!)
• Never put anything solid into the ear canal.
• Dry the ear canals when water gets in. 

• Tilt the head so the ear is down and hold a towel at the edge of the canal. 
• Use a hair dryer on a cool setting several inches away from the ear to dry it. 

• If kids get frequent ear infections or are in untreated water (such as a lake), use over the counter ear drops made to help clean the canal. You can buy them at a pharmacy or make them yourself with white vinegar and rubbing alcohol in a 1 to 1 ratio. Put 3-4 drops in each ear after swimming. The acid of the vinegar and the antibacterial properties of the alcohol help to clear bacteria, and the alcohol evaporates to help dry the canal. DO NOT use these drops if there are tubes or a hole in the eardrum, if pus is draining, or if the ear itches or hurts.

• If your child has a scratch in the ear or a current swimmer's ear infection, avoid swimming for 3-5 days to allow the skin to heal. 
• Avoid bubble baths and other irritating liquids that might get into ear canals.
• If your child has tubes placed for recurrent middle ear infections, talk with your ENT about ear protection during swimming. 

Treating swimmer's ear:

• If you think your child has swimmer's ear, start with pain control at home with acetaminophen or ibuprofen per package directions. Heating pads to the outer ear often help, but do not put any heated liquids into the ear. 
• Most often swimmer's ear is not an emergency, but symptoms can worsen if not treated with prescription ear drops within a few days. Bring your child to the office for an exam, diagnosis, and treatment as indicated. 
• If the pain is severe, redness extends onto the face or behind the ear, the ear protrudes from the head, or there are other concerning symptoms, your child should be seen immediately at our office or another urgent/emergent care setting. 
• Occasionally we will remove debris from the canal or insert a wick to help the drops get past the inflamed/swollen canal. Never attempt this at home!
• The prescription ear drops may include an antibiotic (to kill the bacteria), a steroid (to decrease inflammation and pain), an acid (to kill bacteria), an antiseptic (to kill the bacteria), or a combination of these.  They are generally used 2-3 times/day. Have the patient lie on their side, put the drops in the ear and remain on that side for several minutes before getting up or changing sides to allow the medicine to stay in the ear. Symptoms generally improve after 24 hours and the infection clears within a week.
• Oral antibiotics are usually not required unless the infection extends beyond the ear canal.
• If pain is very severe, ask about prescription pain relievers when your child is being seen and evaluated. Most often they are not needed, but if they are it is best to get them at the time of your visit so risks of these medications and how and when to use them can be discussed.
• If an infection causes more itch than pain or does not clear with initial treatment, we might consider a fungal infection, which requires an anti-fungal medication. 
• No swimming until the infection clears. 
• Kids (and adults) with diabetes or other immune deficiencies are more likely to get severely sick with any infection. Visit your doctor early if you suspect a problem.

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Lawn Mower Safety

This time of year a lot of us must mow twice a week to keep the grass under control.

I have already seen kids in my neighborhood who are far too young to safely mow pushing the lawn mower. Each year I cringe at the sight of kids taking on this responsibility too soon! 

I often see a parent mowing with kids playing near by. 

Thousands of children are injured by lawn mowers each year. They lose limbs and life. This is entirely preventable.

Last week I drafted this picture to quickly show a few safety tips.  It was popular on our Facebook page, so I wanted a more "permanent home" for it. 

Please feel free to share!

For more tips, see the American Academy of Orthopedic Surgeon's page on Lawn Mower Safety.

Original picture altered from Shutterstock.

What kids need to be able to do to leave the nest...

photo source: Shutterstock

It's graduation season, which has me thinking of all the ways our kids grow over the years. They're born, then just a few years later they are in kindergarten. In just a blink of the eye they get a locker in middle school. Then high school is over. The world awaits...

Where does the time go?

I have one who will be starting high school next year, and have spent a lot of time reflecting about at all he's learned and what he needs to learn to be successful, independent, healthy and happy.

I have never really thought that school is about learning the actual subjects. It is more about learning how to learn. How to organize. How to be responsible. I have always told my kids I don't care what grade they get as long as they learn what they need to and do their best.

Home life is also a process of learning. We learn how to live healthily and respectfully with others. We learn to take care of ourselves. We learn to be responsible with money. Ideally we learn to argue a point without losing control of our emotions or being hurtful.

In all of this reflection, I came up with a list that I have shared with my kids, and I invite you to share it with yours.

Things you should be able to do independently before leaving home:

Good hygiene habits

• Brush teeth twice daily. Floss once a day. 
• Shower or bathe daily. Wash hair as needed for oil control. 
• Wash hands often. 
• Shave as needed. 
• Flush.
• Brush hair at least daily and get a hair cut regularly. 
• Clip and groom nails regularly, fingers and toes. 
• Use personal hygiene products correctly, including: deodorant, facial acne cleansers, etc. 
• Wear clean clothes and change underclothing daily. 

Healthy habits

• Get adequate sleep to wake fresh and ready for the day. Set an alarm and get up on your own. 
• Eat healthy foods and limit junk food and sodas. Be able to prepare simple healthy meals. 
• Take vitamins daily. 
• Understand common over the counter medicine indications and how much to take.
• Understand why you are taking medications (if you are), how to take them, and what is needed to get more -- is it over the counter or a prescription medicine?
• Know your medical history, including any allergies and chronic health care problems.
• Know how to take care of common injuries until they are healed. 
• Exercise regularly, at least 3 times a week. 
• Develop healthy strategies to handle stress. 

• Journal 
• Prayer or meditation 
• Sketch or other artwork
• Talk to someone openly—don’t hold bad feelings in! 
• Take a long bath 
• Think before speaking 
• Deep breathing 
• Laugh 
• Exercise 
• Schedule down time 
• Think about the problem from different points of view 
• Break big projects into small parts to be able to complete in parts 
• List the good things going on and be positive 
• Avoid overscheduling
• Learn to say "no"

• Enjoy social interactions as well as alone time. 
• Exercise the brain by doing puzzles or reading.

Things to learn

• How to cook a healthy, balanced meal. 
• How to grocery shop on a budget to incorporate nutritional balance.
• How to properly clean dishes and tidy up the kitchen after eating.
• How to balance a check book, make a budget, and pay bills on time.
• How to do easy repairs around the house.
• Understand health insurance plans - how to get them, what they cover, what is excluded.
• Basics of money investment, retirement planning, savings.
• What to do in case of a road side emergency.
• Important numbers (doctor, dentist, insurance, etc).
• How to do laundry.
• How to clean a bathroom, use a vacuum, and dust.
• How to sew basic clothing repairs (buttons, hems, etc).
• How to get help when needed.
• How to apply for a job and build a resume.
• Choose words carefully: they can build someone up or crush someone down. 
• Drugs and alcohol should be treated with respect and used only with good judgment. This judgment should take into consideration laws and safety. Our brain does not fully develop until the early/mid 20s and early use of drugs or alcohol increases the risk of addiction.

Be a good friend and responsible family member

• Be clear with plans: Look at the family calendar when making plans. Get permission from all parents involved; let family know where you will be and when you will be home. 
• Keep a phone available to be able to call when needed. Answer calls/texts from parents! 
• Treat everyone with respect: family, teachers, friends, and strangers. 
• Require that others treat you with respect. 
• Do random acts of kindness occasionally. 
• Volunteer regularly.
• If you feel unsafe, leave the situation. Tell a trusted adult as soon as possible. 
• Do only things you and your parents will be proud of. 

Things to do to show you are getting ready to leave the nest...

• Complete assigned homework and chores without reminders or nagging. 
• Keep your room picked up and clothes off the floor. 
• Hang your towel to allow it to dry between uses. 
• Clear dishes from the table. 
• Clean up after projects or play. Return all things to their proper place after using them. 
• Throw all trash in the trashcan. Recycle things that are recyclable. 
• Responsible use of cell phone, computer, and other electronics. Turn off before bedtime to allow uninterrupted sleep. 
• Spend and save money responsibly. Never spend more than you can afford. Use credit cards wisely.
• Take pride in your work: schoolwork, chores, job, and helping others. Do it to the best of your ability and ask nicely for help as needed. Recognize that work is not always fun, but necessary. Doing tasks with a good attitude will help. 
• Time organization skills: Do not procrastinate until the last minute. Plan ahead and do big projects in small steps. Be prepared with all materials you will need for a project and ask in advance if you need help acquiring items. Use tools (apps, calendar, check lists). 
• Take care of your things. Keep them in proper working order, clean, and put away. 
• Drive responsibly. 
• Accept consequences with grace. 
• Earn trust. 
• Know when to trust and follow others and when to take your own path. Make independent decisions based on your own morals. Have the courage to say "no" if something goes against your beliefs.

It's [Sports, School, Camp, Yearly] Physical Time!

It's that time of year when school aged children and teens need physicals for school or camp entry or to participate in sports. Parents often want to work in a last minute "quick physical" for a form to be signed before a sport season starts or a child goes to a new school. Plan ahead so you can get an appointment at your preferred time!

Unfortunately some parents calling at the last minute are unable to get an appointment that fits their needs so they decide to go to a walk in clinic to just get the form signed. Keep reading to learn why this isn't a good substitute for a yearly physical in your child's medical home (AKA regular doctor's office).

Some parents don't think a yearly physical is important, and if not required to present a form to a school, sport, or camp, they simply don't do them. Their kids miss out on the benefits of a yearly physical.

Even when you think your child is healthy, there are several things that should be discussed, reviewed, and evaluated during the physical, so the visit isn't quick and it should be done in your child's medical home. If your child's regular physician is not available, there is still benefit to scheduling with another provider at your doctor's office as allowed by their policies. Past records are available to be able to compare current height to past growth. We can review vaccines and update as needed. We can update your child's record as needed since the last visit with new family medical history, changes in the home or school, and with your child's overall health.

Over the years I have "cleared" many student athletes by signing a pre-participation form required for high school sports or camps. On occasion I have not been able to sign the form, and this can lead to frustration for the athlete and his/her family.  If a physician or other licensed medical provider does not feel requriements have been met to "clear" an athlete for safe participation in sports, parents and their athlete often do not understand the "why" behind the need for further evaluation or treatment.

Common reasons to not clear an athlete for participation include recent concussion or a history of passing out that hasn't been fully evaluated.  I had one patient upset that I wouldn't sign the form because of a current broken bone... you can't play a sport in a cast! From the mother's perspective, she just wanted the form done today because the physical was today. From my perspective, the form can be signed when the child is able to play. I can't in good conscience say the student is able to play today if he is not. You don't want me as your child's pediatrician if I am able to attest to something I know is not true.

Please don't go to an urgent care or chiropractor to get the form signed when your regular doctor refuses due to a medical concern. I have seen parents do this -- omitting the fact that their child has passed out and needs further testing or had a concussion. That undermines the reason for the form in the first place! It is for your child's safety!

A glance at the Kansas Pre-Participation Physical Evaluation form's first page highlights many of the important topics to investigate. It would be impossible to completely cover every recommended topic at every physical, but standard recommendations include:

• Review of health history, including chronic conditions (such as asthma, diabetes, learning disabilities etc), hospitalizations, surgeries
• Review of family medical history
• Height, weight, Body Mass Index (BMI), vital signs (blood pressure, pulse, respiratory rate) - comparison to previous values is most helpful
• Puberty status
• Nutrition, exercise, and weight management issues - including performance-enhancing substances
• Sleep
• Risk factors (safety, smoke exposure, violence, alcohol use, screen time, internet safety, and more)
• Mental health (depression screening, drug/alcohol use, bullying)
• Physical exam (special attention to cardiac system, musculoskeletal, neurologic and other sport's preventing problems)
• Update vaccines as needed
• Laboratory evaluation as needed: cholesterol screening, anemia screening, and other risk-based testing

Not included in this list is following up chronic conditions, addressing the issues raised at the physical, refilling all medicines, etc. There are times that addressing one or two specific issues is appropriate, but often there isn't enough time to adequately address all concerns. A separate visit may be needed to be able to devote appropriate attention to each issue. Please don't save up a year's worth of concerns to discuss at one visit each year. 

A well visit is recommended every year for all children over the age of 3 years (more for younger children). If your child hasn't had a well visit in the past year, call today or request a physical through our portal! Don't wait until the last minute... summer physicals book quickly.

The yearly well visit can be used to address all sports and camp physical forms that need to be done. Please bring them to your visit with the appropriate sections pre-filled out to save time in the office.

Allergy Tips

photo source: Shutterstock

It's allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors.

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!

Treatments: 

It is best to treat before the symptoms get bad. I registered on (and recommend) Pollen.com for free alerts at the beginning of the season to anticipate the need to treat before symptoms begin. Treatments include medicines and limiting exposure.

Medications:

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. 

• 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. 

• Nasal spray antihistamines are available over the counter and as a prescription. An office visit to discuss the value of these for your child and proper use is recommended. 

• 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. 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. 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 Nasopure.com 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. 

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 Pollen.com. 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.