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. 

Help! I'm sick and I have a baby at home.

When we have newborns we don't want to expose them to germs. We avoid large crowds, especially during the sick season. We won't let anyone who hasn't washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.

But what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?

In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.

• Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting. Wash Baby's hands after diaper changes too. Make this a habit even when you're not sick... you never know when you're shedding those first germs!

• Wipe down surfaces. Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect. Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area. 

• Avoid touching your eyes, nose and mouth - these are the "doors" germs use to get in and out of your body. Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.
• Resist kissing Baby on the face, hands, and feet. I know they're cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too. 
• Cover your cough. I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs. When you're responsible for a baby, the baby's head is often in your elbow, so I don't recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren't available.
• Vaccinate. If you're vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you're less likely to bring those germs home. Encourage everyone around your baby to be vaccinated. If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity. See Passive Immunity 101: Will Breast Milk Protect My Baby From Getting Sick? by Jody Segrave-Daly, RN, MS, IBCLC to better understand passive immunity.
• Breastfeed or give expressed breast milk if possible. Mothers frequently fear that breastfeeding while sick isn't good for Baby. The opposite is true - it's very helpful to pass on fighter cells against the germs! Again see Jody Segrave-Daly's blog for wonderful explanation of how breast milk protects our babies. 
• Limit contact as much as possible. If possible, keep Baby in a separate area away from sick family members. Wash hands after leaving the area of sick people. If the primary caretaker is sick and there is no one available to help, wear a mask and wash hands after touching anything that might be contaminated.
• Insist on a smoke-free home and car. Even if someone is smoking (or vaping) in another room or at another time, Baby can be exposed to the airborne particles that irritate airways and increase mucus production. These toxic particles remain in a room or car long after smoking has stopped. If you must smoke or vape, go outdoors. Change your shirt (or remove a coat) and wash your hands before holding Baby.

It's never easy being sick, and being a parent adds to the level of difficulty because you not only have to care for yourself, but someone else depends on you too. As with everything, you must take care of yourself before you can help others. Drink plenty of water and get rest! Most of the time medicines don't help us get better, since there aren't great medicines for the common cold. Talk to your doctor to see if you might need anything. Don't be falsely reassured that you aren't contagious if you're on an antibiotic for a cough or cold. If you have a virus (which causes most cough and colds) the antibiotic does nothing. You need to be vigilant against sharing the germs!

Flat heads in babies - What's the best treatment?

Babies often get misshapen heads from laying on one side or even from being squished while still inside mom. The misshaped head is referred to as plagiocephaly, scaphocephaly, or brachycephaly -- depending on the overall shape (see lower photo below). These, especially plagiocephaly, are very common. If I knew I'd one day have a blog, I would have taken pictures showing the head shape of my child who had positional plagiocephaly. That baby is now a teen with a normal head shape, so it's too late for photos. 

Below is a picture of a baby with positional plagiocephaly. Note the flat left back of the head. In this picture you can't see the ears, but we look to see if the ear and forehead are pushed forward to help assess the severity of the plagiocephaly. 

Photosource: By Gzzz via Wikimedia Commons

The Joint Section on Pediatric Neurosurgery of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons have issued new guidelines for diagnosis of as well as treatment options for plagiocephaly with repositioning, physical therapy and helmets.

Diagnosis:

Most of the time we can make the diagnosis in the office without any special tests or x-rays. If there is a concern that one of the sutures (growth plates between the bones of the skull) is closed, a skull x-ray or an ultrasound of the area in question can assess if the suture is open or closed. If the diagnosis is still in question after those studies, a CT of the head may be needed. The picture below shows how the skull shape changes if one or more of the sutures is closed (represented by a missing line).

Photo source:By Xxjamesxx, via Wikimedia Commons Wikimedia

Treatments:

The first treatment used to treat plagiocephaly is repositioning. Repositioning helps with all infants with positional plagiocephaly to some extent. Repositioning is just what it sounds like: change the position of your baby so the side down alternates when sleeping or laying. Put fun items to look at on alternating sides when baby is laying on the back when awake. When feeding, hold baby in alternate arms so when they turn to face you they are looking different directions each feed. (This happens naturally when breastfeeding.) Use supervised tummy time several times each day and hold baby upright as much as possible to get baby off the back of his head when not sleeping. The American Academy of Pediatrics has issued a warning against the use of positioning pillows due to risk of suffocation.  

A stiff neck often is associated with positional plagiocephaly because it limits head movement to one side. The stiff neck is called torticollis. Torticollis makes it difficult for baby to turn his head to one side, but gentle stretching can help. I show parents how to hold one shoulder down while gently moving the head to stretch the neck - with each ear to the shoulder and then the chin to each shoulder. It's important to do a gentle but firm stretch, no jerking or forced movements. Massaging the neck muscles first can help. Think of what you do when you have a sore neck and want to stretch it. Working with a Physical Therapist has been shown to be more effective than repositioning alone and as effective as positioning devices (which are not recommended due to safety concerns).

Babies with persistent moderate to severe plagiocephaly after repositioning and physical therapy may benefit from a helmet to mold the head to a round shape. The helmet corrects more rapidly than positioning alone, so is also used if there is significant plagiocephaly in older infants. I reserve this option for the more severe cases that don't respond to repositioning and physical therapy since it is expensive and often not covered by insurance. I do not know if these recommendations will make it easier for insurance to pay for a helmet when indicated.

Great News About the HPV Vaccine!

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

Photo Source: Jan Christian via Wikimedia

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

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

Dosing schedule ~ Happy News!

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

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

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

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

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

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

Addendum: 

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

One last addendum:

The ACIP approved the changes! Talk to your doctor about your child's vaccine needs. In short, the new recommendations state:

• Kids who get the first HPV vaccine before their 15th birthday need two doses 6-12 months apart.
• Kids who have turned 15 years old before the first dose should use the 3 dose series.
• Kids who have gotten a 2nd dose less than 6 months after the first (regardless of age) need the 3rd dose.

Fevers: How High is Too High?

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

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

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

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

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

What is a fever?

The number on the thermometer can be confusing to parents. How the temperature is taken is as important as the number itself to determine if it is a fever. A fever is often defined as a temperature over 100.4 °F (38 °C) but it can vary based on how you take the temperature (rectal vs oral vs forehead).

This is simply the minimum temperature that is no longer considered normal. The American Academy of Pediatrics doesn't recommend treating fevers until the temperature is over 102°F unless the child is uncomfortable. Thermometers are not very accurate, so when you worry more about a temperature that is 0.5 degree higher than another temperature, it might not even be a significant difference. You could take the temperature twice in a row and get different readings. If your child is playful and the thermometer reads 101.5°F that is a very different story than if your child is barely moving, whimpering, and breathing fast with a temperature of 101.5°F. I wouldn't recommend any fever reducers for the first, but I would recommend the second get evaluated by a pediatrician or other medical provider.

Why do we care about fevers?

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

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

So how high is too high?

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

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

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

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

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

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Flu Vaccine Recommendations for 2016-2017 Season

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

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

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

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

I got mine! 

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

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

Related blogs

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

To Tamiflu or Not To Tamiflu...

Tamiflu: Guest blogger Dr. Mark Helm

How To Keep Your Family Healthy This Winter

Evolution of illness

Fever Is...

My Child's Cough and Breathing Sounds Like...

Cough Medicine: Which one's best?

"But the snot is green…" Or "How can we treat cough and colds?"

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

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

In general there are some things that increase anxiety about shots or just make them seem bad. Lying about shots or threatening them as a punishment are never a healthy approach to the situation.

• Never tell kids they won't get a shot at the doctor's office. They might be due for one (or more) and if they were specifically told they won't get one, they are usually more upset.
• Do not threaten kids with shots if they misbehave. This makes kids see shots as a negative.
• Siblings can increase anxiety with their teasing. Don't share the need for shots with siblings and if it's possible to leave siblings at home when one child will need shots, that might work best. 
• Some kids worry more because parents are worried or presume the child will be worried. When the parent starts talking about shots in a worrisome manner it feeds into the fear. Try to be factual. Don't start telling them it's okay and not to worry. That tells them there's something to worry about.

Oh, no!

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

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

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

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

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

• After kids do things that they were afraid of, congratulate them for the attempt. Remind them that even though they were scared they did it. This helps set the pattern that they can be brave when faced with any fear. They can even keep a list of things that they did despite being scared to try. They can use the list whenever a new fear pops up to see how many things they've already done and how brave they really are. I've started recommending that parents take a video of kids to show their future self if they can say it didn't hurt as much as they worried it would. They tend to remember the anxious phase of excessive worry, but forget that it wasn't that bad. Show the video the next time shots are due. Their own self stating it wasn't bad can be reassuring!

• Use a meditation app, such as Stop, Breathe & Think. It's free and helps with general anxieties as well as mindfulness. Download it and use it at home several times to let them get comfortable using it. 
• Some great articles: 

• 18 Important Things That Kids With Anxiety Need to Know
• 5 Ways Caring Parents Make Teen Anxiety Worse
• 9 Things Every Parent with an Anxious Child Should Try 

• Understand Your Child's Anxiety (with infographic) 
• Anxiety and Social Competencies ("The Spirals")
• It Doesn't Have To Hurt  

Resources

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

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

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