Germ-Fest

So, I am going to digress from the usual sports medicine topics that I love, and talk a little about what to do when germs invade your house.  I mean when your kid gets sick, then you get sick, then maybe your husband, and then your kid again.  The whole process may last weeks (and feel like months).  I'm basing this on recent personal experience that included a nasty upper respiratory illness for my daughter, a GI illness and then pneumonia for my husband, and two nasty respiratory viruses for myself separated by a week. This house is ready for spring.

When one household member gets sick with a viral illness, containing it isn't easy.  If I could have replayed the last month in my house, I might have bought a hazmat suit to stop the spread of germs ... it takes a toll when the virus keeps steamrolling your family members (and the dog Daisy even got depressed - her number of walks/runs dropped dramatically).  Here are a few common sense tips to help prevent the spread of germs.  These steps may seem simple, but I know I skimp a lot on these things when I'm rushed.

Wash your own hands.  Don't get too focused on keeping the germs off of your kids.  If you're not washing your hands, you could be the one who infects your healthy child or spouse.


Make washing your kids hands routine.  Of course this seems obvious, but it can't be stressed enough. Nearly 80% of infectious diseases are spread by simple touch!  When you have a sick toddler or baby, germs get in every nook and cranny (literally).  And when your kids can wash their hands themselves, teach them to do it for at least 20 seconds (maybe sing the alphabet song or something similar).  If soap and water aren't available, use an alcohol based sanitizing gel until it evaporates.

Disinfect, and then do it again.  Wipe off surfaces that sick household members have touched - doors, tables, counters, handrails, etc.  You can even put some plastic toys in the dishwasher and stuffed animals and other toys in the washing machine.  If you're experiencing a GI illness in your house, be extra careful to disinfect the toilet, floor, and bathroom sink.

Don't change dirty diapers in the same place for two different children.  Enough said.  This is a great place to exchange germs.

Mealtime.  Don't share silverware, cups, plates, food, etc.  Germs love these methods of transportation.

Breastfeeding.  Don't stop breastfeeding if you get sick.  In fact, the antibodies you pass on might help protect your baby from getting sick.  And if your little one is sick and you are nursing, again, just practice good hygiene to avoid transmission to yourself.

Ok, I know these seem simple.  But take them seriously when a family member gets sick.  I know we will next time!

Rachel Brewer, MD

Allergies

It's that time of year again...itchy, red eyes, runny nose, sneezing and hives. Allergies make many children and parents miserable. The best treatment for allergies is allergen avoidance, so keep your children inside all spring, with the windows closed and the air conditioner on - IMPOSSIBLE! However, you can try reduce a child's time outside and make sure not to run an attic fan/house fan with the windows open. There are many other treatments, but they all involve using medications. Antihistamines are still the best medications we have available to treat allergies. There are several available over the counter now. I typically recommend a trial of diphenhydramine (Benadryl), which means giving an appropriate dose every 6-8 hours for a couple of days and monitor for symptom improvement. If symptoms are better, your child may benefit from a long acting antihistamine. I do not recommend long term therapy with diphenhydramine (Benadryl), because it can cause sleepiness and adverse behavior effects on children. Long acting antihistamines include loratadine (Claritin), fexofenadin (Allegra), certirizine (Zyrtec), desloratadine (Clarinex). See your doctor before starting a long acting antihistamine, because they all have different and specific dosing for children of different ages. If your child has allergies and asthma, there is another medication available called montelukast (Singulair) available by prescription.

Treatments for specific allergy symptoms include:

Watery, red, itchy eyes:
- Use a cool, wet washcloth to soothe your child's eyes and to keep them from rubbing
- Try an antihistamine eye drop, there are some available over the counter and others that are available by prescription
- Gently remind your children not to rub their eyes, this can lead to infection

Runny nose or congestion:
- Nasal saline several times per day
- Nasal steroid available by prescription

Rashes - hives or dermatitis:
- Cool bathes
- Cotton long sleeve clothing
- Vaseline or Aquaphor

Springtime is the best time to play outside. Allergies affect many children, but there are several treatments available to make life more tolerable when the plants and flowers are all blooming. Make sure to see a physician if your child develops difficulty breathing, wheezing, or severe eye swelling when their allergies flare.

Heather Joyce, MD

Confessions of a Modern "Crunchy" Mom - Cloth Diapers

Though I work as a pediatrician full time, vaccinate on schedule, and sometimes hit the closest drive-though for a quick meal, I am often called "crunchy" by my co-workers and friends. There are many aspects of "natural " parenting that feel right to me, including, cloth diapering, breastfeeding (or pumping) for as long as possible, homemade organic baby foods, and baby wearing. As a working parent, my life is an act of compromise, so I am flexible with my "crunchy" side.

The decision to use cloth diapers with our second child was not easy, but after reading many blogs and talking to parents who have used them, we decided it was worth a try. There are many pros to cloth diapering, including reduced cost, diaper rash, disposable diapers sitting in landfills (for who knows how long), plus they are so cute! We make it work by realizing that we don't have to use them all the time to reap the benefits. We have used several different brands, all with inserts and covers. We use a diaper sprayer on the toilet and we wash them ourselves. However, we don't take them on vacation or use them during diarrhea illnesses and when my son started daycare, we brought disposables to use there. As he gets closer to potty training, we have less diapers to wash and truthfully, I enjoy using them more!

Cloth diapering tips:
1) Talk to other parents who have used them and people who work at local stores who sell them
2) Choose a style that works with your lifestyle
3) Make a washing schedule - we do ours every 2-3 days (buy enough to make it at least a couple of days)
4) Use newborn diapers until the umbilical cord falls off - I could not find a way to make the diaper fit without irritating the umbilical stump. Please comment below if you have the secret!
5) Buy a diaper sprayer for your toilet
6) Use extra inserts for overnight - we use hemp (they are thin, but absorbent)
7) Bleach, strip, and lay out in the sun to dry once in a while
8) Use essential oil in your dry bag to hide the smell

Once you figure out a routine and get used to washing poop, it really is doable for any parent who would like to give it a try.  Every cloth diaper that is used, means one less disposable diaper sitting in a landfill!

Heather Joyce, MD

Osgood What?

Many of you parents out there may be familiar with knee pain due to Osgood Schlatter's disease because your child is experiencing it, or you experienced in the past as a child.  It is definitely one of the most common causes of knee pain in kids (not due to falling or trauma).

I talked about what apophysitis is a few weeks ago, and Osgood Schlatter's is the most well known form of it.  Again, an apophysis is a growth plate that provides a point for a muscle/tendon to attach.  And apophysitis is due to chronic traction of a tendon at its origin or insertion.  Continuous stress at the apophyseal site leads to local swelling and pain.  Stress at the knee comes from things like running, jumping, or squatting.

When Osgood Schlatter's disease occurs, kids develop a bump that you can feel just below their kneecap. The bump is painful to touch.  Pain is worse with running and things like walking up stairs, hills, or any incline.  It is especially painful when a child with Osgood Schlatter's falls on his or her knee.

If you think your child has Osgood Schlatter's it is important for he or she to stretch, stretch, and stretch.  Specifically stretch the calf muscles, hamstrings, and quad muscles.  Icing the knee (right over the bump) at least two times a day and taking an age appropriate dose of ibuprofen is also helpful.  Sometimes kids with chronic or severe Osgood Schlatter's need formal physical therapy.

Bracing with a knee strap (which goes between the kneecap and the bump that forms with Osgood Schlatter's) can also be helpful.  The strap theoretically compresses the patellar tendon and lessens the traction on the apophysis where the pain is.

Osgood Schlatter's disease typically resolves when the apophysis (or growth plate) below the kneecap closes.  However, in some kids, the problem can become chronic and those kids require surgery.  This doesn't occur until high school age or beyond because you have to give the apophysis a chance to close.  There are also experimental treatments with injection for moderate to severe Osgood Sclatter's, which may become a more common treatment in the future.

It doesn't harm a kid to play with knee pain due to Osgood Schlatter's, but it may prolong the course of recovery.  The best thing to do is try a course of rest and rehab to try to eliminate the pain before going back to a sport 100%.

Rachel Brewer, MD

Ankle Sprains

Ankle sprains are one of the most frequent presenting problems that we see in kids and adolescents.  The important thing is to recognize when you should take your child to be evaluated if they experience an ankle injury and also understand how to treat and rehab the injury at home.

First, like I've said before .... young kids don't sprain stuff.  What does that mean?  It means that their bones are the weakest link since their growth plates are still open, and that the growth plates get injured with a joint injury, not the ligaments.  You can "sprain" a ligament, not a bone.  Once a child's growth plate closes, they are more apt to truly sprain a joint.  Ligaments get "sprained," and muscles get "strained."

Ok, so your kid twists his ankle at soccer practice.  Should you run to the ER?  If the foot or ankle appears deformed or pale, yes.  That means there likely is a serious fracture.  If your child has immediate swelling in his ankle and can't bear weight, it is also important to be seen.  However, call your pediatrician first if it is after-hours and they can determine if it is ok to treat the injury at home overnight and be seen the next day.

Bottom line is that most ankle injuries in kids warrant an x-ray - especially if they are young enough where there growth plates in the ankle are still open (prior to puberty).  

If your child is diagnosed with a true ankle sprain (again, this is likely in adolescence), then there are several things you can do at home to speed along recovery.  You may have heard of RICE therapy.  This stands for rest, ice, compression (with a brace or ace bandage), and elevation.  This also works for ankle sprains.  Swelling in ankle sprains can be very impressive, and RICE therapy helps swelling go away faster (anti-inflammatories like ibuprofen can also help).  If your child cannot bear weight because of pain, they may need crutches for a couple days.

Kids are generally pretty good at letting pain guide them in terms of being able to bear weight on their ankle if they experience a sprain.  Once they are able to bear weight (when pain has improved), it is ok to progressively start to walk normally again.  If you rest the ankle too long with non-weightbearing that can lead to stiffness and more pain. 

Rehab is key to getting through an ankle sprain.  Rehab means moving the ankle, getting the strength back, and also getting back your balance.  This handout shows some great things you can do at home.  Remember, flexibility, strength, and balance are all part of rehab.  Sometimes ankle sprains are severe enough that it working with a physical therapist is required (you can be referred by your pediatrician or sports medicine doctor).  

Experiencing an ankle sprain is the biggest risk factor for having another one in the future.  A brace called an ASO (a lace-up ankle brace) is very helpful at preventing ankle sprains.  It is important to wear the brace during any cutting/pivoting sports.  Once you "stretch" the ligaments during an ankle sprain they never "tighten" back up - that's why wearing a brace is very important!  You can get a lace-up brace from your pediatrician or sports medicine doctor.  

Rachel Brewer, MD

Constipation

Believe it or not, I see at least 2 children in the ER each shift with abdominal pain due to constipation. If any of you parents out there have ever been constipated, you know fist hand that it hurts! Children with constipation typically have severe (curl up in a ball and scream) kind of pain. Which can be very scary for parents. Most of the children who develop severe pain have had symptoms for 1-2 weeks, so intervention could have been made sooner if parents knew what to look for and how to treat it.

Constipation is the infrequent passage of hard, difficulty to pass stool - that is the standard definition. Now for what we really see:

Normal infants can have stools with every feed or 1-2 times per week, so constipation in this age group is typically diagnosed when they start having pain with pooping or they develop tears around their anus. It is very normal for infants and toddlers to turn red or purple in the face and grunt or strain with pooping. Infants rarely have constipation under 1 month of age and poop (color, consistency, and frequency) is an indicator of how much milk they are getting. After 1 month, if your baby is having pain with pooping or infrequent, hard stools, you can give 1 oz of Pedialyte, prune juice, apple juice, or pear juice for every month of age (for example a 3 month old could get 3 oz of juice per day for constipation). I recommend giving 1 oz at a time, in between normal feedings until you get results (poop, in this case). Other methods include glycerin suppositories or enemas and a warm bath. If your infant is eating solid food, then giving a high fiber fruit daily helps (prunes, pears).

Toddlerhood is a very common time to develop constipation. It usually starts when potty training begins. Toddlers like to control when and where they poop. When we interfere, they fight back with holding in the poop. These children can hold in their poop for a VERY long time. When the rectum (bottom part of the colon) is holding onto hard poop, it gets bigger and loses its urge to push the poop out. They can develop frequent liquid stools (like diarrhea) that has to make its way around the large, hard poop. These children start to eat less and less, then complain intermittently of belly pain. Typically, the pain is around the belly button or on their left lower side. If your child gets to this point, back off on potty training and go back to diapers or pull ups. Unfortunately, it is very difficult to change a toddler's diet. But, you can try and offer high fiber fruits and juice (4-6 oz per day). Suppositories and enemas also work in this age group, but there is also a very safe medication called polyethylene glycol (brand name Miralax) that has been used in children of all ages and is available over the counter. It works by pulling water into the poop, making it softer and easier to pass. You mix 1 capful of powder into 8 oz of fluid (I like to use juice). Most children only need 1-2 capfuls daily, but you will need to talk to your doctor specifically about your child's dose. You need to treat your child with this medication daily, so it is easy and pain-free for them to poop, then go back to the potty training. It takes 6-8 weeks for the colon to go back to its original size, so this is a long term solution, not a quick fix.

School age is the next time constipation is popular. Trust me, no one likes to poop at school! Plus, parents no longer pester kids this age about their pooping habits. Symptoms are very similar to toddlers', with decreased appetite, nausea, and sometimes vomiting. Belly pain is common and they usually complain in the morning (right before school), after meals, and even in the middle of the night. Treatment needs to be a bit more aggressive at this age. They may need an enema (Pediatric Fleet) to treat the immediate problem, then Miralax and a pooping schedule - have your child sit on the potty 2-3 times daily (morning, after school, and after dinner) for 10 minutes. Try to add high fiber food and juice to their diet, with lots of raw fruits and vegetables. But, even with changes in diet and treatment, it may take even longer to get your school age child regular and pain free, sometimes up to 6 months.

From the minute a baby is born, poop becomes a major concern in every parents' life. Most people think that once a child is potty trained, the poop talk is over...but trust me, it never goes away!

Heather Joyce, MD

Ouch! Traumatic Knee Injuries in Kids

Acute injuries vary from sport to sport, but the lower extremity (the knee in particular) is one of the most common joints injured in the young and older athlete.

So, you're watching your teenage daughter play basketball and all of the sudden she goes down in pain clutching her knee.  What happens next?  If your child is high school age, most commonly there is a trainer on the sideline that can quickly evaluate the injury, but if not, it's important to seek medical attention (or call your pediatrician for advice).  Few knee injuries necessitate a trip to the ER, but it is wise to talk to a medical professional if your child has an acute knee injury.

Swelling in the knee joint is never normal in kids and shouldn't be ignored.  There are only a few things that can cause swelling in children when they injure their knee (broken bones and torn ligaments are the most common in kids), and each of those causes need further evaluation and treatment.

The ACL (one of the 4 ligaments in the knee) gets a lot of attention thanks to Sportscenter - but it is actually one of the more common traumatic knee injuries in adolescents.  It can happen before adolescents, but it is rare because young children still have open growth plates.  Females are more prone to tear their ACL and it is most common in cutting/pivoting sports like basketball, soccer, and football.  Rarely does someone tear their ACL from colliding with another player - the injury usually occurs on a landing or turn/pivot.

Is it always necessary to get an MRI?  In short, no.  Most traumatic knee injuries can easily be diagnosed by the physical exam.  However, an MRI helps assess any other injuries that may be present and also helps prepare for surgery if necessary.

What knee injuries in kids need an operation?  ACL repair is necessary after tearing the ligament, because you can't cut or pivot without it.  Other traumatic injuries that may need an operation are meniscus injuries (the cartilage in your knee) or severe knee cap dislocations.  However, every child is different and some of these injuries do well with physical therapy and other treatments, so surgery can be avoided.

Just like in adults, some of these injuries can be prevented if your child maintains their flexibility and strength in their core and lower extremities.  For instance, their are specific ACL prevention programs that exist (especially for females), which include things like quad and hamstring strength and proper technique for landing and cutting/pivoting.

Your child can definitely get back to playing his or her sport after a traumatic knee injury, but it is important to understand what the cause of the injury is and get it treated appropriately!

Rachel Brewer, MD