Attacking asthma before it attacks you!

   Those of you whose kids are moderate to severe asthma sufferers probably dread the fall and winter months and all of the viruses and upper respiratory infections that go along with the cooler weather. Back to school is code for "cesspool of germs" when your child is asthmatic because the schools are the perfect breeding ground for germs where  many children are packed into tight areas all day long. 


   This blog is probably sparking you to say, "I had better start up my child's preventive asthma inhaler and allergy medications again." When really, your child should be on asthma medications year-round if prescribed by the doctor as such. But, most parents become complacent during the warmer months when viruses and other infections are less likely. Their kids seem to be doing well, not using their rescue inhalers and can play alongside friends without difficulty.  This however, is a facade! 


   An asthmatic's lungs are always asthmatic, not just when there is an infection present. So why does a child seem fine sometimes, even when they are off of all medications? The answer lies in the fact that an asthmatic lung that is not stressed by exertion, exercise or illness does not need to use the parts of the lung that are farthest out from the bronchial tree for day to day activities. So, a child will seem to feel fine and will not wheeze. The problem is that inflammation continues throughout the entire lung, but especially in the lower or more distant airways that are very small. When an illness hits, and the entire lung capacity is needed to oxygenate the blood, the already severely inflamed small airways are not able to help and the larger airways have to work overtime. The larger airways at that time become more and more inflamed, and bronchospasm occurs which means that the muscle running around the airway constricts, making an even smaller passage for air to move in and out. 


   This is when your child hits the point that you will realize they need both the preventive medication as well as rescue medication such as Albuterol or Xopenex every 4 hrs or so. Now, it is too late. The path has already been set into motion and the only way to fix it is to start systemic steroids, give rescue treatments very frequently and perhaps need an admission to the hospital for even further intervention. This whole process could have been prevented by continuing preventive asthma medications (inhaled steroids) year round as prescribed by the doctor. Be sure to talk to your child's doctor before the next asthma attack to see if this is necessary for your child.


See this following diagram borrowed from the Contemporary Pediatrics Magazine in the July 2011 issue, Vol. 28, No. 7

Abdominal Pain in Kids - When to Worry

Every child at some point has complained of abdominal pain, but it is when a child keeps complaining that parents rightfully become worried. The sources of abdominal pain can be many including a virus, a urinary tract infection, strep throat, constipation or even more worrisome, possible appendicitis or obstruction. So, how do you know when to seek medical attention?

 The most worrisome symptoms include severe abdominal pain, especially when it is in the right lower quadrant of the abdomen, abdominal pain with persistent vomiting and no diarrhea, pain with walking or movement, abdominal pain associated with bloody stools, or abdominal pain with high fever just to name a few. These symptoms always warrant urgent medical attention and often require further testing to determine the cause. 

Less worrisome symptoms include mild or intermittent abdominal pain, pain that only occurs when a child does not want to do something, or pain that is associated with constipation. Constipation is the most common cause of recurrent abdominal pain in children and can cause significant pain. Often, a child will have a bowel movement every day or two, so parents don't think of constipation. However, if asked, the child will likely describe painful or bulky bowel movements or sometimes they will complain of leakage of loose stool. Leakage of loose stool sounds like diarrhea, right? Well, often, it can be a sign of a large stool ball in the left colon that is not going anywhere, so loose stool will leak around, often causing incontinence of stool. So, if you suspect your child is constipated, try the standard dietary changes that include increasing fiber (prunes are a great source of fiber), increasing water intake, decreasing milk and cheese intake and decreasing the junk food. If these measures don't help, or the pain worsens, this warrants medical attention.

Take the itch out of eczema!

For those of you who have children with eczema, it is probably one of the most frustrating things that you have to deal with on a daily basis. The itching, the scratching, the scathing looks from other moms in the grocery store whose children don’t have eczema and wonder to themselves “has that child had a bath this month, or should I call CPS?” Fear not, because you are definitely not alone! There are several mainstays of treatment for eczema (also known as atopic dermatitis).

The first is proper moisturizing of the skin. This seems like the simplest, but is often the hardest when you have a busy life and a wiggly kid who hates being messed with. But, it is truly important and must be done at least twice a day (preferably more) if you ever hope to see your child get better. There are several options when it comes to moisturizing the skin. The first and cheapest is Vaseline, which is an excellent emollient and is extremely hypoallergenic to even the most sensitive skin. Vaseline can be applied morning and night and once it has soaked in, it is not greasy to the touch. Other options include Cetaphil, Eucerin, Lubriderm and a newer lotion, called CeraVe, which is unique in that it replaces a lipid that eczematous skin is missing, called ceramide. You want to completely avoid the favorites – brand-name scented baby products, or any other lotion that has a fragrance to it, as the fragrance can act as an irritant. Also, you want to leave the skin wet after bath or showers and instead of towel drying your child, let them drip dry for a minute or so and then apply a thick layer of moisturizer to the skin immediately, so that it locks in the moisture.

The second mainstay of treatment of eczema is topical steroid use. Not all steroids are created equally and there is a broad range available today. For minor eczema, simply using 1% hydrocortisone cream twice daily to the affected areas is often helpful after use of moisturizer. For more severe cases, a prescription strength topical steroid used twice daily is often required to combat the problem areas. Parents are often quite worried about the use of any form of steroids for their children due to the well-known side effects that occur. However, what most parents do not know is that those side effects generally occur with long-term use of oral steroids (not topical steroids.) There are 4 classes of topical steroids from Class 1 (most potent and highest potential for side effects) down to Class 4 (over the counter hydrocortisone). Usually, a Class 3 topical steroid will resolve an acute flare-up of eczema and once improved, decreasing back to a Class 4 topical steroid such as hydrocortisone will usually be all that is required. Class 3 and 4 topical steroids have very little if any systemic absorption, meaning that when you put it on the skin, it stays on the skin. With higher classes of steroids, this is not the case and thus, they must be used very cautiously and sparingly. See the following link for more information about topical steroids: http://dermnetnz.org/treatments/topical-steroids.html With that being said, proper use of topical steroids under the care of your child’s pediatrician is very safe and effective. Another medication exists that can be used to combat eczema and it is called Protopic. There is significant controversy surrounding this medication, as there is concern that it may have the potential to cause skin cancer or lymphoma although this is not proven. It is a medication that works on the immune system, preventing it from making substances that cause the eczema. This medication is typically reserved for patients who have failed steroid therapy and who have severe eczema. This medication is usually prescribed by a dermatologist, although many other doctors feel comfortable with its use. It is important to follow for any side effects.

The third mainstay of treatment of eczema is avoidance of irritants. We already discussed avoidance of scented lotions, but this list should include avoidance of scented detergent, fabric softener, dryer sheets, bath soap or bubbles, hand soap, and any perfumes. Your child’s sheets, pillowcases and all clothing should be washed with a fragrance free detergent and no dryer sheets or fabric softener should be used. A good bath cleanser to use is Cetaphil gentle, as it is unscented and hypoallergenic.

The fourth aspect of eczema treatment is treatment of underlying allergies. In difficult to treat cases, it is important to consider food and environmental allergy testing of the child. Often there is a certain food that the child is allergic to, or many times there are environmental allergens that play a significant role in worsening of eczema. Eczema, allergies and asthma all go hand in hand and form a triad, often referred to as the “atopic triad.” When one aspect of this triad worsens, it can trigger the other aspects to worsen as well. So, if your child has underlying allergies or asthma, it is important to treat those at the same time. Most eczema sufferers benefit from the daily use of an oral antihistamine such as Claritin, Allegra, Zyrtec or Benadryl. However, some children have such intense itching that they often claw their skin at night, and these children require a stronger anti-itching medicine called hydroxyzine, which is a close relative of Benadryl. This medication, especially when given at night, can improve symptoms significantly. 

A fifth element to eczema that must be considered is superficial bacterial infection. Eczema in and of itself is not an infectious problem. However, due to the bacteria that live on skin and especially under the nails, it is quite easy to cause a superficial bacterial infection simply by scratching the skin that is already intensely itchy. This is why it is very important to keep the nails cut very short. When an infection does occur, often a doctor will prescribe topical antibiotics such as mupirocin, which is very effective at combating infections even from the feared MRSA bacteria, which is often the culprit of superficial infections. Occasionally, eczema is so severe that oral antibiotics and oral steroids are required to improve symptoms. Rarely, children have to be hospitalized and placed on IV antibiotics and/or steroids and have special dressings placed on the skin. With such severe eczema, a dermatologist will likely need to be involved in the management.

Hopefully, this will be a good overview of the standard therapies for eczema that you can use as a guide when discussing eczema with your doctor. Make sure to seek medical attention for worsening eczema, as it can have multiple complications that should be addressed promptly.

Bed wetting – A kid’s worst nightmare!

As a pediatrician, I am frequently asked about a solution for the dreaded problem of bed wetting. It is usually a child over the age of 5 that has suddenly been made aware either by siblings or friends that it is NOT normal to wet the bed or to wear a pull-up at night. This can be very disconcerting and can have some major implications on your child's self esteem.

This week, my 6 yr old had his first slumber party with some friends from the neighborhood. One of his friends just turned 5, and the other was 7. Both of them are dry through the night every night and my son just couldn’t believe that they didn’t also wear pull-ups at night. Once he realized this, he suddenly shut down and became very quiet and I immediately felt awful for him. Luckily, they are great friends and didn’t say a word to embarrass him, but I’m sure that will come in the near future, as he gets older. Oh, also, did I mention that my 4 yr old is already dry through the night most of the time? That certainly doesn’t help the situation but he does still wear pull-ups for the occasional accident.

So, why does this happen? Well, the reasons it happens are multi-factorial, but the problem does tend to run in families, especially with males. It is also associated with evening fluid intake, which should be stopped after dinner. Children who wet the bed at night (also called nocturnal enuresis) are very deep sleepers and have difficulty associating the sensation to urinate with the need to either hold it or wake up.

So what can you do about this problem? First of all, you should have your child evaluated by your pediatrician to be sure that there are no problems found on physical exam and that there is no evidence of a urinary tract infection. If your child is cleared from a medical standpoint, then you have several options. If your child is under the age of 7 and not bothered by this problem, then you can simply restrict fluid intake after dinner and wake your child up to urinate several hours after they have fallen asleep. If your child is over the age of seven or is extremely embarrassed or bothered by it, then you can consider a “potty alarm” which is a device that clips to the underwear and attaches to a unit that you put on the shirt collar, near the collar bone that vibrates and makes a very loud beeping sound to bring your child out of the deep phase of sleep. The device should have a two-step process to turn it off so that your child cannot simply turn it off without waking up completely. Over time, your child should begin to associate the sensation of needing to urinate with the desire to wake up, to avoid that noisy alarm going off!  This process often takes several weeks to months to complete, but it is one of the most effective methods available. Another option, which you must discuss with your pediatrician, is a medication called DDAVP. This medication is a synthetic form of ADH (antidiuretic hormone) that causes the kidneys to retain fluid (water) in the body, thus significantly reducing the amount of urine produced, which stops bed wetting. This medication cannot be used with many underlying medical conditions but in healthy children, it can be given every night. However, most pediatricians do not prefer to use this medication long term for obvious reasons and it is usually only used for special occasions such as slumber parties, etc. when embarrassment is likely to occur.

I hope this helps clear up some of the myths and worries surrounding bed wetting. Please let me know what topics interest you and I will try to address those issues as well!

Thanks for checking out my blog!

My name is Dr. Kara Starnes and I am the mother of 2 boys, ages 6 and 4 yrs and I am also a pediatrician. After talking with many friends and parents of my patients, I have decided to start a blog to discuss some of the most common problems that parents face raising their kids. I hope that you will find the information here to be fun and informative. Please always seek the medical advice of your physician for any medical or behavioral problems your child might have and take this information to help guide you to ask the right questions and of course, to entertain you!