Compiled by Jeffrey L. Wampler, MD, FAAP (not one original thought)
One of the most common complaints we get called about is a cough. Many things can cause a cough. Children get many illnesses in the winter that cause a cough. Parents often worry that the cough is a sign of something ominous. Furthermore, coughs that last for a long time are often distressing to both the child and the parent.
What is a cough? Coughing occurs when something gets into the airway below the vocal cords. The upper airway starts at the back of the nose and moves down to the vocal cords. The lower airway include the trachea, the right and left bronchus which leads to each lung, the small tubes of the lungs called bronchioles, and the air sack. On youtube there is a video...(https://wwwyoutube.com/watch?v-usAgJoVYVSc&feature-youtu.be) showing how a cough occurs in the body.
Coughs in chldren are most commonly due to post nasal drip. Mucous drains from the upper airway into the lower airway. However, some coughs originate in the lower airway and it's important to differentiate. Sometimes an xray may be needed. It is very helpful for the parent to be able to describe the cough. (https://pediatricpartners.blogspot.com/2013/12/my-childs-cough-and-breathing-sounds.html)
Common Cold: Colds are viral illnesses that cause mucous production in the upper airway. The cough occurs from post nasal drip of the mucous. They last about 10 days but the cough may linger beyond that. Viral Cough: This is similar to a cold but the lower airway is infected by the virus. This means patients will not have the typical runny nose or congestion that occurs with a cold. Again, this cough can last for weeks.
Influenza: The flu is a severe viral infection that causes fever, body aches, fatigue, headache, sore throat and cough. There is usually less mucous production in the upper airway with the flu compared to a cold. Also, the fever is usually higher compared to the common cold.
Pneumonia: This a probably what parents worry about the most. Pneumonia is not usually present at the start of a cough or cold as it is frequently a secondary infection to the cold virus. This is because the sticky environment that the cold virus creates is a perfect home for bacteria. The infection, and pus it creates, fills the air sacks, making it hard to breathe and causing a high fever. If your child has any difficulty breathing, seek medical care right away. Pneumonia is also caused by viruses so not all pneumonia infections require antibiotics. Furthermore, older kids and teens can get walking pneumonia which is caused by the bacteria Mycoplasma. Your child's doctor may want a chest x-ray to determine if your child has pneumonia and what type they may have.
Bronchiolitis: Caused by RSV, bronchiolitis is an infection of the bronchioles, or small tubes in the lungs. The extreme amount of mucous production plus the airway causing cough, distress with breathing and sometimes wheezing. RSV is more severe for young babies so please take your child to the doctor right away if you suspect it.
Croup: Croup is a viral illness that causes swelling in the upper airway. The cough is described as barky and some children will make a sound when breathing in known as stridor. Placing the child in a steamy bathroom or going out into the cool night air can calm a croup cough.
Sinusitis: The diagnosis of sinusitis is made after a cold and cough have been present for at least 10-14 days. The diagnosis is not made for a child that has a dry lingering cough that is gradually getting better, which is the typcial pattern. The diagnosis should be made in the setting of continued congestion, worsening symptoms after 2 weeks, headache or face pain, and possibly new onset of fever. Even if your child has symptoms of sinusitis, it will often get better on its own, so there is not a rush to start antibiotics. However, it is a good idea to discuss treatment options with your child's doctor.
Whooping cough: Sadly we still diagnose this dangerous vaccine-preventable infection that is caused by the bacteria Bordatella pertussis. The infection starts with mild cold symptoms but eventually progresses to a sever spasmodic cough. Young babies and children will create the classic whoop sound when breathing in following a coughing fit but older children may not. Furthermore, babies may stop breathing all together. Older children will cough so hard that they will throw up following the coughing fit. Unfortunately, whooping cough can be fatal at worst and cause 3 months of cough at best, so make sure your whole family is up to date on their whooping cough vaccines.
Bronchitis: Bronchitis is inflammation in the bronchus, or large tubes, of the lower airway. While it is a common diagnosis in adults, especially smokers, it is not common in young children. The symptoms typically overlap with either a cold or asthma. The most common cause of bronchitis is a viral infection so antibiotics are not indicated unless there is a secondary pneumonia that has developed.
Asthma: While asthma is not an infection and is going to require its own post, the most common trigger for asthma is a cold. Therefore, if you think your child is wheezing during their illness, it is best to see the doctor. Some chronic coughs may actually be cough-variant asthma even in the absence of wheezing so this is something your doctor may consider if you child has a chronic cough lasting more than 4 weeks.
How should you treat a cough? If your doctor has prescribed antibiotics for pneumonia, a sinus infection or whooping cough, give the whole course as prescribed. Because most causes of coughs are viral, there isn't anything we can give to make it go away any faster and antibiotics are not appropriate. But there are things you can do to comfort your child and ease their symptoms.
When is it time to worry? As already mentioned above, if your child is coughing longer than 10 days, has any distress with breathing or chest pain, seek medical care. Watch for rapid breathing, retractions (when the muscles sink between the ribs) and extra labor with breathing. LIsten for sounds with breathing like stridor (whistle sound with inspiration) or wheezing (whistle sound with expiration). Sometimes parents hear a whistling sound that they think is wheezing but is actually from breathing through a blocked nose. Also, parents often worry in a small child that they can feel a rattle in the chest. This is the child breathing through musous that is most likely in the upper airway. When in doubt, take your child to see the doctor and if your child is getting tired from breathing, can't seem to catch their breath or looks blue around the lips, call 911.
Overall, if your child is coughing but is not having any difficulty breathing and has had a normal exam by the doctor, don't worry. It is likely to pass. However, if things get worse or the breathing looks labored, seek medical care.
So you have an explanation for your child's school and perhaps exasperating home life difficulties and perhaps it makes you look in a new way at yourself, a spouse or other relative who also likely has ADHD. You may make an appointment to discuss medication with your pediatrician. What other, non pharmacologic, treatment options might you look at?
Sleep: A classic study in a landmark sleep text talks about a group of children with obstructive sleep apnea who had snoring, their tonsils and adenoids out. Amazingly there were some in the group with ADHD and some with bedwetting who stopped having those problems. What's going on? Poor or inadequate sleep can cause those and other significant difficulties. Sleep hygiene is the term for good sleep habits: No caffeine for 6 hours prior to sleep, no screen time for one or two hours prior to bed time, reasonable and similar bed and wake times between school and off school days, good bed time routines like brushing your teeth, shower, read or be read to. Exercising daily for 30-40 minutes helps to relax us for sleep. Especially in a child with ADHD, the structure of a good bed time routine is comforting, relaxing and promotes a good night's sleep.
Diet: Another old study, the Feingold, said dyes and additives caused ADHD and that a diet free of them worked for a high percentage, there is a lot of controversy around this. There are a small number of individuals in whom red dye causes a marked behavioral disturbance just as some people instead of being made sleepy by Benedryl become wired. These are inherited genetic variations. With the Feingold diet, parents had to carefully plan, structure and monitor what their children ate and when they at it. I never cease to be amazed at how poorly many people eat. Children with ADHD respond to sturcture and quality in their diet or the lack thereof. Some newer thinking on diet, research proven, is around essential fatty acids. A study of the Mediterranean diet in a group of children with ADHD showed that those who followed the diet more closely had fewer ADHD symptoms. Was it the more fruits and vegetables, more complex carbohydrates, fewer simple sugar? No, it was felt to be from the Omega 3's found in the fish emphasized in that diet. That is the basis for one of the medical foods currently being given for ADHD and some other brain issues, like age related cognitive decline. Diet is important; the Mediterranean diet has been shown to help ADHD and many chronic illnesses. Feed your children and yourself breakfast. Find something with adequate protein and calories to sustain them until lunch and if possible make fatty fish like tuna, salmon and other Omega 3:'s a part of your diet. If you're vegetarian, seek out the plant sources like Flaxseed, chia seeds, brussel sprouts, hemp seeds and walnuts.
Exercise is so remarkble in it's ability to calm us, to help us sleep, to relieve anxiety, to impose our sense of well being, to give us confidence. And it has been shown to improve school performance. It is essential for all of us if physically possible and is certainly not limited benefitting ADHD but all of us, find something you and they like to do and do it.
Cognitive Behavior Therapy (CBT) can improve ADHD behaviors by teaching skills for handling life challenges or overcoming negative thoughts. CBT for children with ADHD seeks to improve their behaviour and functioning via praise and rewards for acceptable outcomes like staying in your seat, being attentive, not interrupting and handing in homework. Such therapy should come before medication in ADHD children especially the very young.
School can implement IEP's for children with ADHD, individualized educational programs tailored to the result obtained by testing. In the home, we can implement similar plans like how, where and when homework gets done, rooms tidied, chores done.
So, outside of medication, leading a sturctured, secure life with a good diet, exercise and enough sleep and healthy expectations about behaviors can optomize life outcomes with those special people among us with ADHD.
Good quality, restorative sleep is essential for optimal health and well-being. Insufficient sleep can cause problems with irritability, decreased daytime alertness and poor academic performance, and can contribute to depression, anxiety, ADHD and other mental health issues. Most parents know that sleep is important at all ages, yet in recent years I hear more patients tell me that they often do not sleep well.
Our society has become increasingly dependent on electronics to function in our daily lives. Most parents and children use computers at work and school, and at home we are texting on our smart phones or keeping up with friends on social media. Our children often study and complete assignments online, but recently, more evidence indicates that an increase in sleep problems may be related to these electronic devices. Light receptors in the retina transmit messages to the brain, and the brain responds with an increase in alertness. The particular type of light associated with i-pads, computers, smart phones, video games, e-readers, and other electronic devices with a lighted screen, seems to be particularly stimulating to the "awake" centers in our brains. Some people are more susceptible to this than others.
Making it a habit to turn off electronic devices at least an hour before bedtime can be of great benefit in improving sleep. Some children who are very sensitive may require longer than this, even several hours. Encourage your child to complete their online schoolwork first, so they can read (actual books, not e-readers) and do other non-computer based assignments later in the evenings. Parents should always make sure that their children's access to social media is adequately monitored and developmentally appropriate, but it is also important that electronics not be routinely used late in the evenings and into the night-time hours. Several families have told me that they have instituted a "turn-off, turn-in" policy and at an agreed upon time, their children are to turn their devices off and leave them in a specific location (not in their bedroom, where they may be tempted)
For children that struggle with sleep issues, having a regular bedtime routine can help them "wind down." Depending on the age of the child, bath or shower, getting schoolwork and lunches ready, story-time or reading a book, listening to soothing music or guided relaxation/meditation may be calming and beneficial. Avoid caffeinated beverages and concentrated sweets, especially late in the day. Most of my patients will tell me that they sleep better and feel better when they are involved in sports or other regular exercise. Over-the-counter and prescription sleep aids are not recommended for most children, and should be used only after consulting with your childs' pediatrician.
Some older children and teens tend to fall into bad sleep habits over the summer, staying up late and sleeping in. They then struggle with getting up early for school. Although it can be difficult, try to maintain a consistent bedtime and avoid napping after school, then staying up late again at night. It may take some time to get back into a good routine. If you suspect that a medical issue such as asthma or sleep apnea might be the cause of your child's sleep problem, please call our office to set up a consult appointment to discuss this with us. If you are concerned that your child is suffering from a mental health issue such as depression or a significant anxiety disorder, or if you suspect a substance abuse issue please call for a referral to a qualified mental health provider.
by Dr. Kathleen Maurer
Not too many years ago, children got most of their shots before they started kindergarten, and older children only needed an occasional tetanus booster . Things have changed over the past decade, and several important vaccines are now recommended for 11-18 year olds. Your pre-teen or teen-ager may be less than enthusiastic about getting vaccines when they come if for a sports physical or yearly exam, but it may help if they are prepared and understand the benefits of being protected from some very serious diseases.
1. Hepatitis A - This vaccine protects against a virus that affects the liver and can easily be transmitted person to person. There have also been a number of outbreaks through contaminated food or food handlers. International travel is also a risk factor, but with a more global society, community outbreaks have become more common. About 10-11 years ago, we began routinely giving Hepatitis A vaccine at 15 months and 2 years of age, so most of our younger patients have already had this vaccine, but many over 12 have not had this. Beginning in 2018, Kentucky Schools are requiring this vaccine for all students, so those who have not had it will need to get it. Students will need to have 2 doses of Hepatitis A vaccine at least 6 months apart. If your child has not had both doses of Hepatitis A vaccine, please call our office to schedule an appointment.
2. Pertussis (whooping cough) - Although this vaccine is included in the routine baby shots and preschool boosters, immunity tends to wane over time, and community outbreaks have become common. Older children and adults with pertussis may only have a very persistent and annoying cough, but this disease can be very dangerous and even fatal for vulnerable newborns and babies who are too young to be fully vaccinated. Beginning about 6 years ago, the Center for
Disease Control (CDC) and American Academy of Pediatrics (AAP) recommend all 11 year olds receive a dose of pertussis vaccine which is combined with tetanus vaccine (Tdap). This is now required for all Kentucky School children. (also recommended for all women during pregnancy, close contacts of all newborns and infants, childcare workers, and healthcare providers)
3. Meningitis A vaccine (meningitis A, C, W, Y) -This vaccine protects against several strains of bacteria that can infect the blood, brain and spinal cord and cause serious and life threatening illness. It is most common in teens and young adults, and can spread quickly. The scary thing about this devastating and potentially deadly infection is that it can infect otherwise healthy young people, and its onset tends to be very rapid. A dose of Meningitis A vaccine is required at age 11, with a booster dose at age 16. (Certain high-risk patients may need to get this vaccine before age 11)
4. Meningitis B vaccine - This vaccine protects against a serogroup of the meningitis bacteria that is not included in the required Meningitis A vaccine. Within the past 5 years, multiple college campuses have experienced outbreaks of Meningitis B. The symptoms are identical to the other strains of meningitis, causing serious illness or deaths. Two doses of this vaccine are recommended for 16-18 year olds, and especially encouraged for those who will be heading to college.
5. HPV - Human Papilloma Virus is very prevalent in the population in general and is the cause of almost all cases of cervical cancer in women and some genital and head and neck cancers in men, as well as genital warts. Although its primary means of transmission is through sexual contact, it is not only careless people who contract this infection. Most people have no symptoms at all from this virus and it eventually clears on its own, but some cases will persist and lead to cancers. The first HPV vaccine, which covered for the most common cancer-causing strains, was approved in 2006. The current Gardasil 9, which has expanded protection against more strains of the virus, was approved in 2014. HPV vaccine is recommended for both boys and girls, ages 11 and up (approved down to age 9) Those who receive the first dose of vaccine prior to their 15th birthday only need 2 doses, 6 months apart, while those 15 and older will need 3 doses.
Earlier this year my blog discussed various diets, their common characteristics and best current recommendations. This month, I wanted to begin discussing the individual components and how much we need in our diets.
The first question onmivorous (eat everything) people ask vegetarians is "where do you get your protein?" Most Hindus would beg to differ. They are healthy and enjoy a vegetarian diet or a Lacto (milk products) vegetarian diet. So maybe we don't have to eat meat protein; vegetables, dairy, legumes, eggs, grains and nuts can be rich sources of protein. Humans need less than half a gram of protein per pound of their healthy weight daily or making it real, a 22 pound toddler needs about 8 grams of protein. A single egg contains around 6, a piece of bread 2-4 or more, a 4 ounce glass of milk is 4 grams. So that meal for breakfast would give the child all the protein or a minimum of 12 in that meal alone for the day. Recent studies have shown that children who eat an egg per day in the second year of life are taller generally (similar findings are out there about whole cow's milk vs. plant milks). How should this information form our habits? A typical 110 pound woman needs around 40 grams of protein per day. If we take in about a third of that for breakfast, it will keep us satisfed until lunch compared to a similar breakfast in calories but without enough protein.
Some foods and their protein amounts: Cooked meats and fish are about 7 grams per ounce, 1 egg is 6 grams, 8 ounce glass of milk is 8 grams, 1/2 ounce nuts is 6 grams, 1 tablespoon of peanut or other nut butter is 7 grams, 1/4 cup of cooked beans, peas or tofu is 7 grams, 1/3 cup of cottage or ricotta cheese is 10 grams, 1 cup of cooked oatmeal is 7 grams, 1 ounce of cheese (the harder tend to be higher) is 4-12 grams, breads or a bagel is 2.5 - 10 grams (variable), cerieals, cold per serving are very variable, pasta is 12.5 grams, Quinoa, teff, amaranth are variable but rich sources of protein.
I wrote about the toddler's breakfast; how about for grown ups? If we try to get a quarter or a third of our protein for breakfast, how about a peanut butter sandwich on whole grain bread, an egg cheese and veggie omelet, greek yogurt with fruit, nuts or a quality granola topping, a breakfast burrito? Cereals can be a good breakfast but many are short on protein. Where are these gram amounts shown? On all food labels it's listed. On another blog, I will discuss fats, carbohydrates, fiber and some of the micro nuturients we should get in a varied, balanced diet. Remembering the 5-2-1-0 plan recommended for children (and adults) 5 servings of fruits and bvegetables per day, 2 hours max of screen time (except for school work), 1 hour of exercise and 0 sugared drinks, but getting a good breakfast with enough protein is an excellent start and enough protein the rest of the day is essential.
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