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Teaching Happiness

When asked what we want most in life, the majority of us will reply that we want to be happy. This desire drives much of our decision making and is the motivation behind almost everything we do. Times of elation, achievement, success, and victory are often described as “the happiest” moments of our lives. So how can we be happy? And, just as important, how can we “teach” happiness to our children?

Chicken and Egg

I believe the first step is to change the formula we’ve all been taught about happiness. In his book, “The Happiness Advantage,” Shawn Achor describes the traditional thinking this way:

“If you work hard, you’ll become successful, and once you become successful, then you’ll be happy.”

He goes on to explain that the problem with this equation is that it’s completely backward. Over more than twenty years now, the fields of positive psychology and neuroscience have shown that happiness is one of the precursors to success, not just a result of it. Again, from his book:

“…happiness and optimism actually fuel performance and achievement. …Waiting to be happy limits our brain’s potential for success, whereas cultivating positive brains makes us more motivated, efficient, resilient, creative, and productive, which drives performance upwards.”

Even though the Declaration of Independence famously lists “the pursuit of happiness” as one of our inalienable rights, it turns out that happiness is more a decision and manner of living than a pursuit or achievement. This paradigm shift can make a tremendous difference, and increase our likelihood of being truly happy and successful, in that order.

Certainly, there are times when emotional and psychological problems complicate the picture significantly and may require professional help. At Canyon View Pediatrics, we can help to determine if your child falls into this category. If you, as a parent, are struggling with anxiety, depression, or other related conditions, our family medicine colleagues can be of assistance. But even in these circumstances, the concepts and practices of positive psychology are an essential part of being a happy person.

So how is this to be done? And how is it then to be taught? Well, Mr. Achor’s entire book proposes answers to those questions. It is a fairly fast and entertaining read, so I highly recommend it. But I will summarize just two of the important concepts, specifically regarding how we can help our children live in greater happiness.

Growth Mindset

In her book, “Mindset,” psychologist Carol Dweck, Ph.D., describes the concepts of “fixed” and “growth” mindsets, backed by years of research through dozens of studies. To have a full appreciation for this important topic, I recommend her whole book, which is also a fast and entertaining read. I will briefly summarize the main ideas and how they pertain to our children.

The fixed mindset basically says that things (and people) are how they are and can’t change. Phrases which exemplify the fixed mindset are the following:

That’s just how I am.

I’m not good enough.

I’m a failure.

Why even try?

I can never get it right.

Bad things always happen to me.

On the other hand, the growth mindset is exemplified by phrases like:

I’ll get it next time.

I know I can do better.

I failed that test, but I’m not a failure.

I’ve got this.

Good things are coming.

I can do anything.

This is more than just blind optimism. It’s a state of mind and being, with far-reaching implications for the path of our lives. Those who consistently stay on the growth side of the mindset spectrum achieve significantly more success than those who tend towards fixed mindset thinking. 

My challenge to all of us as parents is to cultivate the growth mindset in ourselves and help our children to do the same. The most practical and measurable way of doing this is to carefully consider the words we use, especially when we are around our children, ensuring that they convey the positivity of the growth mindset. If we catch ourselves expressing fixed mindset ideas, we can consciously turn those phrases around to model the growth mindset attitude. 

This must begin with paying closer attention to our own self-talk, and the stories we tell ourselves. If our internal dialogue is overly negative and critical, this will likely spill over into our treatment of others, especially our children. It has been said that we should treat ourselves like someone we care about. If we talk to ourselves in a way that would be inappropriate for our friends and loved ones, then the change should start here.

Circle of Control

This concept is illustrated by the story of Zorro. You may recall that when Alejandro (later Zorro) first encountered the old sword master Don Diego, the younger man was broken by years of drinking and bad decisions. He felt completely helpless, having (in his view) no control over his own life. Don Diego had to help Alejandro become the director of his own life, and develop real self-control for the first time.

Don Diego drew a circle in the dirt around Alejandro and told him that he must become the master of only that small space. He said, “This circle will be your world. Your whole life. Until I tell you otherwise, there is nothing outside of it.” Once Alejandro mastered control of the circle, he was gradually given other and greater challenges. As he gained greater abilities and discipline, he also regained control of his life, becoming the master of his world. This helped him to overcome the despair that results from falling prey to the victim mentality and restored the internal locus of control necessary for growth and success. Once again, from Achor’s book: 

“Feeling that we are in control, that we are masters of our own fate at work and at home, is one of the strongest drivers of both well-being and performance.” 

My second challenge to all of us as parents is to teach our children how to be the directors of their own lives. The most powerful way to do this is through example. Do our words and actions demonstrate discipline and control, or are they more reflective of the victim mentality? If there are areas of our lives that we can’t seem to master, we may need to start with a small circle, and gradually increase it. This is likely to be the case for our children as well.

An example in the Achor book describes a man whose desk at work was chronically messy, to the point that his productivity nearly ground to a halt. He was given the task of clearing one small corner of his desk, which he did fairly quickly. Rather than progressing to the rest of the desk, he was then charged with defending that small area for the next day, keeping it organized and clean. Gradually he tackled other small sections of the desk until he once again had control over his domain (or at least his desk). 

We can employ the same techniques with our children, from toddlers to teen. Consider how this concept can apply to our young ones in cleaning their rooms, completing their homework, getting out of bed on time, yelling at siblings or parents, common chores, reading a book, and dozens of other everyday situations. Gradually they can experience the increased self-esteem that comes with being masters of their own circles of control.

Your Brain on Positive

Our effectiveness in spreading the “happiness advantage,” and teaching it to our children, will depend entirely on our ability to make the necessary changes in ourselves first. Positivity breeds positivity. The ideas of the growth mindset and circle of control, among other concepts of positive psychology, can transform our lives and our family experiences. When we choose happiness as our way of life, greater success will necessarily follow. And this will be true for our children as well.

Pediatric Scoliosis – Abnormal Curvature of the Spine

Your spine gives your body support and allows you to move and bend freely. It is made up of small bones called vertebrae that are stacked up on top of each other and separated by soft discs. The vertebrae normally form a straight line from your head to your tailbone with a slight forward curve at the top and backward curve at the bottom of the spine. However, sometimes the spine will rotate and twist and develop an abnormal sideways curve. This is called scoliosis.

Types of Pediatric Scoliosis

  • Congenital Scoliosis develops before birth in the womb. It is a rare condition affecting 1 in 10,000 infants. This scoliosis may not be severe enough to need treatment during infancy but may get worse as the child grows.
  • Neuromuscular Scoliosis, also called myopathic scoliosis, may develop in kids with chronic nerve or muscle disorders that influence function of the skeletal system, such as muscular dystrophy, cerebral palsy, or spina bifida.
  • Acquired Progressive Pathologic Scoliosis is the most serious form of scoliosis because it indicates a serious underlying abnormality that may progress unrecognized and result in significant harm. This type of scoliosis is caused by diseases such as spinal cord tumor; tethering of the spinal cord which restricts the growth of the cord and causes neurological damage; syrinx of the spinal cord which is a large cyst in the cord; abnormal vertebrae formation and development that can lead to progressive deformity. Many of these diseases will cause back pain or bowel and bladder symptoms. Without routine surveillance and early detection at physical exams, disease progression may cause irreversible damage.
  • Idiopathic Scoliosis is the most common form of scoliosis and accounts for about 8 in 10 cases in youth. This scoliosis usually occurs in otherwise healthy children around puberty, when the child is going through a growth spurt, but it can also start earlier in childhood or infancy.

Who Gets Idiopathic Scoliosis?

While the cause is unknown, scoliosis tends to run in families. Eighty percent of idiopathic scoliosis occurs in adolescents. It is found in as many as 4 of every 100 children from 10 to 18 years of age. Adolescence is when rapid growth typically occurs and when scoliosis starts to progress. Moderate curvature of the spine (10-30 degrees) occurs equally in both males and females, but 80% of patients who have a curve greater than 30 degrees are female. It is not caused by poor posture, carrying heavy book bags, or by sleeping on your side.

What are the Signs and Symptoms?

In many cases, the early curves of scoliosis are not obvious and are rarely painful. The problem may not be noticed until it is identified during a regular check-up with your pediatrician. As the child grows and the curve progresses, it may appear that one leg is longer than the other one or that one arm hangs lower because of the tilt in the torso. One shoulder or hip may be higher than the other and the head may not be centered. When the child bends forward at the waist, the spine will look like a curved line and there may be a hump on the back at the ribs or near the waist. Scoliosis is easier to treat when caught early so even if you see a minor curve of the spine, your child should be checked by his or her pediatrician.

How is a Scoliosis Diagnosis Made?

Routine well-child visits are a critical opportunity to catch subtle diseases like scoliosis early. When your pediatrician detects a curve in the spine, an x-ray of the entire spine will be done. The x-ray will show the doctor where the scoliosis is affecting the spine and the extent of the curve. Your pediatrician will also look for areas of numbness, tingling, weakness, or other nerve symptoms, which could signal the presence of disease processes causing scoliosis.  We have on-site x-ray capability at the Spanish Fork facility so that you don’t have to drive to the hospital.

Treatment

Untreated, scoliosis may cause life-threatening complications. When the curve is severe, there is less space for the heart and lungs, causing them to work ineffectively. The ribs can rub against the pelvis, causing pain. Nerves being damaged can lead to a loss in motor function, pain, and numbness.

How scoliosis is treated depends on the child’s age and skeletal maturity, the degree of the curve, and other associated medical conditions. Physical therapy and exercise are almost always a part of the treatment plan, but will not prevent the curve from progressing. Chiropractic treatment, electrical stimulation, and nutritional supplements have not been shown to keep curves from getting worse. The four treatment options are urgent surgery, observation, bracing, and preventive surgery.

Urgent Surgical Intervention

Scoliosis caused by disease processes such as tethered cord may require urgent surgical intervention to prevent injury.

Observation

Observation is usually recommended for a curve of idiopathic scoliosis that is not expected to reach 20 degrees. X-rays will be taken every six to twelve months to see if the curve is progressing. The rate of progression of the curve will predict the need for intervention.

Bracing

A back brace is usually recommended for a curve that is predicted to pass 20 degrees, especially if the child is still growing and the curve is likely to continue worsening. Wearing a brace will not reverse the curve, but may help prevent the curve from getting worse. Children who wear braces can usually participate in most activities. The brace will be discontinued after the child stops growing. Scoliosis that is detected too late may not be a candidate for bracing treatment.

Preventive Surgery

Spinal fusion surgery is considered when a curve of idiopathic scoliosis is 40 degrees or higher or if the curve continues to progress despite bracing. The vertebrae in the curved area will be fused together and straightened with a metal rod. Surgery has been found to be highly effective. It can help the person stand up straighter, reduce the deformity, and will prevent the curve from getting any worse. It is generally well tolerated but can limit the flexibility that can prevent participation in some types of sports activities such as gymnastics, dance, cheer, etc.  

What should parents do?

Parents should schedule yearly well visits from two years old through adolescence. Early detection of idiopathic scoliosis may prevent the expense and grief of spinal fusion surgery with inherent complication risk and loss of spine flexibility. Signs of disease processes such as tethered spinal cord that may result in scoliosis can also be detected at routine well visits; this may prevent serious loss of neurological function. Any child with back pain, or signs of back deformity, or sudden onset of incontinence of stool or urine should be evaluated by one of our pediatricians urgently.

References:

Scoliosis Research Society http://www.srs.org/patients-and-families/conditions-and-treatments/parents/scoliosis/adolescent-idiopathic-scoliosis

AAP News & Journals, Scoliosis, Jacob J. Rosenburg, Pediatrics in Review September 2011, VOLUME 32 / ISSUE 9

Scoliosis: What You Need to Know, https://www.spine-health.com/conditions/scoliosis/scoliosis-what-you-need-know

Return to Athletic Activity After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Analysis of Independent Predictors Peter D. Fabricant,

J Pediatr Orthop Volume 32, Number 3, April/May 2012 www.pedorthopaedics

The Power of Sleep

Considering how important sleep is to our proper functioning as human beings it is interesting how easy it is for our sleep cycles to be disrupted, either by circumstances outside our control or more commonly by our own choices. While some view sleep as a necessary nuisance it is clear that good sleep patterns contribute to improved school/work performance, help us maintain a healthier weight, and give us time for mental and physical restoration.

When it comes to school or the workplace sleep deprivation often manifests as decreased attention span and difficulty in task completion.  You may notice these are similar symptoms that we associate with Attention Deficit and Hyperactivity Disorder (ADHD). At times academic struggles can be linked directly back to poor sleep routines and once those bad habits are corrected there is a corresponding improvement in school.  During my time as a Medical Officer for the Navy if there is one thing that I learned, and learned well, it was that the effectiveness of at Sailor or Marine declines rapidly once they become sleep deprived and at times you needed to order them to get some sleep to ensure that they were ready to complete the mission.  As a parent, I’ve also found this same principle frequently holds true for my own children as well.

Another interesting correlation is that the more sleep deprived you become the more likely you are to be overweight. One interesting study by Janice F. Bell, Ph.D., MPH, of the University of Washington conducted in between 1997 and 2002 found that children who did not get adequate nighttime sleep between the ages of zero to 4 years were 33%more likely to be obese than children who had adequate sleep. These effects were slightly more noticeable in those aged 5 to 13 years who were 36% more likely to be obese.  People often ask me why would inadequate sleep lead to this weight gain?  While the complex answer involves the changes that occur to hormone release, the more straight-forward answer is that when we are tired we eat more to try to increase our energy levels. Any good weight maintenance or weight loss plan should begin with ensuring adequate sleep is occurring.

One final thing to consider is that sleep is essential to the restoration of both mind and body.  I frequently talk with teenagers who have always been good students but begin struggling in their very busy lives as they are involved with multiple after school activities and part-time jobs.  The primary concern they present with is that “I just feel tired.”  Parents are often concerned this reflects a thyroid problem or some other chronic disease, but once I ask a few questions it becomes clear that the real problem is they are only getting 5-6 hours of sleep a night.  While a person can compensate for a while with decreased sleep, eventually they will become rundown because it is during sleep that the body rebuilds muscle and the brain organizes all the information and stimuli that it has received during the day.  When you or your child begin to feel to run down a good first step is to double your efforts to get adequate sleep.

Some general guideline on sleep amounts are listed below:

  • Infants 4 months to 12 months should sleep 12 to 16 hours per 24 hours (including naps) on a regular basis to promote optimal health.
  • Children 1 to 2 years of age should sleep 11 to 14 hours per 24 hours (including naps) on a regular basis to promote optimal health.
  • Children 3 to 5 years of age should sleep 10 to 13 hours per 24 hours (including naps) on a regular basis to promote optimal health.
  • Children 6 to 12 years of age should sleep 9 to 12 hours per 24 hours on a regular basis to promote optimal health.
  • Teenagers 13 to 18 years of age should sleep 8 to 10 hours per 24 hours on a regular basis to promote optimal health.

If your attempts to improve your child’s sleep patterns have been unsuccessful and you would like to discuss it further, all of the Pediatricians here at Canyon View Pediatrics are ready to help.

Links:

American Academy of Pediatrics Sleep Recommendations

School Success

With the return of the new school year, young students all across Utah County are hitting the books once more. A very common question I receive this time of year, “How do I help my child be successful in school?” I must admit if I had the perfect answer I would have likely published a New York Times Bestselling book by now and be on a lecture tour, but with that said – while every child is unique there are some things that tend to be true for all children.

Getting children ready for school starts even in the first years of life. In all the research that has been done on getting children ready for learning, the number one thing a parent can do is read with their child. I think that it is interesting that in this day and age with all of the movies, video games, and apps that are available, reading and talking with your child has the greatest effect on verbal development and school readiness. It is also important that a child sees their parents, mother, father and meaningful adults in their life read as well, as a child’s natural tendency is to model the behavior they see.

In older children, it is often important to help them develop good study habits. Things a parent can do is set aside a place in the home where a child can do their homework with minimal disruption. A consistent workspace has been shown to help decrease distractions and thus improve learning and information retention. Along with this, it is important to schedule enough time for homework and study. This is something for you and your child to consider as you pick which after school activities to participate in.

When it comes to such things as TV, smartphones, and computers it is important to know that once a person is distracted it generally takes 15 minutes and sometimes longer before they are fully re-engaged in what they were doing before. So taking time to silence phones and other distractions will make study time more efficient. Along these lines, it is important for parents to monitor internet use, for while there is wonderful and mind-expanding information to be found there, it can also be a place where unexpected dangers exist.

One topic that is often overlooked is the need for adequate sleep. It is during sleep that information we have received during the day is processed and transferred from our short term memory to long term storage. Lack of sleep is associated with lower academic achievement in middle school, high school, and college as well as higher rates of missing school altogether. In most teenagers (13-18 years of age) recommended amount of sleep is generally between 8-10 hours; in younger children, it tends to be about 1-2 hours more.

When academic struggles do occur, I encourage speaking with teachers early, as they often have the best insight into what is going on and can offer immediate recommendations that may help a child succeed. If your child continues to struggle despite your best efforts or you have concerns that your child is having learning or focusing difficulties, please contact us at Canyon View Pediatrics. We are ready to offer any assistance that we can.

If you would like to read additional tips from the American Academy of Pediatrics about going back to school, please click here.

Preventing Heat Stroke

Summer is just around the corner, and with the promise of summer break approaching, you may find that you are planning more outdoor activities for you and your family. The goal of this week’s blog is to discuss the importance of preventing heat stress in children and infants. For more information on sun protection and sunscreen, please see Dr. Paxton’s blog post on this topic from March 2016.

In Utah, we are no stranger to intensely hot, dry weather. In this climate, children and infants can become quickly dehydrated if not adequately prepared. While it’s important to ensure that your children remain active and play outside during the summer months, keep in mind that when the temperature rises too high levels, or if you are traveling somewhere with very high humidity, intense activities such as hiking, running, riding a bike, etc. that last longer than 15 minutes should be minimized to prevent heat stress and heat stroke. Limiting the time spent outside between the hours of 10:00 am and 3:00 pm will also protect against the most intense UV light that can cause sunburns.

Dehydration is the major concern when participating in any prolonged activity outside in high heat and/or humidity. This can be easily prevented by providing adequate rest and hydration to children. Children are at a higher risk of becoming dehydrated compared to adults because, for their weight, children’s body surface area is larger.

Spotting dehydration can be tricky if you’re not sure what to look for. Early on, children may complain of fatigue, thirst, lack of energy, and feeling hot. You may notice that their lips and/or tongue are dry. If a child is complaining of thirst, they are already slightly dehydrated. Children should be given plenty of opportunities to drink water and remain hydrated before, during, and after activities outside. When remaining active outside for less than one hour, drinking water is sufficient. Breaks should be provided every 20 minutes to allow children to have water and/or sports drinks to ensure adequate hydration. They should be drinking 5 to 9 ounces during these breaks. Be sure to dress your active child in lightweight, light-colored clothing when outdoors, and that they change any sweaty clothing with dry clothing as soon as possible. Any child who is feeling dizzy, lightheaded, or nauseated should be removed from the activity promptly and brought somewhere cool and allowed to drink water.

Prompt recognition and treatment of dehydration are important so as to prevent progression to heat cramps, heat exhaustion, and heatstroke. Heat cramps are characterized by painful cramping of the muscles, usually in the abdomen, arms, or legs. Heat exhaustion presents with dizziness, nausea, vomiting, headache, weakness, and muscle pains. Rarely, children can become unconscious when suffering from heat exhaustion. Heatstroke occurs when the core temperature rises to 104 or higher and the child has symptoms of nausea, vomiting, seizures, disorientation, lack of sweating, and shortness of breath. Children suffering from heatstroke may become unconsciousness, and rarely comatose if not treated promptly. Heatstroke is a medical emergency and can result in death if left untreated.

For infants and small children, the focus of preventing heat stress and heat-related illness is different. Most people have heard of the sad event of an infant or toddler who was left in the car during the summer months and suffered heat illness, heatstroke, and even death. Infants and younger children are unique from older children as they lack the ability to regulate their body temperature in the same manner. For this reason, it’s especially important to pay close attention to the comfort of your infants and small children in hot environments, especially in the car during the summer months.

When traveling with infants and young children, make sure that you ALWAYS check the back seat to make sure everyone is out of the car when you reach your destination. For those families who have older children who help take care of infants and toddlers, NEVER entrust this responsibility to them. As a parent, it is your responsibility to make sure that everyone is safely out of the car. Too often have infants and children been left in the car unintentionally because an older sibling was responsible for getting them out and, for whatever reason, forgot. Because the temperature inside the car can reach dangerously high levels quickly, you must NEVER leave a child alone in the car, even if it’s just for a quick trip into the store. If your infant or small child is accidentally left inside a hot car for a prolonged period of time, seek immediate medical attention for observation to ensure that they are OK.

Resources:

Understanding Sepsis

A newborn baby is the greatest miracle of life. There is nothing more incredible and supernal than the creation of a new human being. Newborns enter a world of many dangers and their small bodies are as yet unproven in competency to deal with many trials. The infant’s intestines have not yet been tested with the volumes needed to maintain growth (we’ll discuss bowel problems next week). The baby’s hormone system, heart, and blood vessels, and immune system have yet to prove themselves healthy in adapting to life outside the womb.

Parents must be careful observers for signs of problems that may manifest after discharge from the hospital. The health care staff at the hospital, including your doctor, will evaluate your baby for any outward signs of problems. Many tests will be done to check for any hidden abnormalities, but not all problems can be detected before discharge. Parents may naturally assume that with the sophistication of health care they can be reassured that all will be well. Although this is generally true, there are some problems for which parents must be vigilant and will be the first line observer to warn of dangers.  Intestinal obstruction is one that I’ll discuss next week. Today I would like to talk to you about serious infections that may jeopardize your infant and how to recognize them.

Sepsis is the leading treatable cause of death in infancy. Partially preventable causes that are more common are Sudden Infant Death Syndrome which I discussed last week and injury. A 2005 population study of sepsis revealed over 42,000 cases in the U.S. in youth with 4,400 deaths, approximately 7% of the total death rate. The incidence is likely lower now with improved vaccine rates and perinatal care measures to prevent infection. Despite its danger, frequency, and treatability there are no studies that I could find investigating parents’ ability to detect this problem at home. Identifying sepsis is a particular challenge because the symptoms all mimic other problems. The main symptoms are fever over 100.4 F rectal, low body temperature less than 96.8 rectal, fast heart rate, decrease activity and consciousness, and fast or labored breathing.

Septic shock is an insidious and dangerous hazard. You must understand this process and how it affects the body. Bacteria enter the child and begin to grow in the lungs, blood, urine, or spinal fluid. These bacteria grow in an increasingly rapid fashion and can cause your infant to get sick very fast. As the bacteria continue to grow, so does the danger. The body’s reaction to the bacteria can cause the blood vessels to become leaky to the point that they can’t keep the blood pressure high enough to bring oxygen and nutrients to vital organs.

The urgency and emergency of treating sepsis depend upon the reserve and health of the child, the immune function, and the level of exponential bacterial growth in the body. Newborns up to 3 months of age are at especially high risk of complications and death from sepsis because their little bodies have naive immune systems and they have a little reserve to cope with serious disease. Fever does not equal sepsis, but it is a sign of urgency in a child less than 3 months old. Ten percent of babies less than 90 days old with a fever will have a serious bacterial infection, and if left without prompt treatment may progress to septic shock. Fever is a temperature taken rectally that is over 100.4 degrees Fahrenheit or 38 degrees centigrade. See information on how to take a rectal temperature below.

It is not necessary to routinely take your child’s temperature; only if he feels warm or cold or acts sick.  Any child less than 90 days old with a fever should be seen by a physician promptly.

Unfortunately, fever is not the only symptom that you have to watch for to indicate that your newborn may have an infection that could lead to septic shock. Some sick infants will only develop a fever once and for a short period of time so it is possible to miss a fever. Some newborns will have low body temperature with other signs of illness. Hypothermia or low temperature is a temperature less than 36 degrees Celsius or 96.8 degrees Fahrenheit.

Other symptoms of illness in newborns can be subtle and difficult to discern as problematic. Newborns have very responsive heart rates and can elevate quickly in response to discomfort, excitement, etc.   Normal awake heart rates can be from 85 to 205 depending on the activity state of the child. Normal sleeping heart rates can be from 80 to 160. Baby’s heart rates can be a challenge to measure because it can be so fast.

Decreased activity and consciousness as a symptom of disease can be a challenge because newborns sleep the majority of the time, and when in a deep sleep they can be hard to arouse. Most babies don’t have predictable and consistent sleep-wake cycles until three to four months of life. Some babies periodically have longer than typical sleep periods which can be normal. When your baby is awake she should look, act, and feed like her normal self.

Breathing patterns in newborns can likewise be hard to assess for parents because they can be erratic.  Some babies have a normal breathing pattern called periodic breathing when they sleep. This is a pattern of fast flutter breathing alternating with pauses in breathing up to 15 seconds. Some infants will tummy breath which can look abnormal. Normal breathing rates in young infants are up to 60 breaths per minute.   It may be normal for some babies to briefly breathe faster than this if they are excited or have periodic breathing but a breathing rate over 60, especially with labored respirations, should not be sustained. There are some videos demonstrating normal and abnormal breathing at the end of the blog.

The subtlety of sepsis onset and the explosive nature of its finish present a terrifying challenge to parents and doctors alike.  Here are a few pearls that I believe will help.

1. Sepsis is progressive. If your infant seems a little more tired than usual, or a bit more warm but doesn’t register a fever, or has intermittent faster breathing but doesn’t seem abnormal – then watch frequently and carefully.  If there is any sign of worsening have your baby seen urgently.

2. In the progression of sepsis, symptoms will eventually combine. If your baby has a faster than typical heart rate but seems happy, that is not likely sepsis. If your baby seems to have mild labored breathing but looks good, that is not likely sepsis. If your child develops a fever over 100.4 F rectally and has no other symptoms, that is still not likely sepsis. But if you start to combine symptoms you may have a tiger by the tail and need emergent evaluation. Especially in need of rapid evaluation are infants with fever, fast heart rate, or those looking ill with decreased activity. In my experience, persistent rapid or labored breathing developing in addition to these symptoms is a foreboding sign of rapid deterioration.

3. Sepsis symptoms are a change from normal appearance and functioning. You will know your infant best and how she acts, breathes, feeds, feels, etc. If she seems to not behave normally, have her seen by a doctor. If changes are subtle and you’re not sure if there is a problem, it’s not likely an emergency but watch carefully for the progression of symptoms.

4. Don’t be falsely confident that sepsis won’t occur because your child was recently evaluated by a health provider. Some people feel inappropriately convinced that everything will be ok because they have interacted with a sophisticated health care system. Remember, sepsis is a progressive problem and the onset is subtle with its individual and separate symptoms presenting in many other illnesses.  Doctors depend on parents, at home and even in the hospital, to help monitor for worsening of symptoms and combining of symptoms that may indicate the progressive disease of septic shock. If you feel your child’s condition is worsening from when she was seen by the doctor, call or have her seen again.

5. Your infant less than 3 months old has a naive system and must be seen urgently with any rectal fever over 100.4 F or under 96.8 F, rapid or labored breathing, or decreasing activity or level of alertness when awake. Your infant must be seen emergently if these symptoms are progressing and/or combining.

6. The best prevention for sepsis in young infants is good prenatal care, hand hygiene, vaccinations, and avoiding contact with sick people. If the contact is unavoidable, make sure the sick person wears a mask and uses good hand hygiene. Begin immunizations at two months of age because these vaccines prevent some bacterial infections that can cause sepsis in addition to other complications such as brain damage and deafness.

I blog about the serious things that can cause you misery because I want you to understand them so you can worry about them less.  Sepsis is still a rare event, like getting in a car wreck. I want you to maximally enjoy the precious time you have with your newborn baby.   Your baby grows up so fast, so treasure every minute and let us know if you have any concerns.

Proper hand-washing

http://www.cdc.gov/handwashing/when-how-handwashing.html

The U.S. Centers for Disease Control and Prevention recommend the following steps for hand-washing:

1. Wet your hands with running water and apply soap.

2. Rub your hands together to make a lather. Scrub well for at least 20 seconds.

3. Pay special attention to your wrists, the backs of your hands, between your fingers, and under your fingernails.

4. Rinse your hands well under running water.

5. Use a clean towel to dry your hands, or air-dry your hands.

You may want to leave the water running while you dry your hands on a paper towel. Then use the paper towel as a barrier between the faucet and your clean hands when you turn off the water.

If soap and water are not available, use a hand sanitizer or alcohol-based hand wipe that contains at least 60{81e69a3ca26977ac766aed87a28b2a1ecd92f9787a94c83a7ea2b436f670aee6} ethyl alcohol or isopropanol. Carry one or both with you when you travel, and keep them in your car or purse. These products can help reduce the number of germs on your hands, but they do not get rid of all types of germs.

If you use sanitizer, rub your hands and fingers until they are dry. You don’t need to use water. The alcohol quickly kills many types of germs on your hands.

REFERENCES

An Emergency Department Septic Shock Protocol and

Care Guideline for Children Initiated at Triage

PEDIATRICS Volume 127, Number 6, June 2011

Serious Bacterial Infections in Febrile Infants 1 to 90 Days Old With and

Without Viral Infections

PEDIATRICS Vol. 113 No. 6 June 2004

Scope and epidemiology of pediatric sepsis

Pediatr Crit Care Med 2005 Vol. 6, No. 3 (Suppl.)

http://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2014-a.pdf

NEWBORN BREATHING VIDEO

This is a healthy baby with occasional tummy breathing.  Notice the breathing is effortless and you don’t see the chest move much with each breath.  The baby is happy.

http://www.bing.com/videos/search?q=normal+newborn+breathing+patterns&&view=detail&mid=EA92DAED1539D48B3A49EA92DAED1539D48B3A49&FORM=VRDGAR

ABNORMAL BREATHING

This is labored breathing in an older infant.  Notice the chest move up and down excessively and the retraction or sinking in of the skin between the ribs.

http://www.bing.com/videos/search?q=videos+labored+breathing+in+child&&view=detail&mid=F47720852848C999BF2BF47720852848C999BF2B&FORM=VRDGAR

NORMAL OR ABNORMAL?

This baby has a fast breathing rate of about 70 breaths per minute. The breathing in intermittently fast with pauses.  The chest moves up and down more than most babies and you can see some retractions.   The infant has some upper airway congestion.  The baby is active and appears happy.

This presents the complexity of the symptoms babies present.  This breathing is likely perfectly normal for this child.  He have developed some recent nasal congestion worsening his breathing.  If this was a new pattern of breathing for this baby he should be seen by the doctor.

http://www.bing.com/videos/search?q=abnormal+newborn+breathing+patterns&&view=detail&mid=8CD57A1E4978A659E2398CD57A1E4978A659E239&FORM=VRDGAR

NORMAL PERIODIC BREATHING

This infant is sleeping, has normal baby wiggles and is not distressed.  You see some tummy breathing.  He has mild upper airway congestion.  You will notice periods of pauses about ten seconds followed by faster breathing rates.  This is likely a normal breathing pattern for this baby.  If he had never breathing like this before I would still have him evaluated.

http://www.bing.com/videos/search?q=normal+periodic+breathing+in+infancy&&view=detail&mid=97516DF3B4F827EE4E6F97516DF3B4F827EE4E6F&FORM=VRDGAR

LARYNGOMALACIA AND FAST BREATHING WITH EXCITEMENT

This baby has something called stridor which is an upper airway noise likely form laryngomalacia.  He is happy and breaths very fast when excited.  This is likely normal breathing for him but if it was a new breathing pattern I would have him evaluated.

http://www.bing.com/videos/search?q=normal+periodic+breathing+in+infancy&&view=detail&mid=132B9565509724CBDBFA132B9565509724CBDBFA&rvsmid=97516DF3B4F827EE4E6F97516DF3B4F827EE4E6F&fsscr=0&FORM=VDQVAP

How to Use a Digital Multiuse Thermometer

Rectal temperature

If your child is younger than 3 years, taking a rectal temperature gives the best reading. The following is how to take a rectal temperature:

  • Clean the end of the thermometer with rubbing alcohol or soap and water. Rinse it with cool water. Do not rinse it with hot water.
  • Put a small amount of lubricant, such as petroleum jelly, on the end.
  • Place your child belly down across your lap or on a firm surface. Hold him by placing your palm against his lower back, just above his bottom. Or place your child face up and bend his legs to his chest. Rest your free hand against the back of the thighs.
  • With the other hand, turn the thermometer on and insert it 1/2 inch to 1 inch into the anal opening. Do not insert it too far. Hold the thermometer in place loosely with 2 fingers, keeping your hand cupped around your child’s bottom. Keep it there for about 1 minute, until you hear the “beep.” Then remove and check the digital reading.
  • Be sure to label the rectal thermometer so it’s not accidentally used in the mouth.

This description of taking a rectal temperature is from the AAP website healthy children.org.

Skin Protection – For More Fun in the Sun

Spring – a common time for sunburn

Spring is a wonderful time of year for many reasons. The days are getting longer, the winter illness season is coming to an end, and many outdoor activities are beckoning once again. However, it is also the time of year when many severe sunburns occur. There are several reasons for this:

  1. Many people’s skin is quite pale after the long winter, and more vulnerable to burn.
  2. The air is generally cooler than in the summer, so it is more difficult to feel when a burn is occurring.
  3. The sun is getting higher in the sky, so the rays are becoming more direct, and are therefore more likely to cause skin injury.
  4. Spring sports and yard work can abruptly increase the amount of time people spend outdoors.
  5. Some people are anxious to get tan after winter and try to do it all at once.
  6. While we associate many summer activities with the need for sun protection, spring activities often don’t trigger this thought.

Preventing sunburn is important

There are many health hazards associated with sunburn, the most serious is the aggressive form of skin cancer known as melanoma. Occasionally, this type of cancer is diagnosed in people in their teens. Exposure to the sun’s radiation increases the risk of genetic mutations in our skin cells which can lead to this dreaded condition.

But that’s not the only reason to avoid getting burned. These are true burns and can range from superficial first degree burns with only mild discomfort, to deep second degree burns with blistering, extreme pain, and sometimes permanent skin changes. The younger a child is when sunburn occurs, the more severe the damage is likely to be.

Another concern with sunburn is the increased risk of other heat-related injuries. Someone with a severe sunburn is more likely to suffer heat exhaustion or heat stroke, which can lead to severe illness and even death. Occasionally, sunburns can affect a large enough portion of the body to cause the serious conditions associated with other significant burns, including susceptibility to infections and temperature regulation problems.

How to protect our children (and ourselves)

As with many things relating to our health, an ounce of prevention is worth a pound of cure. We should think about sun protection every day. Here are a few specifics that may help:

  1. Sun protective clothing and hats are usually the most effective means of preventing skin injury due to the sun, especially in infants and toddlers.
  2. Sunscreen, with an SPF of at least 30, is important to use on exposed skin.
    • It should be applied about 20-30 minutes before sun exposure, sweating, or getting wet.
    • Be sure to use enough. For an adult, this might mean up to 1-2 ounces per application.
    • Reapply after getting wet, even if the sunscreen claims to be waterproof.
    • Sunscreen can be used on babies, but the time spent in the sun should be very limited in this vulnerable population.
    • Remember that sunscreen and insect repellent often don’t go well together, and may even inactivate each other. Read the labels carefully.
  3. Beware of the reflected sun, whether from snow or water or even concrete, as this can greatly increase sun exposure, especially in young ones.
  4. Pay attention to the UV index, found on most weather reports and apps, to know when the sun will be most likely to cause harm.
  5. Avoid being outside between the hours of 10:00 AM and 3:00 PM as this is when the UV index is typically highest.
  6. Wear sunglasses which block 100% of the UVA and UVB rays, because eyes can get sunburned too.
  7. Avoid the use of tanning oils and creams as these do not block the sun’s harmful rays.
  8. Never use tanning beds, especially children and teens, as this direct exposure to harmful UV rays greatly increases the risk of the problems mentioned above.

As pediatricians, we strongly encourage outdoor activities because of the many health benefits they provide. Most adults and many children would do well to spend more time out of doors. We should also focus on doing so in a safe manner, so as not to cause unintended harm. By keeping these simple ideas about sun protection in mind, we can all better enjoy this wonderful spring season and the summer which is just around the corner.

Influenza Q&A

A short Q&A about Influenza:

Q. “Why do doctors give flu vaccine?”

A. So that fewer people die.

We give influenza vaccine to all people over 6 months old to prevent serious illness, hospitalizations, and death.  Did you know that the flu shot saved 40,000 lives (including 9,000+ children’s lives) in the last 9 years?   Also, an unimmunized person with a milder case of influenza that they don’t even notice can pass the germ to an elderly person or a baby, which can lead to another’s death.  We have reports of severe disease, and teenagers being life-flighted to Children’s hospital, as well as babies hospitalized with influenza locally.   I want to be immunized, so that at least I have some protection (60% is better than zero!) for myself, but also to do my part to protect babies and kids and elderly folks in my community.

Learn more – http://www.cdc.gov/flu/news/flu-vaccine-saved-lives.htm  

Q. “Do I need a flu shot if I already had the flu?”

A. Yes.

First of all, vomiting & diarrhea illnesses are most likely NOT influenza.   The viruses that cause vomiting and diarrhea have nothing to do with influenza or flu shots.   Influenza causes a sudden onset of high fever, muscle aches, and respiratory complaints.   Even if you had bona fide influenza disease, you should still have an influenza vaccine, because late in the season another vaccine-preventable strain of influenza can rage through the country.   The American Academy of Pediatrics has written a great summary of influenza disease for this 2015-2016 season.

Learn more – https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/the-flu-seasonal-influenza-2014-2015.aspx

Understanding Croup

Last week we discussed bronchiolitis, which is usually caused by RSV.  Today I want to help you better understand croup.  Croup is swelling of the upper airway caused by a virus, usually Parainfluenza.  Despite the name, Parainfluenza has nothing to do with Influenza.

Parainfluenza circulates in Utah any time it feels like it and makes children’s tracheas swollen, which earns it a place on pediatricians’ “virus enemies” list.  It usually affects older infants, toddlers, and young children.  Little children’s tracheas are usually narrow and floppy, so even a little bit of swelling around on the inside can make it very difficult to breathe.*

 The symptoms of croup include barking cough and stridor (which I will explain) that are worse at night,** and fever.  Usually, the second night is the worst night of croup, then it gradually turns into a normal cold that can linger for 1-2 weeks.  The child is contagious for 2-3 weeks, but other children with the same virus might be contagious with croup but not have croup symptoms.  By barking cough, I mean it sounds like a seal barking.  Click the link to hear a barking cough: 

By stridor, I mean a tight or squeaky sound when the child is breathing in.  This is different from wheezing, which is a multiple-whistling sound when you breathe out.  Here is what stridor sounds like:  

When should my child see the pediatrician for Croup?

Come in for stridor, working hard to breathe, or under-immunized status.  Further explanation follows:

If your child has barking cough without stridor, you can probably manage this at home with close observation, increased fluids, and breathing cold air outside.  However, children who have stridor (even if it’s only at night) should see the pediatrician. If the stridor is only with crying, then you can wait until daytime to be seen.  However, if there is stridor with labored breathing when at rest (not just with crying), that is not relieved right away by breathing cold air outside, then go to the emergency department.  If your child has difficulty breathing with retractions (a “sucking in” of the skin above, below, and between the ribs or at the bottom of the neck when breathing in), then seek immediate medical attention at the office or ER.  Children who are behind on immunizations (especially the Hib – Haemophilus vaccine***) should go to the ER or their pediatrician right away if they have stridor or difficulty breathing – and be sure to remind the doctor that your child has not had all the shots.  If a child has a high fever (over 102) and is leaning forward and drooling, this can be a sign of bacterial infection of the trachea or epiglottis (the flap that can cover and plug up the top of the trachea) which can be life-threatening.  Also, see your pediatrician if you think the stridor might be caused by something else (like an object or food that got stuck in the trachea, or a baby who has had “stridor since birth” who might have an abnormality of the airway).

What is the treatment for croup?

The two best treatments for croup are breathing cold air and a single dose of anti-inflammatory steroids (injected or by mouth). High-concentration humidity with a cool air humidifier right in front of the child for 10 minutes, can also help.  If the croup is mild, the steroid helps but is not mandatory.  Moderate to severe croup usually is treated with the steroid.  At night, if your baby has stridor, bundle him up and take him outside to breathe cold air.  The cold air molecules touch the inside of the trachea and can help decrease the swelling.  In the office or emergency department, if the croup is severe, we sometimes give nebulized adrenaline (epinephrine), which can decrease the trachea swelling for a couple of hours while we wait for the steroid to start working.  This medicine is generally not prescribed for home use.  If the treatments are not working, or if the stridor is significant during the day, then she might need to be admitted to the hospital, usually for a couple of nights, until the tracheal swelling decreases.

I hope you feel more empowered to take care of your child with croup.  Your pediatrician is ready to help you through it if you are concerned.

Payson and Spanish Fork, Utah, USA

Footnote factoids — some croup questions that curious parents sometimes ask, and nerdy doctors love to answer:

* Why do children get croup and not adults?  A child with a trachea narrowed from croup is often miserable because it’s hard for her to breathe in.  An infant’s trachea is sometimes only about 4 millimeters in diameter.  If it’s swollen only a little, say 1 mm all the way around the inside, then that shrinks the diameter to 2 millimeters.  The flow rate of air through a pipe is proportional to the fourth power of the diameter of the pipe.  So, if a baby’s trachea is half its normal diameter, then only 6{81e69a3ca26977ac766aed87a28b2a1ecd92f9787a94c83a7ea2b436f670aee6} of the normal air can get in.  If the baby is crying, it’s even worse.  With the turbulent airflow during crying, the flow of air is proportional to the 5th power of the diameter, giving the croupy baby only 3{81e69a3ca26977ac766aed87a28b2a1ecd92f9787a94c83a7ea2b436f670aee6} of the normal airflow.  If an adult with a 16mm trachea gets the same virus, and his trachea has the same 1mm swelling so that it narrows from to 14mm, it’s not such a big deal, because air can get in at 88{81e69a3ca26977ac766aed87a28b2a1ecd92f9787a94c83a7ea2b436f670aee6} of the normal adult flow rate (14/16)^4.

**  Why is croup worse at night?  Croup is worse at night for two main reasons: the muscles in the neck and throat that hold open the airway in the day are more relaxed at night, and our body’s adrenal glands make more natural corticosteroids during the daytime hours, which partially treat the croup in the daytime.  Often, when I see toddlers in the office on a morning after a stressful night of croup with seal-barking cough and stridor, they are not doing it anymore for me because it’s daytime.  The parents and I sometimes resort to dramatic reenactments and listening to recordings of croup cough and stridor to describe well what was just happening last night at home.  Without treatment, the second night is usually worse than the first night.

*** I am so glad I’m a doctor in this century and not the last one!  Before Hib vaccine became available in the late 1980s, a more severe and life-threatening form of bacterial croup, caused by Haemophilus B, was more common.  The bacterial versions of croup (also called bacterial tracheitis and epiglottitis) were so much worse than viral croup, that in the old days viral croup was called “faux croup” and the bacterial croup was just called croup.  Thanks to Hib, epiglottitis and bacterial tracheitis caused by Haemophilus are rarer.  I have only seen it twice, both in children whose parents had refused immunization.  Both were hospitalized, their windpipes became blocked almost completely, and they nearly died.  Some older doctors I know have stories of kids dying from Haemophilus bacteria before we had Hib vaccine.  If we keep our children immunized, then Haemophilus B epiglottitis and tracheitis (along with meningitis also caused by Haemophilus) won’t come roaring back to Utah.  

Secondary Bacterial Infections – Pneumonia

In an earlier post, I discussed the care and management of cold symptoms, ear infections, and sinus infections. Now I will focus on the least common secondary bacterial infection seen with colds: bacterial pneumonia. What I will be discussing is a different illness with different treatment than viral pneumonia.

Bacterial pneumonia is an infection caused by bacteria present in the lungs that lead to inflammation. Worsening cough or fits of coughing along with high fevers over 101 degrees or fevers for more than 5 days are the most common symptoms. Your child may also have some difficulty breathing, rapid breathing, or shortness of breath. Infants and toddlers may have a difficult time eating while older children may have chest pain that worsens with deep breaths.

If you are concerned about pneumonia, bring your child to their pediatrician. Only a physical exam performed where your doctor listens to your child’s lungs can diagnose bacterial pneumonia. If you ever notice any blueness around the kissing part of your child’s lips, bring them in for evaluation immediately! This may mean that your child’s lungs are unable to exchange oxygen adequately.

In most instances, bacterial pneumonia will be treated with antibiotics. Some children with bacterial pneumonia may require hospitalization for various reasons. Your doctor will help decide what the best treatment course for your child.

An important point to remember is the value of immunization in preventing pneumonia. During your child’s regularly scheduled immunizations, they receive vaccines for certain bacteria that are known for causing severe pneumonia. Since these immunizations were introduced, the number of cases of pneumonia caused by these bacteria and the severity of the disease has decreased significantly in children younger than 2 years old. So remember to get your child immunized!

Important points to remember about bacterial pneumonia complicating a cold:

  • The first signs of bacterial pneumonia will be worsening cough, spells of daytime coughing, and worsening fevers (over 101 degrees or for more than 5 days)
  • Bring your child in for evaluation if you notice blueness around the kissing part of the lips, labored breathing, pallor, or increasingly sick appearance
  • If antibiotics are prescribed, be sure that your child completes the entire course
  • Many children with bacterial pneumonia will require hospitalization
  • Remember to get your child immunized to help protect against serious pneumonia and their complications
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