Rotavirus (or the lack thereof): A vaccine success story

As a hospitalist, I see a sicker patient group. Only when a parent is very worried or a clinic provider feels they need ongoing attention do I see a child in the ED or in the hospital. Now, as we approach the end of summer, I can’t help but feel like something is missing. Five years ago, it was common in the spring and early summer to have children in the hospital for vomiting, diarrhea and dehydration from rotavirus. Rotavirus is a common virus that infects most children under 5 years of age and is most severe for children under 2 years of age. Every year there was a significant number of children who needed to stay in the hospital for IV fluids while they recovered from this virus. So, where did it go?

If your child is less than 4 years old then you may remember an oral vaccine received at the 2, 4 and 6 month visits. In 2006, the FDA approved the vaccine RotaTeq® and shortly thereafter, it was recommended routinely for infants. Since that time there have been other similar vaccines approved as well. This vaccine is not 100% effective in preventing rotavirus, but its goal was to reduce the severity of illness and prevent the need for hospitalization.

Recently, there have been some published studies on the effect this vaccine has had in the United States. One study showed a 46% decrease in need for hospitalization. Another study showed 100% effectiveness in preventing hospitalization compared to children who did not receive the vaccine. Wow! As a younger physician, it has been wonderful to see the impact vaccines can have on the health and well being of our children.

Although I love meeting the children and their families, I am glad more kids are at home. Staying in the hospital is no fun for anyone. To rotavirus, I say good riddance and you won’t be missed.

Dr. Jim Bencivenga

Pediatric Hospitalist

Meriter Hospital

meriterkids.com

What Every Parent Should Know About Concussions

As a parent, it is exciting to watch your young athlete from the side-lines, making a great catch or kicking a goal. Also, as a parent, safety is always something that is in the back of our minds. One injury I would like to address is a concussion. It has brought recent media attention due to famous athletes or movie stars sustaining an injury to the head. However, it can affect any athlete.

What is a concussion?
A concussion is any injury to the head that potentially affects the function of the brain. It is usually the result of a blow or jolt to the head. However, it is important to know that it can also be secondary to a blow to any part of the body that causes the brain in the head to move back and forth, as per definition from the CDC. It is important to be aware of this because an athlete can sustain a serious concussion without a blow to the head. For example, imagine a hit to the shoulder, causing your head to move back and forth like whip lash.

A CDC study found that among youth ages 5 to 18 years old, the sports and recreation activities that generated the greatest number of emergency department visits for Traumatic Brain Injury were popular activities such as bicycling, football, basketball, playground activities and soccer.

What are some signs of a concussion?
After a blow to the head, talk to your doctor if you have any of the following signs of concussion:

• Headache
• Vision disturbance
• Dizziness
• Loss of balance
• Confusion
• Memory loss (called amnesia)
• Ringing in the ears
• Difficulty concentrating
• Nausea
• Feeling foggy or groggy
• Sensitivity to light or noise

However, some athletes may just say that they “don’t feel right.” This could be a sign of a concussion as well. Remember, you do not need to have loss of consciousness in order to have a concussion. If an athlete has been suspected to have a concussion, they should be evaluated by a physician. Secondly, due to new rules and regulations, the athlete will not be able to play that day and will need medical clearance by a physician in order to return to play for future games.

Recovery and safe return to play:
It is crucial to allow enough healing and recovery time following a concussion to prevent further damage. Research suggests that the effects of repeated concussion are cumulative over time.

Most athletes who experience an initial concussion can recover completely as long as they do not return to contact sports too soon. Following a concussion, there is a period of change in brain function that may last anywhere from 24 hours to 10 days. During this time, the brain may be vulnerable to more severe or permanent injury. If the athlete sustains a second concussion during this time period, the risk of permanent brain injury increases.

I encourage you to visit the CDC Web site to understand more about concussions.

Meriter Pediatrics now offers ImPACT concussion management baseline testing. Think of it as a pre-season physical for the brain!

Dr. Viren Bavishi
Pediatrician
Meriter Middleton Pediatrics
608.417.8388
meriterkids.com

The New Rules of Head Lice: Part 2

Continued from yesterday's post ...

What should you do if your child has head lice? First, all other household members should be checked. So should any kids who were likely to have direct head-to-head contact. Anyone with live lice or eggs close to the scalp should be treated. Anyone who shares a bed with the infested person should also be treated.

Hair care items and bedding that have been in contact with the infested person in the 48 hours prior to treatment should be cleaned. (If it’s been longer than 48 hours, any lice will already be dead.) A temperature of 130 degrees or more (by washing or drying) will kill lice and eggs. Furniture, carpeting, and other fabric covered items can be vacuumed. Pediculicide sprays are not necessary. If there is a concern about eggs surviving and hatching, items that cannot be washed may be placed in a plastic bag for 2 weeks.

Unless there is known resistance in the community, the first step in treatment is permethrin 1% or pyrethrins which are available over-the-counter. Permethrin 1% is the most studied and the least toxic of the pediculicides (lice-killers). Conditioners and silicone-based additives will interfere with permethrin, as will vinegar which is often used in an attempt to loosen nits from the hair shaft. When rinsing off pediculicides, use a sink instead of a shower or bath in order to reduce skin exposure. Using warm instead of hot water will minimize absorption. There are many other prescription medications that can be used if these over-the-counter products fail.
For those who cannot afford or who would prefer not to use pediculicides, wet combing or using suffocation methods can be attempted. An example of suffocation would be applying petroleum jelly to the hair and scalp and leaving it on overnight under a shower cap.

Misapplication is the leading cause of treatment failure. No treatment will kill all the eggs, so retreatment at specific intervals is recommended. Shaving, although effective, is not recommended. Any product that is meant to loosen nits can also damage the hair itself. Acetone, bleach, vodka, and WD-40 do not loosen nits. Please do NOT use kerosene, gasoline, or any other such flammable or toxic substance. They are not effective; they are just dangerous. Do not use products that are meant for animals.

Infested kids should definitely get treated, but they should not be kept out of school. The chance of transmission may not be zero, but it is lower than in other settings where head-to-head contact is more likely. One study at a school where over 14,000 live lice were found showed zero lice in the classroom carpeting. In another study, infested people spread lice to pillowcases only 4% of the time. And remember, head lice don’t carry any diseases, unlike mosquitoes which transmit a large number of diseases.

Just to put things in perspective, dust mites (see photo) thrive in bedding, mattresses, carpets, furniture…anyplace where there are tiny flakes of shedded human skin. Their fecal matter is a leading cause of allergies and asthma exacerbations. They are much more insidious than lice, but they don’t keep kids out of school.

Dr. Tracy Lee
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

The New Rules for Head Lice: Part 1

On July 26, the American Academy of Pediatrics updated its clinical report on head lice. It is common in school-aged kids, and it can be found all over the world. It affects all socioeconomic groups, and it can affect anyone regardless of hygiene. Mere mention of it can cause itchiness. It seems that resistance to standard treatments is on the rise. And yet, the AAP is pushing for kids to stay in school despite having lice. What’s going on?

Head lice are tan to grayish-white, and they are 2-3 mm long. Their eggs are even smaller. Their life cycle is about 3 weeks long. They feed by sucking tiny amounts of blood. Sensitization to their saliva as they feed is what makes us itchy, but this can take 4-6 weeks to develop. This means that by the time the diagnosis has been made, a kid in school has already been around other kids for a month. The good news is lice can only crawl; that means that they can only spread by direct contact. They cannot jump from head to head. This is also why brushing your hair will not prevent you from getting lice; it will only reduce the number of lice you are infested with. You are better off not sharing personal items (like hats, combs, brushes, etc.), but this is NOT an excuse to refuse to wear protective headgear. Lice that fall off or are combed off are usually injured or dead. Live lice and nits need our body heat to survive, so they are found close to the scalp (within 4-10mm). Farther than that, live lice only survive up to 48 hours, and eggs cannot hatch.

Many cases of “lice” are actually misdiagnosed. Dandruff, hair debris, dirt, and other insects have been mistaken for lice. This adds to the number of “resistant” cases. School screenings and forcing kids to stay home doesn’t reduce the incidence of live lice. Instead it means lost days in education and missed work days for the parents.

So what are we to do? The AAP does encourage parents to check their kids’ heads regularly and whenever the kids are itchy. Especially after sharing sleeping quarters, like at a camp, child care center, or sleepover. Using a louse comb on hair that is wet (with water, oil, or conditioner) is the easiest way to go about it. Eggs are most easily seen at the nape of the neck or behind the ears. Remember to look close to the scalp!

Please check back tomorrow, as I'll talk more about what to do if you find lice in your child's hair.

Dr. Tracy Lee
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

Feeding your Baby: The Transition to Solids, Part 2

(This post is continued from yesterday's Part 1 segment)

So, when do you start your baby on solids? My advice is to watch your baby and see when he wants to start solids. It should not be until she has developed enough body and head control to be able to sit up in a high chair, but babies vary on when they can do this. It’s generally in the four to six month range. For my first daughter, it was at five months that she could sit in a chair, but she didn’t eat solids until six months of age. After your baby can sit up in the high chair, you’ll naturally start putting him there, likely with some toys on the tray, when you have things you need to do (like eat your own dinner!)

There will come a day when you see your baby watching the food make its way from the plate to your mouth with great interest. Then she’ll give you a look like “I’d like some of that!” This is when you need to convince him, at your next sit-down together, that what you were eating was mom’s milk (or formula) mixed with a small amount of rice cereal and "sure, you can have some." Just put a small amount in, and keep in mind that you want it to be runny at first, and the mixture will continue to thicken for a couple of minutes as the flakes absorb moisture. Put a small amount on a spoon and hold it up in front of baby. If she’s ready, she’ll lean forward and take the spoon into her mouth. If he doesn’t seem all that interested, it’s no big deal. The essential source of nutrition for a baby is human milk (or formula) from birth to six months, and from six months to one year, it’s still the major source for nutrition. You can try again later.

I do recommend starting solids by nine months, because by that time we’re talking about picking things up (like Cheerios) and learning to eat various things is an important part of brain development. Nutritionally speaking, a baby can do just fine on nothing but mom’s milk (or formula) until one year of age. Generally, everybody can’t wait to feed the baby, and I can recall only one time I’ve ever had to urge a mother to start solids with her baby at a nine month well child check.

Now, I just described using rice cereal mixed with human milk or formula because that’s been the most common first food advised over the past 40 years, and it’s what I gave my own kids. I should note, however, that not everybody agrees with this. Some feel that pureed meat should be the first food, because it is an excellent source of bio-available iron and zinc, for which some older babies have deficiencies. One thing is certain: do not give honey to a baby less than one year of age, due to the small, but real risk of infant botulism. If you’ve been nursing your baby, she’s been exposed to the variety of flavors that is in your own diet, so adding a little dried spice or herbs could be o.k., but don’t add salt or sugar to your baby’s food.

That’s all we have space for today — ask questions in the comment section and I’ll try to address them!

Dr. Julia Mason
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

Feeding your Baby: The Transition to Solids, Part 1

If you have a baby, you’re probably getting advice (from all corners!) on how to feed her. Everybody can agree these days that mom’s own milk is the best food for babies, but after that, there can be a lot of confusion. I’m going to focus today on the transition from human milk or formula to “solid foods.”

Some new parents are being advised by relatives that they should start the baby on solids, (which usually means baby rice cereal) basically, as soon as possible. This may be because several years ago mothers were actually being advised by their pediatricians to start rice cereal at earlier and earlier ages. The hope was that adding rice cereal to the bottle (and that’s what we’re talking about, because a typical baby less than four months old is not going to slurp food off a spoon) would help the baby sleep through the night, or eat less often, or have less spit-up. This advice is no longer being given, except by the well-meaning grandmothers who are passing on what they were told. Still, you can find “infant feeders” in the baby section of stores which are basically just bottles with an extra large hole in the nipple, to allow the thicker cereal mixture to come through. (Just because something is sold in stores doesn’t mean it’s a good idea to buy and use, even with baby supplies.)

Giving a baby solid foods early is not going to make him sleep through the night at a younger age. Babies do tend to sleep longer periods of time as they get older, and they start solids when they get older, but giving solids to a three month old is not going to turn her into a seven month old. Babies sleep through the night when they sleep through the night (and you should know that the technical definition of this is "greater than five hours of sleep," not the eight hours you’re dreaming of). There are things you can do to encourage this behavior, but that will have to be the topic of another post. Feeding solids to a baby less than four months old is not going to get them to sleep for longer periods. It may help with spitting up, but I wouldn’t advise it unless the problem is severe. It will lead to weight gain, and I think we’ve all figured out that this is not necessarily a good thing. For many babies, rice cereal will cause constipation.

Visit again tomorrow for part 2, when I'll discuss the appropriate time to start the transition to solids.

Dr. Julia Mason

Pediatric Hospitalist

Meriter Hospital

meriterkids.com

The Importance of Vaccinating Parents and Siblings to Protect Babies

“Whoop” This is the awful high-pitched inhaling sound people can make after a burst of coughing associated with pertussis. This sound is what gives it the common name: “Whooping Cough.” It has also been called the "100-day cough" due to the duration of the cough.

For adults, getting a case of whooping cough is annoying and sometimes painful given the severity of the cough, but usually only slightly worse than the common cold, especially early on. Many adolescents and adults don’t even develop the stereotypical “whoop.” For children, especially infants, this illness can be deadly. 85% of the deaths associated with pertussis occur in infants less than 3 months of age.

The good news is that we have a vaccine for pertussis. Fortunately, there has been a dramatic decrease in the number of pertussis cases since the introduction of the vaccine in the 1940’s, but we continue to see outbreaks every couple of years. Currently, California is experiencing an outbreak and there have been cases in Wisconsin as well.

The vaccine is given in a combination vaccine with diphtheria and tetanus, usually at ages 2, 4, 6 months, 12-18 months and 4-5 years. The vaccine is not fully effective until 3 doses are given, so children that are less than 6 months are at higher risk of getting the illness. Teenagers and adults tend to be those that spread the disease, because their illness is not as severe and many do not even know that pertussis is what is causing their illness. They also have waning immunity from the vaccines they received as a young child. Fortunately in 2005, a booster vaccine was developed.

This vaccine should be used in place of one tetanus booster. It contains tetanus, diphtheria and acellular pertussis (Tdap). Anyone that is around small children, especially new parents, should make sure they have received the Tdap vaccine. It is recommended that any new mother that is not immunized should receive it during the immediate postpartum period. If she is around children less than 12 months old during her pregnancy, she should receive it during the pregnancy.

If you have questions about your or your child(ren)’s immunization status, please be sure to discuss them with your primary care provider.

Dr. Dana Johnson
Pediatrician
Meriter McKee
3102 Meriter Way
Madison, WI
608.417.8388
meriter.com/pediatrics