Bed-wetting

Nocturnal enuresis, otherwise known as bed-wetting, is something that many patients and families have to deal with. More than half of the bed wetters are boys. To give you a sense of numbers and make you not feel so alone, 15% of 5 year olds still wet the bed; 5% of 10 year olds continue to have issues of staying dry at night. Most of the persistent older bed wetters will grow out of this by puberty without any intervention, but hopefully you don’t need to wait until your child is a teenager to get this resolved; that is the purpose of this post.

There is definitely a genetic tendency at work. Unless on-line dating has taken it to a new level, history of bed-wetting is typically not a subject that comes up on the first date, but now it is worth knowing if one of the parents had the same issue. For those of you washing the sheets every night for your twelve year old, please keep in mind that there is a reason that most camp forms ask about bed wetting. This is not an uncommon situation. The goodnight pull-ups come in such big sizes because there are plenty of older kids needing them

If a child had been dry at night and the bed-wetting is new, check in with the doctor to make sure there isn’t something else going on. This post is referring to patients who have never consistently been able to stay dry through the night.

This can be a really frustrating issue and there are many opinions about how to deal with it. Wetting the bed should not a punishable offense. Waking up wet and feeling loss of control is punishment enough. It is not okay to humiliate your child. Having your child begin to accept some responsibility however, is not a punishment.

The natural consequence for having a wet bed is to be part of the clean up team. Perhaps your child can be in charge of stripping the wet sheets off the bed. Let them be part of the solution rather than being the cause of the problem.

Until your child has shown that they can be dry at night, I would have them in special nighttime pull ups and make sure you have waterproof pads on the bed. Expecting dry sheets before your child has shown they are ready is just going to be aggravating for everyone.

There are some basic considerations and common sense approaches to start with.

The very first thing is to figure out if there could be any constipation issues. (click here for a link to my previous blog post)

Once the kids are out of diapers and off at daycare or school, many parents lose track of the kids bowel habits. Are they pooping daily? Do they have to sit for a while before the poop comes out. Does it come out in hard little pieces? Constipation is a huge factor and is your first step to eliminating bed-wetting issue. Often times, kids are found to be constipated even if they are pooping once or twice a day and the poops seem normal. According to Anne, the wise and wonderful nurse at the UCSF Continence Clinic, this may be because the kids don’t always take the time to get all of the poop out. When we end up sending patients to the continence clinic at UCSF to treat the enuresis, they start off by cleaning almost all of the kids out with a combo of Miralax and sometimes suppositories.

Other common sense steps include  having them better hydrate during the school day. Some kids are “camels” at school and don’t drink. Talk about what the fluid options are. Is there an accessible fountain? Do you send something to drink with their lunch?

Recommended fluid intake for children is measured by weight:

<2 year/<10 kg        30-35 ounces/day

2-5 years/<20 kg     40-50 ounces/day

6-12/<50 kg             50-60 ounces/day

Teens                      60-70 ounces

While we want to bump the fluids during the day, it is time to start  limiting fluids after dinner. Consider taking your child for a “dream pee” before the adults go to bed.

Often you can walk your sleepy child to the bathroom without having them fully wake up. If these "twilight trips' to the bathroom appear to be  disrupting their sleep cycle, see if you can adjust the timing.

If they are impossible to rouse enough to get to the bathroom without you practically carrying them, Dr. Schwanke would suggest that this is a big sign that they aren’t ready yet.

Let's give that bladder some exercise. The continence clinic does not generally recommend “kegels”  exercises for their patients, but once in awhile it is okay to have them practice starting and stopping the urine stream if they can. Another activity is to see if they can hold the pee for a couple of moments when they first realize that they need to go. Without good relaxation of the perineum, children are unable to empty their bladder completely. Try to teach your child to relax when they are peeing. One way to do this is to have them give a big sigh. Sighing is a normal relaxation trigger.

If none of the above actions has made a difference, it is up to you when you want to stage an intervention. I usually wait until your child has expressed readiness to tackle this. Dr Kaplan says that in her opinion, once the kids are old enough to read, they are old enough to be dry at night. She gives her patients a little talking to and tells them that they are in charge of telling that good brain of theirs that they need to not pee at night. She claims a degree of success!

Sometimes, once they are old enough for summer camp or sleepovers, kids are more invested in a cure. If they don’t care one way or the other, you can increase their role in the clean up, but until they are an active and motivated part of the team, I would wait a bit.

Once you are ready to intervene there are several options.

Some of my families have had long lasting success with the bed-wetting alarms. There are several on the market. Here is an email that was sent to me from a mom who wanted to share her experience"

"We purchased a Chummie bed-wetting alarm (along with an extra sensor so we'd have two of those) and I read a really helpful book called "7 Steps to Nighttime Dryness" (by Renee Mercer) which I read through quickly and highly recommend.  

Some takeaways from the book:

-- kids who wet their beds after age 6 likely will benefit from an intervention (like a bed-wetting alarm, which is the most effective intervention available) WHEN both the parents and the child are ready to take the time and effort to do so and are willing to have the disruption to their sleep (which can be tough on everyone).

-- When first starting use of the alarm, parents need to respond promptly when the alarm goes off to scaffold the learning process for their child -- i.e., they'll have to help the child wake up and get to the toilet to start developing and patterning that behavioral response.  Slowly, over a period of time (12 weeks total on average), the child's body will start to learn to wake up when their bladder is full and they'll be able to get themselves to the toilet... until eventually their bladder learns to hold urine until the morning.

-- The author recommends using a chart to track progress. This helps you see and feel a sense of progress, which is helpful to everyone involved.  For example, at first our son would pee heavily twice each night (those wake-ups every four hours reminded us of our prior sleep disruption patterns when we had a baby!)... then it became lighter pees since he started to stop himself mid-stream and would get the rest into the toilet with our help... and then he would pee once per night lightly, and so on until he was dry and slept through the night without disruption.

-- Once your child consistently has dry nights for 2 weeks straight, you wean them from the alarm for another 2 weeks by using it every other night.  This weaning leads to the most effective long-term results.

Before starting the alarm intervention, I had imagined in my head that perhaps our son's bladder got full while he was sleeping, his bladder communicated its fullness to his brain, but he didn't wake up to respond properly so he simply would pee while sleeping.  The alarm helps that transmission of info work properly.

Our experience:

Our son was highly motivated to stop wetting the bed, so we decided to try this alarm approach to see if it might help him.  At bedtime, our son put on his undies, taped the sensor to the outside of his undies as instructed (so the alarm goes off when the sensor starts to feel pee), and then he wore a pull-up outside of all that (so we didn't have to change his bedding a gazillion times).  Our son's first dry night happened 3 weeks into the alarm intervention (although we had forewarned him that it would take 12 weeks so his expectations were realistic).  At 3 weeks, for a few nights he was dry every other night, and then he was miraculously dry every single night from thereafter.  We continued with the alarm for another several weeks and did the weaning process and he has been dry ever since (we first used the alarm 3/26 so it's been 2 months. Woohoo!).  We are thrilled and surprised since he is such a deep sleeper and always has peed at night.  He was a quick-results case, which we were not expecting.  It feels like the alarm kind of magically connected a synapse that wasn't there before!

We used a weekly chart to track his progress.  We used tiny reward stickers both for cooperation (in the "good determination award" cell) and for "dry night" (the latter obviously doesn't happen for a while so it's nice to feel rewarded for at least trying.)"

There is no medication that cures enuresis, but there are some medications that can address the symptoms. The most commonly used is DDAVP. This is a prescription approved for children over 6. It comes as a  tablet. It used to be available as a nose spray but that has been discontinued due to side effects.

When the drugs are stopped, the bed-wetting usually returns unless the child has naturally outgrown the condition. It is nice to know that this possibility exists for use on an intermittent basis such as an overnight or summer camp.

Please note that even when you feel like you have successfully put this behind you, it is possible for mini relapses to occur with little illnesses or increased stress.

​

Night Terrors/Update with new treatment option

Night Terrors/Update with new treatment option 5/16

Night terrors rank up there with things that are pretty horrible for parents, but ultimately usually not dangerous. If you want to practice your Latin, they are also known as Pavor Nocturnus. These are not your typical nightmares. Your child might wake up screaming and thrashing. They may be sweating, wide eyed and terrified. Their hearts are racing. They seem frantic but you can't calm them down. No one is going to sleep through this. Except your child. They seem awake, but they won't remember a bit of this.

Your job is simple. Keep them safe until this passes. Of course there are some conflicting opinions about how to handle these. If your child is small, I have found that it is helpful to try to swaddle them with a big sheet. Think straight jacket! Hold the sheet wide and try to wrap around the thrashing arms until they are snuggled tightly. Sing quietly until they are calm. If you can't manage that, just make sure they don't hurt themselves until it is over. These rarely last longer than 20 minutes. Bigger kids might get even wilder if they feel restrained so see if you can put a comforting hand on them, but mostly you are just being present.

If your child is toilet trained, see if you can manage to walk them to the bathroom and have them pee. Believe it or not, that might settle them down.

Pediatric night terrors happen to between 1-6% of kids. The typical age range is 3-12 years of age. There seems to be a genetic component. If you put your parents through this yourself, it is payback time. I think I may have had a few younger patients over the years that had bouts of these, but with really young infants, a sudden wake up is more likely from gas pains or something illness related.

These tend to happen in intervals and you may have days or weeks with frequent episodes and then they go away. It is worth trying to figure out if there is some extra stress or changes going on. Are they on any new medications? Any change in their diet? Lots of extra sugar perhaps? Are they overtired? Have they been watching any over-stimulating videos, movies or games (if they are in the room when an adult is playing or watching something, that counts)? If night terrors are happening on a routine basis and there is no obvious cause it is worth having them checked out by their physician. Some kids who are plagued with these for an extended period might have sleep apnea at the root of the problem.

Unlike dreams or nightmares, night terrors do not occur during the REM sleep. They usually occur during a phase of the sleep cycle that comes about 2-3 hours after falling asleep. If you are going through a stretch where you dealing with them nightly, some experts suggest breaking the cycle by waking your child about 15 minutes before they routinely occur (this would be a fine time to walk them to the bathroom for a "dream pee.") This assumes that you are on a regular bedtime routine and the terrors are happening roughly at the same time nightly.

Take comfort in knowing that extensive studies have found absolutely no correlation between kids with night terrors and an increase in occurrence of psychiatric disorders.

NEW INFO

A new product came on the market in 2016, called the Lully Sleep Guardian. This is the first device scientifically proven to stop night terrors. One of the founders of the company grew up with a twin sister who suffered from these. He understands as well as anyone how disruptive they can be.

https://www.lullysleep.com/

Vicks VapoRub on the feet (update)

I saw an interview recently where a well respected pediatrician completely dismissed the value of any natural remedies. He didn't believe in doing anything for his patients that wasn't completely "science based". In his practice, coughs just have to run their course.

He and I wouldn't get on very well. I love science too, but in my  years of practice I have seen many people feel quite a bit better from reaching for some alternative solutions. As long as they are benign and not taking the place of necessary prescribed medication, I love to see what relief can be achieved without standard medication. This post is all about one of the odder things I have tried. It seems to help!

Seasons come and go. Occasionally I find something that seems to work well for patients, but then the illnesses quiet down and I don’t think about it much. With all the never ending coughs plaguing my patients and families, I recently added a link in the “what’s going around section”. The link was to one of my earliest posts about the benefits of putting Vicks Vaporub on the feet. Several dozen folks clicked through and followed up with feedback that this seemed to be the difference maker. The kids had much quieter nights without nearly as much coughing. With cold season in full force, it seems like it is worth updating and re-posting.

The internet is a minefield. It is a goldmine of valuable information. Unfortunately, it also has the power to terrify unwitting folks who go online to look up symptoms or whatnot.

Most wise folks know enough to realize that the good information is muddled up with loads of crap. It is hard to know what is real. Therefore, when I got an email several years ago touting the magic of applying Vicks VapoRub to the feet to stop a cough, I promptly dumped it into my spam. Frankly anything that tells you that it works 100% of the time is 100% false (have fun with that statement!) But then a variation of the same email came to me again and I thought it might be fun to see if there was any merit to it.

The claim is that covering the soles of the feet with the VapoRub and then putting socks on is very helpful for coughs. I am always looking for safe, natural remedies to help relieve symptoms of colds and coughs for my patients without loading them with systemic medications. So, several winters ago I set out to do a completely unscientific study.

While talking to the hundreds of my Noe Valley Pediatric parents who were trying to relieve the coughs that were keeping their kids up at night I enlisted them to give the "Vicks on the feet" a try. I asked them to report back.

To my surprise, well more than 50% of the folks who tried this seemed to find that it was quite helpful; imagine that! Even Snopes doesn't completely debunk it; just labels it as unproven. No one who tried it had any ill effects. I occasionally completely forget about this, but someone asked me about it the other day. With the colds and coughs out there in full swing, this might be something you want to try.

Before applying anything topical, it is important to make sure you or your child do not have a reaction. Place a small dab on the leg and rub it in. If there is no irritation within 30 minutes or so, you should be fine. (I do this same test with a new sunscreen.)

 Folks ask about the difference between the adult and the baby Vicks. I think that either is safe for the feet. If you happen to have only the regular Vicks in the house, feel free to use it. If you are going out to the store and you have options, go ahead and get the baby version.That is especially preferable if you are going to put in on the chest as well as the feet.

Along with the Vicks, don't forget about steam, sinus irrigation and keeping heads of beds/cribs on a slant.

If you have an infant who is under 4 months of age with a cough that is keeping them up or interfering with their eating, they need to be seen.

If the cough is lasting more that a couple of weeks it is probably worth a listen.

Any significant shortness of breath needs to be evaluated.

Tis the season and we are seeing loads of coughs and colds out there, so if you or your family members are hacking away, unfortunately you are running with the pack.

I still do love getting feedback, so if the Vicks works magic, let me know!!

One of my mom readers who is also a physician shared the following warning from a physician reference called Up To Date and it is certainly worth adding to this post.

Approximately 11,000 pediatric camphor exposures are reported to United States poison control centers annually [2]. Exploratory ingestion of camphor-containing products by children younger than six years of age is most common, accounting for about 80 percent of exposures. Toxicity from topical absorption of camphor is less common than from ingestion but has been described after application of unlabeled camphor oil in a four month old infant [4] and copious application of a labeled topical ointment hourly for 10 hours in a three year old child

With anything, please use common sense child proofing precautions and don't leave your kids alone with  anything that they can ingest.

I remain confident that the ingredients in Vicks, when applied topically are quite safe.

Nurse Judy

Zika Virus

Please see updated post on 2/2017 with current Zika updates

This week we received a health advisory from the public health department regarding the Zika virus. There are 3 categories of announcements from the health department:

• A health update  provides us with updated information regarding a situation; these are unlikely to require immediate action
• A health advisory may or may not require immediate action
• A health alert conveys the highest level of importance and does require immediate action

You may have heard about it on the news, in between stories about snow storms and absurd politics. As expected the questions are coming in:

-   Is there concern about breastfeeding mothers and Zika?

-   Are there any particular concerns for children getting the virus?

-   The CDC site says the virus leaves the blood after a week. Are there concerns for possible future pregnancies?

Here are some Zika factoids:

Zika virus was first identified in 1947 in a rhesus monkey in Uganda's Zika forest (which gave the disease its name.) For decades Zika was a virus that turned up in monkeys and occasionally in humans in Africa and southeast Asia. Its symptoms were mild and the number of confirmed human cases was low.

This virus is on the rise. Until now, almost no one on this side of the world had been infected. Few of us have immune defenses against the virus, so it is spreading rapidly. Millions of people in tropical regions of the Americas may have recently gotten it.

Zika virus is spread to people through mosquito bites. The most common symptoms of this disease are fever, rash, joint pain, and conjunctivitis (red eyes). The illness is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon. Only about 1 in 5 people infected with Zika virus even become symptomatic.

The nasty type of  mosquito responsible for Zika,  also spreads dengue virus, yellow fever virus and Chikungunya. Mosquitoes that spread Zika virus bite mostly during the daytime. My general  warning to be especially careful to avoid mosquitoes during dusk and dawn doesn’t offer any protection in this case.

Just as with malaria, people are the source for spreading the virus. A female mosquito bites an infected person and then can carry the virus to the next person she bites, so when people travel, they can bring the virus with them. They are thought to be infectious the first week only. The virus can take hold if enough people become infected for it to become endemic, meaning it's in a region permanently.  Mosquito bites and mother to unborn baby aren't the only ways this virus is transmitted. The new CDC report notes documented cases of infection from sexual transmission, blood transfusion and laboratory exposure. To date there are no confirmed cases of mothers passing the virus to the baby through breast milk. Either way, the benefits of breastfeeding way outweigh the risk and exposure would not be a reason to stop nursing. People infected with Zika virus don't infect one another through casual contact.

There is no vaccine or specific antiviral treatment available for Zika virus disease. Treatment is generally supportive and can include rest, fluids, and use of acetaminophen for fever and/or discomfort. Because of similar geographic distribution and symptoms, patients with suspected Zika virus infections also should be evaluated and managed for possible dengue or Chikungunya virus infection.  People infected with any of these illnesses should be protected from further mosquito exposure during the first few days of illness to prevent other mosquitoes from becoming infected and reduce the risk of local transmission.

Zika has a few especially  frightening aspects. There seems to be an alarming rise in Guillain-Barre syndrome that is probably related. This is a nerve disorder that causes muscle weakness. Most people recover in a few weeks, but severe cases can require life support to help with the breathing. Anyone of any age can get Guillain-Barre, although it is pretty rare. It is thought to be triggered from an infection. The scientists are actively studying this possible link.

There is also a probable connection between birth defects and pregnant women infected by the Zika Virus. In Brazil, where most of the reported cases seem to be, there have been many babies born with microcephaly (small heads) and the associated significant health issues. The most dangerous time is thought to be during the first trimester – when some women do not even  realize they are pregnant. Experts do not know how the virus enters the placenta and damages the growing brain of the fetus. Some countries are so concerned about this that they are suggesting that no one get pregnant until they have a better handle on controlling the spread (good luck with that!)

Okay how does all of this impact you? If you have not been traveling lately and have no plans to travel this should have little or no impact on you. If you have recently returned from a trip to any of the Zika hot spots AND have any illness symptoms, make sure that you share that info with your doctor or nurse. If you are pregnant and may have been exposed, contact your OB as soon as possible. Testing must be coordinated with the local health department and would only be done for someone who has been in one of the impacted areas and is showing symptoms.

If you have an upcoming trip planned, keep in mind that until there are firm answers, the CDC has issued a travel advisory to pregnant women to avoid traveling to any countries where the Zika virus is rampant. If travel is not optional, strict mosquito avoidance is essential. Keep body parts covered, use DEET or other mosquito repellents according to the labels. Stay indoors with screen protection as much as possible.

http://nursejudynvp.blogspot.com/2015/10/mosquito-biteswest-nile-virus.html

The good news is while it's not certain, scientists believe once an individual has been infected with the virus, they are immune and won't become infected again.There is currently not concern for future pregnancies.

For up to date information on which countries are impacted, check the CDC website:

I

http://www.cdc.gov/zika/

Cradle cap/Nurse Kenlee's tips

Cradle cap is one of those things  that we get calls about on a regular basis. I was amazed to find that Nurse Judy had not yet tackled the issue in one her blogs.  I asked if I could give it a shot and she agreed, so here we go!

Cradle cap, also known as infantile or neonatal seborrhoeic dermatitis, crusta lactea, milk crust, or honeycomb disease is a yellowish, patchy, greasy, scaly and crusty skin rash that occurs on the scalp of recently born babies. The cause is unknown but most doctors believe it is hormonal and is related to an abnormal amount of oil in the hair follicles. It is common to see cradle cap on the scalp but can occur anywhere there is hair growth, such as eyebrows, eyelids and armpits. It usually occurs within the 1st few months of life and can continue until around 1 year old or until they get their hair.

 Pediatric dermatologist, Dr. Sorrell of Lucile Packard at Stanford advised to use plain mineral oil (found in constipation aisle) daily to area. Use a soft toothbrush or baby brush to gently brush away the scaly skin. If this does not work, try using a mild topical hydrocortisone cream 1% twice daily. Also, use a liberal amount of Vaseline to scalp to lock cream in. Yes, your child’s head and hair will look greasy but it will improve the cradle cap. If scalp is still resistant, talk to your doctor about adding an antifungal cream, stronger steroid or getting a dermatology referral.

Natural approaches that many people have luck with include massaging pure natural oil into the scalp such as coconut oil or olive oil and letting it soak for about 15 minutes per day prior to washing head. After shampoo, gently brush scalp with a soft bristle brush or cloth to remove loose, dead skin. Also, a baking soda rub overnight was reported to help a few patients. On occasion, for stubborn cases, Dr. Kaplan may suggest an OTC dandruff shampoo such as Selsun Blue or Head and Shoulders.

Of course if at any point the dryness spreads beyond the scalp, the scalp becomes inflamed, painful or starts to bleed; you should notify us right away. Bottom line from Nurse Judy, if you child seems bothered from the condition in any way, check in with your doctor.

While working in the emergency room, cradle cap was not a common complaint but I did see it from time to time and knew that it was normal, harmless and no treatment was really required. Then along came my daughter who stayed bald until right before her 1 year photo shoot. As her hair grew, her head started to get flaky.  I initially thought I must have let my poor baby’s head get sunburn and it was peeling. After crying with mommy guilt to Dr. Hurd, she assured me, it was cradle cap and I started my home remedy of coconut oil massages. However, no one ever warned me that as the skin peeled off so would clumps of her new beautiful hair!

I swore that she must have had alopecia but she is now a 21 month old beauty with a full head of wonderful blonde hair.

Parapertussis/Whooping cough's milder cousin

What is parapertussis? It is annoying for sure, but it isn't quite as scary as it sounds.

Bordetella is a bacterium best known for whooping cough in humans (B.pertussis) and kennel cough in dogs (B.bronchiseptica). B. parapertussis is a lesser known member of the family. It is estimated that 1%-35% of known Bordetella infections are caused by B. parapertussis. Because only a small percentage of patients actually ever get tested, these are tough statistics to get accurate. To compound the challenge of data gathering, parapertussis is not one of the diseases that mandates reporting it to the public health department, so it really is tough to have a real sense of numbers.

The nastier cousin, B.Pertussis is making the rounds. Because it is currently active at some local San Francisco schools and daycares, several of our coughing  patients have asked to be tested. A number of those results came back negative for pertussis (fortunately), but  positive for parapertussis. The PCR test done to rule out pertussis tests for both. (It is actually possible for folks to have both illnesses at the same time, how unfair is that?!)  Parapertussis has some distinct differences. It is very similar to regular pertussis but not nearly as severe or long lasting. One main difference is that parapertussis does not produce the pertussis toxin which is responsible for some of  the more severe symptoms.

With parapertussis, patients can still have the prolonged cough, (with characteristic coughing fits) and vomiting but we are talking about 3 weeks instead of 3 months. This is a fairly variable illness; up to 40% of patients with it can be almost symptom free.

Just as with Pertussis, we are more concerned about infants younger than 6 months, or someone with an underlying health condition or compromised immune system.

This month our patients who tested positive were all fully vaccinated, and that makes sense. While the whooping cough vaccine gives about 80-90 % protection against pertussis to folks who get it, it does NOT protect against parapertussis.

Just like pertussis (and the common cold), parapertussis  is transmitted from coming in contact with respiratory secretions.

The incubation period is also similar to that of pertussis. This is measured from the time someone was exposed until they come down with the illness. Most commonly it is 7-10 days, but it can be as short as 5 days and you can’t really count yourself as out of the woods until at least 21 days have past since the exposure and no symptoms have presented.

A patient is infectious (they can spread the illness and make someone else sick) from a day or so before showing the first symptom until up to about 3 weeks after the beginning of the illness. If treated, a person is still considered  contagious until they have finished a 5 day treatment.

There are not really any official guidelines for managing the illness. Basic symptomatic treatment measures such as steam, fluids and rest will help get you through. Certainly if the patient is less that 6 months old, or in close contact with a young baby or someone high risk, they should get treatment as soon as possible. The standard treatment is five days of Azithromycin. Remember that patients are considered contagious until they have completed the course.

For the older, lower risk patients, should we treat? The limited studies that are out there suggest that treatment that is initiated within the first 6 days of the onset of the symptoms may possibly help get the patient better faster. Another benefit of early treatment is that it can minimize the spread.

Prophylactic treatment, to prevent the disease in someone who was exposed but isn’t sick yet, is worth considering for high risk contacts, if started within 2-3 weeks of the exposure. Most experts agree that starting prophylaxis more then 3 weeks after the exposure is probably of no benefit.

But in most cases, it isn’t that simple. We don’t tend to bother seeing patients unless they have a cough that is really troublesome or lingering; we couldn’t possibly bring everyone in the minute they start to cough. The other issue of course is that nobody wants to overuse antibiotics. With pertussis and parapertussis, the illness often starts for a week or so with a mild cold before the coughing begins.By the time we recognize that we are dealing with parapertussis, the reasonable window for treating may already be passed.

I do have my antenna up for any illness that has coughing spasms. Many of these patients seem fairly well, until a coughing fit hits. Often there will be vomiting from coughing so hard. There may or may not be a characteristic whoop.

Here is the question many of you are asking: Can they go to school? Officially parapertussis is considered a mild but irritating illness. It is not a reason to keep them home. Keep in mind that people are contagious a bit before they have flagrant symptoms, so we have to exercise a bit of common sense here. Someone who was at school on Monday and starts coughing on Tuesday has already exposed all of the classmates. They also likely picked it up from a fellow student. Keeping them home if they feel fine and have no fever makes no sense. If you have a child who is miserable, feverish, poor appetite, poor sleeping, with labored breathing, that child should not be at school. Likely they need to be seen by the doctor!

Even though school and normal activities are fine, please be cautious about letting your coughing child be around any vulnerable newborns. I recognize that siblings present a uniquely complex issue. It is usually not reasonable or even possible to try to quarantine them for weeks.

Check out the links below for help with symptomatic treatment

Pertussis review

vicks vapo rub on the feet?

humidifier vs vaporizer

colds/coughs review

Cord care

Cord care

 

 

Before birth, the umbilical cord is the connection between the baby and the mother through which the baby receives nourishment and oxygen. After birth it becomes useless. By the time the baby is several weeks old, this is something you will likely never think about again, but right after birth it deserves a bit of attention.

 

You may have heard of cord banking. Cord banking is a trend that comes in and out of fashion. The idea is to save your baby’s stem cells as an insurance policy in case there is a future medical need. In theory it is great. Unfortunately it is very expensive and it is hard to predict if the bank you choose will still be around in the future should you need it. At the time of this post, very few of my patients opt to do this, but it is worth checking to see if there are any updates.

 

The optimal timing for clamping the umbilical cord after birth has also been a subject of controversy and debate. There is a current trend to delay clamping for a few minutes after birth.  It is best to discuss this with your OB ahead of time. The important thing is simple that the baby is tended to. If everything is stable, by all means, delay the clamping for a moment or two. If for some reason the baby needs attention, the clamping is done immediately, and you don’t get that extra time, please don’t focus on this as something to fret about. I imagine your baby's chances of becoming president one day won’t hinge too closely on how quickly they got their cord clamped!

 

Whenever it occurs, the umbilical cord is clamped and cut close to the baby's body. There are no nerves in the cord, so this is a painless procedure.

The cord clamp should be removed prior to leaving the hospital. It is a good idea to double check. I have occasionally seen newborns discharged with the clamp still on. Once the clamp is off, an umbilical stump remains attached to your baby's navel.

 

There is not much you need to do to care for it. Often, the less you fuss with it, the sooner it will fall off. It tends to fall off between 7-17 days (not everyone follows those rules.) At some point it will be hanging by a thread and you will see who the lucky person is on diaper duty when it finally comes off.

 

There are newborn diapers that have the little cutouts that are very useful. This helps you avoid having the cord rubbed and irritated. Hopefully you won’t need more than a few boxes of those. If you have a larger baby who is too big for size one, just roll down the diaper to avoid rubbing.

 

We want to keep the area dry so no actual submerging the baby in a tub until it falls off.  Sponge baths can get the job done. Yes, babies get some pee and poop on there, don’t freak out. Just clean it as best as you can. If the cord gets a foul odor (trust me, you will know if it is smelly or not) call your pediatrician to get it  checked out. A stinky cord can be a signal that the baby has an infection (called omphalitis.) The docs will do a good cleaning and get in there in a way that the parents often aren’t comfortable doing. If needed, the doctor may apply silver nitrate. This is a chemical that cauterizes the area. That will leave a grayish/black discoloration around the area that may take a few weeks to fade. It may take more than one application for the cord to be healed.

 

Once in a while a small piece of the cord stays in place. This is called a granuloma. If the baby is acting perfectly fine in every other respect, there is no need to rush in, but your doctor will want to take a look if things are not healing up. A persistent granuloma will usually need attention.

 

Once the cord is off, it is normal for the area to continue to ooze a bit for another week or so. It is quite common to have a bit of green or yellow stain on the diaper or shirt. Sometimes there is also what looks like blood. Unless there are actual drops of blood coming from the cord, I am not concerned about little staining. At this point you can clear around the area with a bit of alcohol and a dab of Neosporin.

 

Another thing that parents might call  about are umbilical hernias. An umbilical hernia occurs when part of the intestine protrudes through the umbilical opening in the abdominal muscles. Umbilical hernias are common and typically harmless. They are most common in infants, but they can affect adults as well. In an infant, an umbilical hernia may be especially evident when the infant cries or strains causing the baby's belly button to protrude. This is a classic sign. Some of these are as big as golf balls. Usually this resolves on its own. As long as you can gently push the belly button back in, it is not a concern. If you have an inconsolable baby and the area seems to be stuck on the outside, that would need an immediate evaluation.

 

Before you know it, that cord will be off and most likely you won’t be giving much thought about your kid’s navel until they are teenagers and begging for permission to get it pierced. (It is also quite possible that when they turn that C in geometry into an A you will reluctantly give your blessing, as we did with our daughter Lauren!)