Colds, Coughs and Congestion: when to worry. How to treat

 My grandson Coby is currently 10 months old and has a pretty constant runny nose. My daughter Lauren actually suggested that we work on this topic and call it, “Will I ever be healthy again?”

There are lots of colds going around. Dr. Ted and I are both fielding questions from friends and patients about kids who are frequently snotty and appear to be getting one thing after another.

We are right in the peak of the respiratory illness season. While it is never wrong to get tested for what’s causing a cold, it is generally more important to focus on the symptoms instead of a specific diagnosis.

Our primary goal with this post is to give some guidelines to help you figure out when a trip to the doctor's office is indicated. Many times, there is nothing to do but wait it out, so we are including some tips to help you and your child get through the illness as comfortably as possible. I have included standard treatments along with plenty of alternative options at the end of the post. I am comfortable trying some of the more natural approaches AS LONG AS you or your child are dealing with something mild. At the end I add some prevention tips.

Even if you don't have young children, colds and coughs can nail any of us. But if you are a new parent, buckle your seat belt. Studies say that most children will have an average of 9.4 symptomatic viral infections each year in the first two years of life. Think about that: if they’re clustered in the winter, that’s more than an illness every month. No wonder parents come in asking “will my child ever be well again?”

Most of the time the congestion is caused by a viral syndrome. Allergies and teething* can also be the underlying culprits.

{*Medical literature often disputes whether or not teething is connected to any symptoms, but I still maintain that at times it feels like it is an x in the equation.}

All that mucus is the perfect breeding ground for bacteria, which is why something that starts as a virus can turn into a bacterial infection. I have seen ear infections come on in a flash, riding the heels of mucous that’s backed up from the nose.

What symptoms do you need to pay attention to?

If you are dealing with a congested or coughing family member, consider the following questions. The most pressing concerns are listed first, and then go in order of decreasing importance:

Is there any labored breathing?

If someone is gasping for air and changing colors, stop reading this and call 911! This is on the top of the list because it doesn’t matter what else is going on. If there is any labored breathing or wheezing the patient usually needs be assessed. Grunting during an exhale or wheezy whistling sounds can indicate trouble.

When someone is working hard to breathe, respirations are faster and actually look different. You might see retractions, where it looks like the areas at the base of the throat, the sternum and between the ribs are actually sucking in. The nose might be flaring. The patient's color might be pale or bluish around the mouth. With young babies you might see their little tummies going in and out more than usual. Think about what your child might look like after running a baby marathon. It’s like that.

These kids that we are really worried about are never the ones happily running around and playing. They are low energy and look distressed.

Of course, simply noisy breathing isn’t always something to worry about (a congested nose can sound like a wheeze or a whistle), but it can be a clue.

Sometimes a big mucus plug may be momentarily blocking an airway, causing a minute of distress that clears with a big cough. If coughing and steam are able to clear things up, it is more likely that it is upper airway congestion which is not as much of a concern.

If you find that you are having a hard time assessing the respirations, try sticking your ear up to their lungs and see if you can hear anything. If you can hear nice clear swooshing air noises, that is great. If you hear whistles or squeaky noises, that may mean the congestion has spread down to the lungs. Using your ear as a stethoscope doesn’t always work; more than half the time you won't be able to hear anything, but once in a while parents are able to get some important clues from the "ear to chest" evaluation.

If your child is old enough to cooperate, have them take a great big deep breath, in and out.

If they are wheezy or have any inflammation in their lungs, that deep breath will often trigger a bit of a coughing fit.

It is a great idea to get a sense of what “normal” looks like. If you are lucky enough to be reading this when your child is healthy, lift up their shirt and watch them breathe for a minute or two. How fast are their normal breaths?

Check out the Tik Tok that Dr. Ted and I did. This was from our RSV post from a couple of years ago, but it is a really good illustration of what labored breathing actually looks like. A video is worth 1000 words.

(if someone had told me a few years ago that I would be doing TikToks, I would not have believed them.)

Knowing the actual oxygen level can be a good data point. There are oximeters available that can measure this. A number above 92% is generally considered adequate. Keep in mind that the oximeters out there that are available to consumers might not be as accurate on kids. With a little one, try using a toe instead of the finger. A low number might be garbage, so please don’t freak out. Remember: how a child looks is more important than a number from any device. If they have rosy cheeks, are running around and are smiling, we promise their oxygen is not truly below 86%. Remember, it is only one data point; one of the team members who summitted Kilimanjaro with Lauren and Sandy did so with a pulse ox of 70; that was his only symptom and he was fine.

Are they dehydrated?

If your baby is nursing well, that is very reassuring. We don’t get too worried if your child isn’t too interested in solid foods for a couple of days, as long as they are drinking. A sick child may not want to eat, but as Dr Ted often reminds his patients, they can technically survive up to 7 days without a single bite of solid food (although watching them temporarily lose weight drives parents nuts).

Hydration, on the other hand, is essential. If your child isn’t urinating 3 times per day, if they aren’t capable of making wet tears or have a dry mouth with cracked lips, you should call your doctor. Dehydrated kids are usually very low energy. There are hydration tips down below in the management section.

Do they have a fever?

Plenty of colds come with fevers. A fever that doesn’t go below 102 ninety minutes after the proper dose of medication, or a fever that is lasting more than 3 days should be checked.

More on fevers here.

How is their mood?

Anyone is going to be grumpier than usual if they have a cough or cold, but if your little one is really fussy and doesn’t have the language to tell you what’s wrong, I might suggest getting their ears checked to rule out an ear infection. Not all ear infections need to be treated, but it is worth seeing what’s going on in there. A dose of Tylenol or Advil usually makes a huge difference with the mood when a child is sick. If you have a miserable kid on your hands or if your child is still looking very out of sorts despite their fever being controlled, that might be a reason to get checked.

What’s the quality of their cough?

There are a lot of different coughs. Wet coughs, dry coughs, coughs that come in spasms, and coughs that are so forceful they can break blood vessels in the eyes. Not all wet and productive coughs need to be seen, nor do all of the frequent dry coughs. Here are some of the coughs that should be seen sooner than later. Coughs that:

• Are associated with respiratory distress (see above)

• Come with blood

• Cause repeated vomiting

• Break multiple blood vessels in the face or eyes

Are they sleeping well at night?

A cough that consistently wakes a child up from sleep is worth getting listened to. The congestion and coughing alone can be a reason that it is hard to sleep, but if the ears are an issue, ear pain is worse when your little one is in a flat position, so we would want to rule out an infection if you have more than one completely miserable night.

What color is the mucous?

We are more interested in mucus that is getting thicker and greener. Green mucus does not automatically signal a problem (green mucous signals length of illness time, not necessarily the presence of a bacterial infection); it is just one more clue. It is common for mucus to have more color when they first wake up and then to clear throughout the day.

How long has this been going on?

Most colds and coughs can last between 1 and 2 weeks but it is common for some coughs to linger for another couple of weeks before they are completely gone. It is also possible that they caught something new. Sigh.

A 6-week cough in and of itself is not a concern if it’s not getting worse.

It is okay to play the wait and see game if your little one is:

• Reasonably consolable

• Mucus is mostly clear (greenish in the morning that clears throughout the day is fine)

• Staying hydrated (drinking and peeing)

• Sleeping isn’t horrid

• No breathing concerns between coughs

• Fever controllable and lasting less than 72-96 hours

If your baby is less than 3 months we are often quicker to get them checked out.

Tell your doctor if there has been a recent exposure to Covid or another illness. If family or friends are having similar symptoms, that information will be useful.

Nurse Judy’s Management tips

Hydration is key! The best way to manage congestion at home is to make sure your little patient is getting plenty of fluids. This will help to keep the mucus thinner; it will also keep the mucus membranes moist, which in turn makes it easier for them to clear debris. It’s also the one thing they can’t go without.

With some older kids, cow's milk may not be the best choice because it can increase the amount of mucus (it doesn't impact everyone the same way.) I have plenty of patients who love their milk, and taking it away for a couple of days is not a reasonable option (without kids and parents having a panic attack). Relax, sometimes thinning it with a bit of extra water is a good compromise. Breast milk is the perfect liquid if you are lucky enough to have it.

Warm tea with honey (for kids over the age of one) can soothe the back of the throat and ease the coughing.

I am not a big ‘juice’ fan, but a splash of some juice into their water can sometimes be the magic that gets them to drink a bit more.

Perhaps make a sticker chart to incentivize sips.

For older kids and adults, don't minimize the value of chicken soup!

Steam is great. As we mentioned above, moist mucous membranes in the nose clear debris much faster. Hang out in the bathroom when anyone takes a shower. Running a humidifier or vaporizer at night can be very useful. Turn it off during the day and give the room a chance to dry out so that you don't grow mold. Make sure you change the water daily. And don’t forget to periodically clean the unit. As long as you follow those rules, I don't have a preference between warm or cool mist.

Keeping the head elevated makes a huge difference. Some of the younger babies will do best napping someplace where they are on an angle. This is fine as long as they are monitored. For night time, if you want them on a little slant, according to the new AAP guidelines it shouldn’t be any greater than 10%.

You can put saline drops or breast milk into the nose (and then suck it out with a nose frida. This is likely the best way to actually clear the nose. Your baby will no doubt hate this, but if you can manage to do it about ten minutes before a feeding, it may clear the nose up enough to make eating much easier.

I really like xlear nose spray. But I am realistic enough to recognize that it is the rare toddler who is going to cooperate with any drops or spray of any kind in the nose. If that is the case for you as well, try the AYR saline gel. When my grandson Elliot was younger, Lauren got creative and convinced him to ‘see if he could smell it’ and it worked well. Now he is four and actually likes the spray when he is in the mood. Don’t give up.

Some of my parents really like the Oogiebear nose and ear cleaners. These are safe, soft little plastic scoops that allow you to remove stubborn little boogies.

Consider acupuncture! One of our neighborhood acupuncturists gets some good results from her treatments for your basic coughs and colds. Her treatment of children often does not use any needles. She also has some Chinese herbs that can be very helpful. Find her at: The Acupuncture Den

Is there something I can give them?

The standard cold and cough meds that many of you grew up with are no longer recommended for children under the age of 6 years. If your kids are utterly miserable and are having an impossible time sleeping due to coughing and congestion, many seasoned pediatricians may recommend a dose of Zyrtec or Benadryl at night to help dry the kids up and give them (and you) a break. Before I would do that, I would want them checked out to make sure the lungs and ears are clear.

Homeopathic and Other Remedies

There are some homeopathic remedies. Boiron and Zarbees are two popular brands. They both have products that are safe for infants. Make sure that anyone under a year uses the appropriate formulation.

There is another product on the market that you likely haven't heard of. Dr. Loo, a local physician, has created a patch to treat the symptoms of congestion with chamomile and ginger.

Dr Loo Harmony Patches

These are safe for any age! Several years ago she gave me samples for my patients to try. In some cases, the parents reported that they thought they indeed seemed to help. In any case, they are not terribly expensive and there are no safety concerns.

For night coughs, without taking anything orally, you might try a bit of Vicks Vaporub on the feet! Trust me, I scoffed at that as much as anyone, until I asked my patients to test it out and was shocked at how much it seems to help. A little dab under the nose can also sometimes help clear things up. Do NOT place it inside the nostril.

Prevention

For parents and big kids I really like

• Sambucol

• zinc lozenges.

• Ester C

I have heard folks consider these to be placebos, but in my case I say "bring it on" because they seem to work.

Remember that I used to work in what could have been considered a veritable germ factory and (knock wood) I usually managed to avoid many of the things I was exposed to. The second I feel that little tickle in my throat or any tell-tale signs of an illness I take a zinc cold therapy lozenge and a Sambucol lozenge twice a day.

Nasal/sinus irrigation

Another very good thing to do for folks who are old enough is to use a Neti Pot or sinus irrigation. Make sure to use distilled water. NeilMed has quite a few excellent products to help clear out the nose. For nursing moms, this is my absolute favorite remedy. If you have a deviated septum, this may not work well for you.

Teach your kids who are old enough how to blow their noses.

Lots of kids have ZERO idea how to do this, so they need to be taught. Important factoid: never blow both nostrils at the same time. That’s more likely to send mucous into the ear canals. Instead, plug one nostril at a time and blow. Play games with a tissue. See if they can make it dance by blowing on it. Start with the mouth and then see if they can make it move by blowing it with their nose.

It is also good to teach your kids to cover their sneezes and coughs when possible by coughing into their elbow

Good hand washing is of course essential.

Related posts:

• When is your child contagious?

• Croup

• RSV

• Boosting your immune system

Thank you to my models Sawyer, Elliot, Noam and Aviv!!!

Tummy Bug Basics/Poop Puns because you may need to laugh

 

Tummy Bug Basics

Norovirus is making the rounds. Dr Ted and I decided that this is a good time to update our tummy bug post from a couple years ago.

By far most of the tummy bugs that people get resolve on their own. A tincture of time will usually take care of them. The typical symptoms are stomach aches, vomiting, loose stools and sometimes fever. Not everyone has every symptom. Vomiting without the loose stools could also indicate something else going on, like strep throat, a urinary tract infection, an ear infection or even appendicitis. When the diarrhea comes along, the good news is that it usually signals that we can narrow our attention to some type of gastro-intestinal issue. The bad news of course is that when the patient is losing fluids from both ends, dehydration now becomes more of a concern. I also don’t want to minimize how miserable it is when you are in the full throes of an acute GI episode and don’t know whether to sit on the toilet or kneel at it.

How do they spread?

Viruses like the Norovirus or Rotavirus are spread in a variety of ways including

• Having direct contact with an infected person

• Consuming contaminated food or water. If an infected person is involved in preparing the food, tag, you’re it

• Touching contaminated surfaces and then putting your unwashed hands in your mouth. For parents of kids who are vomiting, be careful when you are cleaning up after them. This can easily go from family member to family member

• Note: A swipe of hand sanitizer isn’t going to help all that much. It doesn’t kill these viruses. For handwashing, you need soap and water. For surfaces you need something that contains bleach.

For young babies

If your baby is under two months old and you suspect that they have a tummy bug, it is important to monitor them closely. Young babies can get dehydrated much more easily than a larger child or adult.

Of course it is not always easy to know what's up with the little ones. Many babies spit up on a regular basis daily. Actual vomiting will usually have a larger volume and be more forceful. Baby poop can seem pretty liquid and diarrhea-like even when everything is perfectly normal.

It may be worth checking in with a doctor if the stool is copious, watery, and clear, there has been more than one episode of vomiting in a several hour period, and they are fussier than usual.

If they are nursing well, and peeing fine, that is very reassuring, but if they are little and you are worried, go ahead and get them checked.

How to assess hydration

If your child is running around and has good energy, I am usually not too concerned. There is a big difference between subdued and lethargic. Some kids are well hydrated but still feel lousy and are quieter than usual. We can call them subdued. If you have a kid with big juicy tears and lots of drool, they are probably not terribly dehydrated. The body doesn’t waste the fluid.

On the other hand, a dehydrated child is lethargic. They do not want to play. The urine is more concentrated (darker and smellier) and way less frequent. Their mouths feel dry. Their breath might be stinky (of course if they have been vomiting that is probably a given.) Their skin may be dry. Normally if you pinch up a bit of skin on the wrist, it will immediately correct itself. If someone is dry, it may remain up in the pinch for a moment.

Please note, so that you don’t freak out, right before someone is going to vomit, it is normal for them to look quite miserable. Some kids get very pale and shaky. Some folks actually look greenish. Once they throw up, most of the time they feel a bit better and the color normalizes.

Home treatment is usually adequate

Frequent but tiny amounts of fluids is a remarkably effective approach. If you are breastfeeding, smaller, more frequent feeding will often be much easier for the baby to keep down. It is okay and even expected for the patient to have less of an appetite for food for a few days. Unless the person is extremely slender, we are not too worried about a bit of weight loss. Most folks will gain it right back up when this passes. Don’t stress about the food intake. Pushing food will likely just aggravate the situation if they aren’t hungry.

Your only job is to make sure that they are getting adequate fluids.

Dr. Ted reminds us that children can technically go seven days without a bite of solid food before it’s medically a problem. You just need fluids with electrolytes to survive. Start by giving clear fluids (breast milk is great if you have it.) Because we lose lots of those electrolytes when we vomit or have diarrhea, it is best to replace the fluids with something that replaces the electrolytes as well. Water is not your best choice (but works if it’s all they’ll take). There are products on the market that are specially formulated for this purpose.

Pedialyte is the classic brand that has been around for many years. They have significantly improved the taste over the years. It used to taste like soap.

The exercise drinks like Gatorade are another option but have more sugar than the Pedialyte. Pedialyte is one of the products that is worth keeping on hand so that you are prepared if a tummy bug strikes. It also comes in popsicle form which is great for older kids, as well as a little tube of powder that you mix yourself. (I believe that it makes a great addition to any travel emergency kit.)

I don’t have any hard and fast rules about fluid amounts. Electrolytes are the better choice, but you have to do the best you can if they simply refuse those. Try some diluted juice, coconut water, ginger ale, or colas that have lost some of the fizz. Whatever they are agreeing to drink, wait a bit after they have thrown up before offering anything. There is nothing exact about the timing. I generally try to wait 30 minutes after they vomit before giving anything. Many folks tell you to wait longer than that. But if they are begging you for sips, go ahead and offer something.

Think of a drip irrigation system. If all you can get in there is a dropper-full, that’s okay! Get that fluid in, drop by drop, ice chip by ice chip. Do the best you can. Plus, if someone is busting your chops for a cracker, a nibble of a saltine may actually feel a bit soothing. If the worst comes to worst, and you move too fast, they will just throw up again and you will know that you need to wait a bit longer before offering the next sip or nibble.

Don’t let them guzzle. Stick with an ounce at a time. If you have a tiny tea set, or a fancy shot glass, those are fun ways to measure small amounts. You can have a star chart for the reluctant drinkers.

If your child has an elevated temperature as part of this illness, a tepid bath can help get the fever down. If the bath hasn’t done the trick, the fever is over 101, and your child is miserable, it is worth giving some fever-reducing medicine. Ibuprofen tends to be a bit harder on the stomach so I would choose acetaminophen (Tylenol) when I have an illness that includes tummy symptoms. Another advantage to the Tylenol is that it comes in suppository form, so it is more easily tolerated by a vomiting kid (Tylenol/Advil Dosage Chart).

Generally, vomiting is the first thing to ease. If they remain nauseated, there is a magic pill called Zofran. This is an effective but strong medication. Most doctors would like to do a quick evaluation prior to prescribing this, to make sure they are not ignoring an underlying cause that needs treatment.

Time to get evaluated

If they are refusing fluids or can't keep down anything, you need to check in with your doctor’s office. That is a signal that their tank is really empty and they need help turning things around. These are the kids that are significantly low energy. It is worth remembering, however, that most doctor’s offices don’t do IVs.

If the child is truly lethargic (can’t be roused for more than a couple seconds) and you have been attempting small amounts of fluids and failing, or if they are vomiting up blood, or anything that looks like copious coffee grounds, or bile (bright green, not just yellow) then a trip to the emergency room is appropriate. Once there, your child may get some IV fluids which will often perk them right up.

For adults, just google mobile IV services to see if you live in an area where that is available. If you know you simply need fluids, this is a great way to avoid a trip to the emergency room. If you don’t know what is going on, it is worth seeing an MD

Recovery and advancing the diet

Once your child has started keeping down fluids, it is okay to advance the diet if they are interested in food. More often than not, we expect the stools to continue to be looser than normal for a bit longer. Dr. Ted observes that the younger the child, the longer the stools tend to remain loose. Trust your kids to some extent. I find that most of the time they crave the foods that their bodies can handle. If you have an outlier asking for a hotdog, follow your instincts and say no.

Bland starchy foods are your best bet. I suggest a modified BRAT diet. Bananas, rice, applesauce, crackers, toast, potato, pasta, boiled chicken and watermelon are all okay. I find that folks have a quicker time getting over this if they avoid dairy (some folks can stay on yogurt and tolerate that fine). There are plenty of dairy alternatives.

In my experience, getting started with probiotics right away can be helpful in getting over this quickly. Fermented foods are also very beneficial when they can handle them. We need to get the gut healthy again so that it can tolerate a normal diet and the good bacteria in the probiotics is critical to this. There are plenty of good brands out there. Jarro is usually easily available at Whole Foods and has a baby formulation.

One of the most common calls to the doctor’s office after a tummy bug is when a patient seemed like they were improving and seemed to have had a bit of a relapse. This is usually caused by advancing the diet a little too quickly (especially dairy.) You may need them dairy free for a week before things return to normal. Yes, this includes cheese. See Dr. Ted’s tidbits below for an explanation about this.

What if it isn’t a virus?

It could be bacterial. If you or your child has a fever, chills, bloody diarrhea and vomiting, that could be bacterial food poisoning. The most common culprits are E. Coli, Salmonella, Shigella and Campylobacter. Sometimes the symptoms might not show up for a few days, making it hard to identify the source.

Even though many of those illnesses are self limiting, getting seen is a good idea. Your doctor may send a stool sample to the lab to check for a bacterial stool culture. If testing is positive, doctors are mandated to report these diseases to Centers for Public Health (so that outbreaks can be tracked). There are usually special containers required for this.

It could be parasitic. If you or your child are just back from travel or camping and have awful gassy, incredibly stinky stools with bloating, we should make sure that you don’t have giardia or some other parasite. If that is a possibility, we would send another type of stool sample to the lab that requires a different set of specialized containers. This is called an O&P (ova and parasites.) As opposed to many of the other tummy issues, these do not usually resolve without help of some medication. Even if you haven’t been around any obvious sources, if you have a pet with loose poops, that can be an important clue. Dogs can get it from drinking nasty water and then can spread it to their humans.

Dr. Ted’s Tidbit

The intestines can take a long time to recover after an infection. It’s important to understand that vomiting or diarrhea after recovering from a tummy bug are not necessarily signs that the infection is still active. Up to one third of patients will have weeks of irritable bowel symptoms after recovering from bacterial gastroenteritis. Many symptoms after recovery from a tummy bug can be explained by understanding the physiology of the intestines. The intestines represent your largest internal organ and demand a ton of cellular energy. Often-times, the entire internal lining can be significantly damaged after a tummy bug. In the weeks it takes to repair all that lining, patients can feel unbelievably drained because of the energy required to create new cells. The damaged intestinal walls also may lack the enzyme lactase, which typically sits in the walls of the cells that line the intestines and can be lost after infection. That may cause new symptoms of lactose intolerance, diarrhea, bloating, or even vomiting or reflux after having dairy or other large meals. If you’re experiencing symptoms after recovering from gastroenteritis, stick with Nurse Judy’s advice and eat small, easy to digest foods.

Extra discussion points

• With anything poop related, often defense is your best offense. Wash your hands!!!

• While it is quite normal to lose a little bit of weight, getting a baseline and monitoring recovery is important.

• Any steady abdominal pain that is lasting more than several hours should be evaluated.

Most of the things we discussed above can be considered acute issues. Ultimately with time or appropriate treatment they will be relegated to just a bad memory.

When you don’t find an answer and the symptoms continue to be an issue, I would no longer consider it to be acute.

Chronic intestinal issues should not be ignored. Many times general tummy pain in an otherwise healthy child is from constipation. Gas pains tend to be sharp and intermittent. Start keeping track. When and if you do see a doctor this data will be valuable:

• Where is the discomfort?

• How long has this been going on?

• Do other family members seem to be impacted?

• How severe are the symptoms?

• Does it get better or worse with food?

• Does it come and go away on its own?

• If not, what did you try the may have helped?

• How often are the poop? Are they hard or soft?

If you’re in the mood for it here are the poop puns

Many years ago when I was working at Noe Valley Pediatrics, Norovirus was out in force and was making headlines.

One of our patients' moms was a reporter on a local news station. She wanted to interview one of the providers about what we were seeing. I cajoled the doctors to no avail and ended up being the only one willing to be on camera.

Later that day I did a little facebook post letting folks know that they might get a glimpse of me on television.

My facebook post took an unexpected turn.

My family can’t pass up a good opportunity to make puns and they jumped right in.

They were joined by an assortment of friends and family. The thread comes up on my facebook memories every once in a while.

If you are one of the unfortunate folks who is trying to decide between sitting on the toilet or kneeling by it or is busy cleaning up someone else’s poop or puke,I am going to attempt the challenge of giving you something to laugh about.

Judy: I had 30 seconds of fame on the local news….talking about poop

Several friends asked for the link and then the puns started to roll in

Lauren ( my oldest daughter): mom, i believe it is your doody to share this link with us

Lena (my niece):Bahahah.

Judy: well, number #1, I don't have the link yet and number# 2 Lauren, do you really want to go down that road??

Alana (youngest daughter): Awww shit. More puns?

Sandy (my partner):I almost fell off my stool!

Lena: Impressive dedication to defecation!

Alana: Now you're just talking crap, daddy

Aza( Alana’s friend) You guys…just can it

Alana: Oh come on, we’re just getting loose

Sandy: Well, this is a well formed discussion, but it does occasionally get a little loose

Emily (friend of Alana) Alana invited me to come join the potty, so I figured I’d dump everything else

Lauren: There are so many crappy puns floating around enema head, I don’t think I could flush them out if I tried

Anya (Alana’s friend): Well lookie-loo what do we have here? Do I need your permission toilet me join in the fun?

Sandy: I wish I had a pun to add to this, but I feel like I’m constipated

Anya: Well maybe you need to try some re-laxative breathing

Lauren: I just hope these puns don’t get too corny, because you know they’ll stay that way for days

Anya: Don’t make me Crohn

Lauren: You know, intestine me with your puns, you’re making me want to keep going, but for everyone’s sake we should take some time to digest what just happened on Judy’s wall. Log it away as a complete waste of time...and just stop and enjoy this video

And with that I bid you a-doo

Anya: You’re correctum, I should probably get back to anal-lizing my homework. Toot-eloo

Judy: I feel like I must apologize to the innocent original folks who commented on my status without knowing what they were in for

Anita (one of my best friends): Wow, I’m impressed by all the really good puns. I can’t seem to pinch one out myself

Aunt Millie: Well, my thoughts on this. DEPENDS on a myriad of…. SO proud of my family!

Lena: It’s a very odd thing to be proud of, but I have to agree. I may or may not be posting a screenshot of this to Reddit. And when I changed people’s names to protect the innocent, Alana may have become cousin #2…sorry

Laurie P (a friend of mine): This has got to be way more entertaining than the orig-anal airing

Sandy: Enough of this, I’m pooped

Lena: I thought I had a good pun to add here, but it seems to have been wiped from my memory

Jim (my Brother in Law): I’ve been straining all morning to come up with a pun to add to this thread, but it’s just not happening right now

Amy (my sister): I too have the urge to contribute to this pile but I’ve got nothing…besides this conversion is becoming ab-turd

Judy: I thought you were al colon it quits but these puns keep coming

Aunt Millie: Ha, this is becoming fumier and fumier, tee-hee to the French

Jeannie (an old friend from nursing school): I’d still like to see the original news clip to see if it is as funny as all of the comments

And over the years when it came back as a facebook memory it still gets a few random comments

Lena: Are we all going to start droppings in here again?

Judy: I was looking for this link to show to my Oath team, time to wipe it off

Alana: Just a reminder that this exists

Sandy: Alana, you little turd, you had to bring this up again?

Kenna sera: #1 I still never got to see the clip and #2, I’m genuinely impressed by the puns and the effort

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And there you have it. Can you think of another pun that didn’t make it to the list?

The Christmas Cactus

 My grandmother had an enormous plant known as a Christmas cactus. These plants are expected to bloom once a year. December is the common time for the flowers to come out, hence the name.

Grandma gave a cutting to my mom.

The cutting that my mom had thrived. It didn’t know that it was supposed to bloom just annually and would occasionally burst into bloom throughout the year.

Regardless of what was going on in the world or her personal life, mom would be joyful every time the plant bloomed. For her it was a signal of hope and positive energy. It was infectious and the entire family would somehow feel a lift.

When my parents were still alive, I made sure to go home to Pittsburgh every four months or so; these visits were even more frequent as both my parents got older. Scoff if you like, but more often than not, the plant would flower right before my visits and stay that way for several weeks.

My older sister inherited Grandma's plant which also seems to have a mind of its own.

When mom died, my sister gave me a cutting of the plant. To say that I have not been very good at keeping plants alive is an understatement. Fortunately, Sandy has taken on the role of the plant tender.

Historically he was no better at gardening than me, but after years of killing anything even remotely green, we now have an array of indoor plants that are flourishing under his care. The centerpiece is the offspring of the family plant. It has quadrupled in size since we have had it. It now has several offspring of it’s own.

This month right before my grandkids came to visit, it burst into bloom with gorgeous pink flowers.

Coby was captivated and we spent quite a bit of time directing him away from the plants. He really wanted to see how they taste.

The kids left, but the plants are still flowering. They magically fills me with a sense of joy. I feel my mom’s presence.

Goodness, we all need hope and optimism more than ever for this new year. There is so much going on.

If you are feeling down, please hang in there. The cactus is blooming.

The Gasoline Balloons/Mama said there'll be days like this, there'll be days like this Mama said Mama said

 As a grandma who has plenty of opinions, I make an effort to hold on to my thoughts and advice until they are asked for. I may or may not always succeed at that.

What makes it pretty easy to hold my tongue is that I think my grandsons have excellent parents.

This week I watched Lauren successfully navigate one of those situations where she manages to keep her sense of humor and says something along the lines of “Jesus, take the wheel”

The kids were visiting for the week. Adam and I took Elliot to one of those stores on Clement street that are full of inexpensive, imported items. Safety standards are likely nonexistent. For any of you who know a bit of Yiddish, we refer to this as “Schlock,”

We were in the market for things to stick in goody bags for EJ’s upcoming 4th birthday party.

There really wasn’t anything worth getting, but at the last minute Adam grabbed a package of fancy balloons.

When we got to the car, EJ convinced us to give him one of the balloons. We opened the bag and let him select one. As we were driving we noticed a strong smell. After a bit of sniffing, it became apparent that the source of the nasty odor was in fact the balloons. Now in general, balloons often smell a bit like rubber. These smelled more like gasoline.

But Elliot was really enjoying himself.

When we got home we allowed him to blow up a few more and then convinced him to move along to other activities.

The next day Adam left for the weekend to go to a bachelor party of a close friend.

By Saturday, after multiple comments over how horrible the balloons smelled, Lauren made the wise decision to get rid of them. Shame on me for not having that instinct immediately. She didn’t want her son handling anything that smelled so frankly toxic. What’s more, he was putting them in his mouth as he blew them up (sidebar, this almost 4 year old is pretty astonishing when it comes to inflating a balloon.) Add to the equation a baby who was very interested in getting his hands and mouth on them.

So now allow me to set the stage. It had been a stretch of gloomy rainy days. We all had a bit of cabin fever. Elliot was also missing his daddy.

“Where are my balloons?”

“I had to throw them away because they smelled like gasoline”

“But I love my gasoline balloons”

“I know, lovey, but it isn’t good to handle those. We can get other balloons that don’t smell bad”

“NO! I WANT THE ONES THAT SMELL LIKE GASOLINE”

“I never like disappointing you, but sometimes there are ‘nos’ that are health and safety ‘nos’.

“WHERE ARE MY GASOLINE BALLOONS. I AM GOING TO THE GARBAGE TO FIND THEM”

“I threw them in a trash can that isn’t in the house”

“I AM GOING BACK TO THAT STORE TO GET MORE”

“I am afraid they don’t have any more. They had to get rid of them when they realized they weren’t safe.

This went on for a bit. It included Lauren making a call to Adam, who fortunately caught on quickly.

“Hello, is this the store where we bought the gasoline balloons? Is it true that you needed to get rid of all of them?”

“Yes indeed”, said the voice on the phone in some kind of fake, terrible accent. “We had to throw away all the balloons because they weren’t safe.”

Lauren offered many options including running out to a store to get other special balloons. Maybe some that light up? How about balloons with team Spidey or Paw Patrol? Nope, if they didn’t smell like gasoline, they were not going to make the cut.

As this tantrum was going on, Coby, the almost 10 month old was trying to climb up on his mom. Bowie, the 80 pound dog was tossing a ball at her feet asking her to play.

I am a terrible person. I had to add to the chaos by starting to giggle uncontrollably. It was infectious. Lauren and Sandy both started laughing along with me. That did not improve Elliot’s mood.

Lauren is hands down the funniest person I know. If she ever starts to do stand up comedy, the Gasoline balloons need to be added to the routine.

The balloons pictured were survivors of the ‘purge’. How long they stay inside my piano is anybody’s guess.

Wishing everyone a peaceful and happy holiday season and a year absent of noxious odors.

Holiday Angst and Joy/Often they are two sides of the same coin

 Holidays can feel magical for some lucky kids, but by the time most people reach adulthood, those same holidays can stir up a lot of powerful feelings. Not all of them are necessarily positive. In many cases, the holiday season is the absolute set up for potential stress and disappointment. Depending on the person and the family, these feelings are often a mix of joy and dread. Hooray for you if you are an exception.

There is a reason that therapists need to work overtime in December.

Hallmark Christmas movies are an absolute treat, but the fact is, society sets a high bar for how it should be. Sparkling lights, delicious food, getting a pile of perfect gifts, family and friends gathering happily. What could go wrong?

The sad thing is that for many people, if you end up having a perfectly fine day, that isn’t good enough when anything less than extraordinary is apt to disappoint. Writer Rebecca Solnit puts it well. “So many of us believe in perfection, which ruins everything else, because perfect is not only the enemy of good; it’s also the enemy of the realistic, the possible, and the fun.”

It is a great time to focus on small moments of joy that we have within our grasp. Are you feeling low? See if you can dig down and find something that can bring some cheer. Even looking at some sparkling lights, or being cozy inside on a rainy evening. If you are lucky enough to have your kids at home, can you do a family snuggle and tell stories?

This is also a good time of year to remind ourselves to be clear on the difference between things we have control over and those that we don’t.

Gifts

You have very little control over what you receive, but if you pay more attention to what you are giving, you can’t be disappointed. This is a great lesson for the kids.

Start early focusing on how wonderful it is to give. A good gift doesn’t have to be something you buy. Give the gift of your time, or something you make. How about a foot massage to family members? Sign me up.

In case you didn’t see it, here is the post that I recently did about gift giving

Something to keep in mind is that when it comes to gifts, everyone has different wants and needs.

This is the perfect time to remember those “love Languages”

You might also decide to give one big family gift, like an outing or a trip, instead of individual ones. There are no rules.

Another thing that can be tricky might be the timing of the gift. There are many things out of your control including shipping and/or availability of a desired item. The value of the gift should not be dependent on whether or not it ends up under the tree in time. If something is delayed, take a photo of whatever it is and put that in a box or envelope. The actual gift will get there when it gets there. I remember some years when people were ready to take out an extra mortgage in order to get a hold of tickle me Elmo or a Cabbage patch kid. Try not to get caught up in that. Take a deep breath.

Family

Some families have complicated dynamics that can be very stressful. If this is you, please know that you are by no means alone. Try to focus on the things that you love and appreciate about each other rather than the things that you disagree with. If it is at all possible, maybe have an agreement ahead of time to leave politics at the door.

If you are lucky enough to have a family that you want to be with, and it is the togetherness that is what counts, forgive me for this suggestion, but the actual holiday maybe doesn’t need to be the exact time of year that you gather. There is something very freeing about avoiding travel when the rest of the world is also fighting to get to their destinations and paying twice as much to get there.

I know plenty of people who celebrate a week early or later. There is nothing wrong with that! (If you are reading this from a long line in a crowded airport, maybe consider this for next year.)

My friend Brittany, who is a wise therapist, adds that it is important to be cognizant if this is the first holiday/Christmas since a loved one passed. If you have experienced loss, it is okay to initiate dialogue about how you miss the friends and/or family members who are no longer with you. Try to tell stories and share happy memories instead of avoiding their absence.

Traditions

Take stock of your holiday traditions. Believe it or not nothing actually needs to be set in stone. You get to choose which ones are achievable or not and which ones bring you joy. Is there something on the list that should no longer be on there for whatever reason? Cross it out! See if it is missed. Identify which things matter and which things simply cause stress and don’t add value. Talk to the kids and find out which things matter the most to them.

Food tends to be an important part of any holiday culture. Making a family recipe or special meal can make you feel close to relatives even if you are far away from each other. Bring the laptop into the kitchen and cook or bake together on zoom.

You can also adopt new traditions. Have a virtual sing along with friends and family near and far, watch the Twilight Zone marathon. Reach out to people in your lives who may not have friends and family around.

Last year we started the tradition of taking Elliot out in search of fun holiday lights. Watching his enthusiasm when he spots pretty ones is the best.

“These are the most beautiful lights I have seen in my entire life!” says the almost four year old.

Moving forward, forge traditions that feel positive and are easy to achieve.

Maybe your kids will be the ones who grow up without any holiday angst!

Here are some past Holiday related posts that you might want to check out

Holiday safety tips

Talking to your kids about Santa Claus

Pertussis and Walking Pneumonia/ Both of these are making the rounds

 Dr. Ted has been seeing quite a few patients with nasty coughs this season.

We decided to address two of the main culprits here; walking pneumonia and whooping cough. (There is a trifecta of sorts going around. RSV numbers are also up, Here is the link to the post we did on that just a couple of years ago)

Pertussis and walking pneumonia are similar in that they are both very long lasting and very annoying. They do have some key differences.

Pertussis

Commonly known as whooping cough, pertussis is a very contagious respiratory illness caused by a type of bacteria called Bordetella pertussis. These bacteria attach to the cilia (tiny, hair-like extensions) that line part of the upper respiratory system. The bacteria release toxins, which damage the cilia and cause inflammation.

Historically there is a population-level cycle associated with whooping cough. It seems to peak every 3-5 years or so, and we are currently seeing a bump in numbers. Preliminary data show that more than six times as many cases have been reported as of November 23. 2024 compared to the same time in 2023.

Vaccination

Fortunately most kids are vaccinated. It is routinely given as part of the standard shot schedule. The P in the Dtap and then later in the Tdap stands for Pertussis.

The vaccine does a pretty good job of preventing death and severe disease. Unfortunately it only partially decreases transmission and vaccinated people can still get sick, but it is usually a much milder case.

Even though most kids in the USA get the protection, it remains one of the leading causes of vaccine-preventable deaths worldwide. According to a CDC 2014 publication, there were an estimated 24.1 million pertussis cases and 160,700 deaths in children younger than 5 worldwide. By far, most of the deaths occur in young infants who are either unvaccinated or haven't had at least 2 shots in the series.

Babies routinely get their first vaccination for this around 2 months of age. The primary series is given at the ages of 2, 4, 6 and 12-18 months, and again before kindergarten entry. Unfortunately, significant protection isn't achieved until the 4th shot at the 12-18 month visit. The four doses gets them up to 75% protected. This goes up to ~90% after the 5th dose (known as the booster.)

Thankfully, ever since the state law imposed vaccination entry requirements for school, we don’t have many patients trying to avoid getting this immunization. Back in the day, I did have some parents opt out for a variety of reasons. Most of them deeply regretted it and confessed that watching their kids suffer with the months of coughing spasms was torture. The shot is well tolerated and it makes no sense to pass on it. I have deep concerns if the vaccination ever stops being required.

The Tdap (Tetanus/Diphtheria/Pertussis) vaccine was licensed in the US in 2005 for people over the age of seven. Because babies are so vulnerable to this illness, current practice recommends giving all pregnant moms a Tdap (with every pregnancy). This immunization should be done in the third trimester between 27-36 weeks. Studies have found that since this program began there has been a 75 percent reduction of infant pertussis hospitalization and a 46 percent reduction of any infant pertussis cases. That is enormous progress.

For folks who will have a newborn in their lives, if it has been more than 2- 3 years since you had the shot or the actual illness you should get another booster. The immunity wanes. Researchers claim that three out of four babies who get pertussis get it directly from family members or caregivers. It is essential that all close family contacts have current vaccine protection. This means partners, grandparents, caregivers and siblings or anyone who anticipates spending lots of time with your new baby. This way everyone will be able to remember the date of their most recent tetanus shot; it will be right around your baby's birthday!

If you have family members giving you push back about this, (sigh, people can be so disappointing) they are welcome to keep a mask on at all times. Unlike COVID, which is airborne, pertussis is spread by respiratory droplets, so masks actually work to slow the spread.

Symptoms

This illness usually starts with a week or two of a runny nose and cough. There may or may not be a low grade fever. Those little snot nosed kids don’t always look terribly sick, but they are quite contagious.

This is why, when you have the option, please keep anyone with a cold from being around your infant. We never know if it is going to turn into something worse.

At week two, the cough becomes much more troublesome. The patient will often have coughing fits….and I mean FITS!! This is spasms of coughing for minutes at time that make even the hardiest person feel like they can't catch their breath.

Patients may or may not have a high pitched "Whooping" sound with the cough (hence the name). Some folks will vomit after these coughing fits or pop blood vessels in their face. Sweating, gagging and choking episodes are common. Some people cough so hard from this that they can break ribs.

Remember, these symptoms may all be much more mild in people who have been vaccinated, but the overall pattern of the coughs coming in deep sporadic fits throughout the day (not just at night) remains the same.

Babies often don’t whoop because young infants often do not have the intercostal (rib) muscles required to cough. Instead, they might just stop breathing briefly or seem really lethargic. They can look cyanotic from the lack of oxygen. It is scary!

For both the vaccinated and unvaccinated, this cough lasts and lasts and then lasts some more. In Chinese medicine this is referred to as the "Hundred day cough" and they aren't kidding. This is a miserable illness for anyone, but for young infants pertussis can be deadly.

Plenty of adults get this and don’t get a diagnosis. It is not on the radar for many adult doctors.

Exposure

People who have been exposed to whooping cough will usually start showing symptoms 7-10 days after the exposure and are contagious by the time they give that first sneeze. Remember, this disease is spread by respiratory droplets, so mask wearing and hand washing are very effective at decreasing exposure.

Testing

Unfortunately, testing is far from perfect. There isn’t a rapid test that will give you immediate answers, and waiting for results is not ideal. Testing requires a deep nasal swab (nasopharyngeal), and results often take 3-5 days to come back. Most doctors who suspect Pertussis are likely to start treatment right away, especially if there is a young baby in the household. But according to public health departments, it’s recommended that anybody with a high enough suspicion for a test should be treated automatically (before results come back). Then, presuming they might have the disease, it’s recommended that they stay home from school or work until they’re done with the course of antibiotics. More on treatment below.

Treatment

Treatment usually involves 5 days of antibiotics like azithromycin or clarithromycin, but these are mainly to prevent the spread to others since antibiotics don’t do much to shorten the course of illness once the cough has set in. The good news is that after you’ve finished 5 days of antibiotics or you’ve had symptoms for 21 days (whichever comes first), you’re no longer contagious to others. Therefore, if you’ve been sick for 22 days, you can probably skip the testing as well as the antibiotics. Testing is simply for data purposes, it won’t really change anything. The stick up the nose is not particularly comfortable.

Symptomatic treatment is similar to what you would do with other coughs. This includes a cool mist humidifier and drinking plenty of fluids. The extra moisture in the air can really make a difference with the pertussis cough, so if you don’t have one, a humidifier is a good investment. Smaller more frequent meals may help make vomiting less of an issue.

Inhalers, steroids and cough medicines don't seem to be of much use alas, although honey (Manuka if you can get that) might be soothing. Remember that babies who are less than a year old can’t have honey yet.

Smoke exposure will make things much worse. Skip the campfires.

Walking Pneumonia/Mycoplasma Pneumoniae

We wanted to include a section on walking pneumonia, because it’s another reason you might have a months-long deep cough that doesn’t seem to be getting better. The numbers for it are also up enough that it is getting some media attention.

Symptoms

This is more of a slow-burn infection that settles deeper in the lungs. It typically causes a lingering, dry cough, fatigue, and sometimes low-grade fever. It can leave you feeling out of breath. Unlike pertussis, it doesn’t release toxins but instead, it directly invades the respiratory lining.

Testing

If the section above about pertussis testing left you feeling unsatisfied, then get ready for the ultimate disappointment. There are very, very few commercially available tests for the causative agent, mycoplasma. Physical exams will sometimes show little signs through the stethoscope, but that’s not consistent. You can get an x-ray of the lungs, but that also doesn’t always pick it up. So we’re left with the story, symptoms, exposures, and good guesses.

Treatment

Like pertussis, treatment usually involves antibiotics like azithromycin or doxycycline, which actively target the bacteria and usually help symptoms resolve faster (unlike pertussis). For those who really resist taking antibiotics, time is the great healer and it will go away on its own…eventually. While the vast majority of cases resolve without treatment, immunocompromised individuals can have some serious sequelae.

Whooping Cough vs Walking Pneumonia

How can you tell the difference between these two diseases? In summary, from a physiological standpoint, the big difference is that pertussis mostly affects the upper airways and is toxin-driven, while mycoplasma pneumonia targets the lower airways and works by directly infecting cells. Both can be annoying, but walking pneumonia tends to be less dramatic and more sneaky. The patients don’t always feel super sick but just kind of ‘off’. The cough here is more nagging and dry, usually without the violent fits of pertussis. Your child might seem tired, have a sore throat, or complain about mild chest pain. Fever tends to be low-grade or not even there. It’s actually most common in older kids and teens because mycoplasma pneumoniae, the causative agent, likes to circulate where kids are packed together—schools, sports teams, etc. Kids with asthma or other chronic respiratory issues are more likely to get hit harder if they catch it.

While vaccines exist to prevent pertussis (hello, Tdap!), as of yet there are no vaccines available for Mycoplasma pneumoniae.

Dr. Ted’s advice:

If your child’s cough has been dragging on, especially if it’s dry and disruptive at night or after activity, or if they’re looking more tired or out of breath than usual, those are good reasons to check in. Whooping cough can feel more urgent because of how intense it gets. Always worth a quick listen to those lungs or a swab to rule things out. Follow up with your pediatrician if you think something’s up!