Cocooning our future butterflies

Recently there have been several news articles about cocooning.  No, it’s not a way to raise butterflies in your backyard. It means surrounding high risk people, especially infants, with other people who have been vaccinated against one or more diseases.  The idea is that people who are vaccinated against disease are less likely to carry that disease home.  Besides infants, high risk people include those on chemotherapy for their cancer, pregnant women, the elderly, those with HIV, people with asthma or cystic fibrosis or those on long term steroids, including people who have had an organ transplant .

The two diseases most commonly targeted are influenza and pertussis (whopping cough.)  Infants cannot be vaccinated against the flu until they are 6 months old; they start their pertussis vaccine series at age 2 months but are not fully protected (depending on the child) until after their 3^rd (at 6 months of age) or 4^th (usually around 15 months of age) dose.  Hence these children rely on maternal antibodies from crossing the placenta before birth or to less extent, those found in breast milk.  Those received before birth usually last about 6 weeks; the effect is much stronger if mom was vaccinated during pregnancy.

In the past few years, there has been a resurgence in the number of whooping cough, and sadly, an increased number of infants dying from the disease.  About 2/3 of infants less than 2 months of age who get whooping  cough get hospitalized for pneumonia or seizures and not infrequently need to be on ventilators.  Children who die from whooping cough usually suffocate, with the blood vessels in their lungs so clogged that new blood cannot enter to carry oxygen to the rest of the body.  Brain damage can also result from the illness.

In the past, efforts have focused on vaccinating mothers, either while pregnant or immediately after giving birth.   Pregnant women are themselves at high risk for complications, including death, from influenza.  One of the saddest days of my career was during my residency, when a pregnant mom died on the operating table from influenza right before Christmas.  It was clear she would not survive the infection, so a C-section was done to save the baby.  The mom died less than 12 hours after her first symptoms.  Miraculously, the baby lived.

Vaccinating mom during pregnancy protects her as well as maximizing the amount of antibodies transferred to the baby.  In June 2011 the American Committee on Immunization Practices (ACIP) officially changed its recommendation to vaccinating against pertussis during pregnancy, instead giving it immediately post-partum.  It noted that the vaccine had been determined to be safe and effective during pregnancy, and vaccinating during pregnancy improved the amount of antibodies transferred to the baby.  In addition, mothers were found to be the source in over a third of infected babies.

Recent efforts have encouraged vaccination against pertussis and influenza for all people with close contact with infants, including dads, grandparents, old siblings and child care workers.  Sadly, this approach has been slower to catch on, in part because these people are usually being seen in a doctor’s office on a regular basis.  This fall, the Larimer County Health Department received a grant to offer the pertussis vaccine (also known as Tdap) to family members of newborns for free.  Unfortunately, the grant has expired so the vaccine is no longer free, but fortunately it is still available for a small fee.

A recent article from Canada questioned the cost –effectiveness of cocooning.  There are very little actual data, so instead researchers created a model and predicted that 1 million people would have to be vaccinated to prevent 1 infant death; fewer people would need to be vaccinated to prevent hospitalization or illness.  However, even the accompanying editorial noted the cost of the Tdap vaccine was trivial in comparison to the overall cost of a delivery.

The influenza and Tdap vaccines are available at the health department, many pharmacies and most doctors’ offices who serve adults.  So if you’re the parent or close contact of an infant, roll up your sleeve and take one for the team.  You will be rewarded with a beautiful smile from your little butterfly.

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Tylenol vs Motrin

It’s 2am, your child is wailing because she has a fever, and you’re staring at the medicine cabinet, wondering what will make her feel better and let both of you get to sleep sooner rather than later.  Sound familiar?

Non-pharmaceutical options for making her feel better is the topic of another blog.  Today I will discuss the pros and cons of the 2 major pain relivers/fever reducers in children: acetaminophen (e.g.Tylenol) and ibuprofen (e.g. Motrin, Advil.)  Aspirin, even baby aspirin, is not used in children because of its association with Reye’s Syndrome.  Reye’s Syndrome is the profound liver failure and brain swelling seen in children who received aspirin during a viral illness, especially chicken pox and influenza.  It is almost unheard of anymore since warnings against the use of aspirin in children appeared.

Tylenol and similar products are the only fever reducers licensed for children less than 6 months.  It is processed by the liver which makes it safer in kids with kidney problems or dehydration.  It is not associated with stomach irritation or ulcers.  It is available as a suppository so febrile kids who are vomiting can still receive it.

The down sides of acetaminophen are potential liver toxicity and concerns about its association with asthma. Too much acetaminophen, whether from too big a dose, a correct dose given too often or getting it from more than one source (e.g. regular Tylenol plus Tylenol Cold and Flu) damages the liver; in extreme cases permanently and irreparably. If the overdose is discovered early, it can be treated with an antidote called N-acetylcysteine, but almost always requires admission to the hospital.

Dr John McBride, a pulmonary specialist at Akron Children’s Hospital (and one my residency mentors) published an article in the December issue of Pediatrics outlining studies that showed that children who received more doses of acetaminophen had more asthma.  Whether the acetaminophen caused (or at least exacerbated) the asthma or whether kids with asthma are just sicker and more likely to have a febrile illness is not clear.  Still, Dr McBride recommends avoiding it, especially in high risk children, until the question is answered definitively.

Ibuprofen has the advantage of being an anti-inflammatory in addition to an analgesic (pain reliever) and fever reducer.  Probably for that reason, ibuprofen was shown to be superior to both acetaminophen and Tylenol with codeine in reducing the pain associated with broken bones.  A dose of ibuprofen tends to last longer (on average 6-8 hours) than an equivalent dose of acetaminophen (4-6 hours).

Ibuprofen cannot be used for kids less than 6 months of age because it can be toxic to their kidneys. It has also been known to cause kidney damage or even failure when given to dehydrated children.  It can cause stomach irritation (which is reduced when taken with food) and, if taken for a long period of time, stomach ulcers.  Rarely, people who are allergic to aspirin are also allergic to ibuprofen.  It is not commercially available as a suppository although some pharmacies will compound it for you.

So, which to choose?  In general, I tell people to use the one that is already in front of them.  Acetaminophen is really the only choice if the child is less than 6 months old.  I don’t recommend the use of ibuprofen in children with vomiting and/or diarrhea or who are drinking poorly.  Ibuprofen lasts longer, so that is a bonus at night.  Ibuprofen is superior for bone pain like fractures. I think the data for asthmatic children are too limited to make a strong recommendation against acetaminophen, but it would something to consider if there is a strong family history of asthma.

If you have questions about your specific child, ask his regular health provider for guidance.  And use caution when determining the correct dose for your infant.  In an attempt to limit confusion and avoid overdoses, the traditional “Infant’s Tylenol”, which is more concentrated than “Children’s Tylenol”, is being pulled from the market.  However, old packages remain, both in stores and in homes.  In addition, there are packages of “Infant Fever Reducer” available which have the new concentration of acetaminophen.  Read the package carefully, especially the drug concentration, and don’t hesitate to ask if you are unsure.

Here’s to some restful sleep!

The Year of the Barking Seal

Have you ever woken up in the middle of the night, certain that your child has been replaced by a barking seal? If so, you’ve experienced croup. You can hear an example at http://mommyhood101.com/baby/audio/croup.html

Croup, otherwise known as laryngotracheobronchitis, is inflammation around the vocal cords. In its mildest form, the child experiences a barky cough; in its worst form, the swelling closes off the airway and requires a breathing tube until the inflammation is resolved.

What causes it? It can be caused by a number of viruses, including RSV and influenza, but the vast majority are caused by parainfluenza virus. There are 4 types or strains of paraflu, and parainfluenza 1 is responsible for most major outbreaks. For reasons that are not entirely clear, the outbreaks occur in the fall of odd numbered years. Hence this year is the year of the Barking Seal.

Most children start with a runny nose and the cough becomes more barky on the second and third days of illness. The croupy sound is usually worse late at night. Again, the reason is not clear; some people say it’s because the body’s natural steroid levels are lowest in the early morning, others say it’s because gravity can’t help drain the swelling when the child is lying down,

If your child develops a barky cough, give him or her a dose of ibuprofen to help reduce the inflammation. Sometimes taking the child out in the cold air helps. Despite the numerous references in parenting magazines and even old medical textbooks, there is no proof that mist helps croup symptoms. (I had an attending in residency that went nuts every time the nurses went running for a humidifier for a kid with croup and we residents would have to listen to his lecture *again* about the endless studies showing it doesn’t help.) In kids with lots of nasal congestion, it can help clear their nose.

If your child starts making high-pitched noises while breathing (called stridor) or seems to be having trouble breathing, he or she needs to be seen by a physician right away. Unfortunately, since this is usually in the middle of the night, it often means a visit to the emergency room. Sorry, but that’s the way it goes. Depending on the level of distress, your child will receive a breathing treatment, steroids or both.

If it is just a barky cough, bring your child to the office in the morning to determine if he or she needs a dose of steroids to prevent worsening symptoms.

It is fairly contagious; 50% of kids of evidence of having parainfluenza infection by age 12 months. Kids can shed the virus from their nose for 1 week before and up to 2 weeks after the barking cough. Translation: wash your hands, wash your hands, wash your hands!

How to Save a Life Before You Are Even a Day Old

Sounds like a pretty cool, huh?  It’s actually pretty easy.  Cord blood donation is an amazing thing.  Why would you want to do it?  Because it is a chance to save another person’s life, not just for a week or two, not just for couple of months, but potentially for DECADES to come. Umbilical cord blood contains cells that can be used for bone marrow transplants in patients with leukemia and certain other cancers and metabolic diseases.  Even better, the match or the sameness between the donor and the recipient does not have to be as good as in a traditional bone marrow transplant.

How does it work?  About 2 months before the baby is due, a mother talks to her OB or midwife to make sure that mom has no known communicable diseases.  A health form is sent to the cord blood bank and a collection kit is sent back to the mom.  When mom heads to the hospital to deliver, she brings the kit with her.  Be nice to the nurses and they will draw the necessary blood from mom when they start her IV.  The blood is drained from the umbilical cord after the baby is born (the baby doesn’t feel any pain with this procedure) and then is either mailed or picked up by courier.

The blood is then tested for disease and other things.  The donation is then posted (without any names) on the national registry for any cancer center to request and use.  Even if the volume is too small to use for donation, parents can consent to donate the blood for research on the use of cord blood for future cures.

I donated the cord blood from both of my daughters  and it was incredibly easy.  I couldn’t donate my son’s because he was a preemie.  Oh well, 2 out of 3 isn’t bad.

The cord banks do not charge mothers anything to donate even the cost to them is about $1500.  Some providers charge for drawing up the cord blood, so discuss that ahead of time.  Make sure you are clear that you are donating it, not banking it for personal use; that often makes a difference in the decision to charge for the service.

There are private cord blood banks out there.  With very few exceptions, it is so unlikely to be used by the donor or his/her family that it doesn’t justify the cost.  The American Academy of Pediatrics does not recommend private banking in most cases but encourages cord blood donations.  If you have specific questions, ask your doctor.

The National Marrow Donor Program states on their website that they urgently need donations from people of diverse racial and ethnic  backgrounds because of the current lack of donations from minority populations.

Interested or know a pregnant lady who might be?  Call the University of Colorado Cord Blood Bank at 303-724-1306 (before the 34^th week of pregnancy) or visit their website at www.clinimmune.com/cordbloodbank.  For more information you can also go to the National Marrow Donor Program at www.marrow.org

And make your baby a superhero from day one!

About Dr Konda

Dr Rachel Konda is a part time pediatrician at the Loveland Youth Clinic and a full time mom of 3 in Loveland, Colorado.  Her academic interests include pediatric emergency care, toxicology, breastfeeding, female adolescent medicine and asthma.    It has been her great privilege to volunteer at St Damien’s Hospital for Children in Tabarre, Haiti.

Her undergraduate degrees are in chemistry and French literature from Harvey Mudd College.  She did graduate work in chemistry at the University of Illinois before graduating medical school there.  She completed her residency at Akron Children’s Hospital, including research on the treatment of RSV in infants.  Prior to coming to the Loveland Youth Clinic she worked for Children’s Hospital Colorado as a hospitalist and in the emergency and urgent care departments.  She is a senior instructor of pediatrics at the University of Colorado.

Hiding Veggies

“All I can get him to eat is bread and pasta.”  “She won’t eat anything green.” “Is it possible for a kid to live on just milk?”  Sound familiar?  I hear comments like this every day in the office.  And while the government recently put out a more visual  “food plate” to replace the somewhat confusing food pyramid, (http://www.choosemyplate.gov/ ), a lot of adults are overwhelmed at the prospect of putting that many fruits and veggies on their own plates, never mind their kids’ plates.

The good news is, it’s okay to hide the veggies.  A study published this summer in the American Journal of Clinical Nutrition compared 2 groups of kids, one who ate standard “kid fare” and the other who ate the same foods but with hidden vegetable purees.  The kids who got the hidden veggies ate twice as many vegetables in a day and fewer calories.  There was no difference in how much each group ate, meaning the kids really couldn’t tell much of a difference.

This is a trick I use with my own family.  Finely grated zucchini and carrots hide well in chili, spaghetti sauce and even muffins.  Pureed cauliflower slides right into a bowl of mashed potatoes.  You can hide almost anything in meatloaf. If you are looking for some ideas, check out Jessica Seinfeld’s book Deceptively Delicious: Simple Secrets to Get Your Kids Eating Good Food or Missy Lapine’s The Sneaky Chef: Simple Strategies for Hiding Healthy Foods in Kids’ Favorite Meals. They are both available at the Loveland Library.  I admit that my kids weren’t big fans of the sweet potato chicken nuggets, but be willing to experiment a little.  If buying and steaming a bunch of veggies to puree is not your cup of tea, buy jars of baby food and just dump that in the pot.

Of course, we just wish they’d eat the veggies!  Try cutting them in fun shapes or encourage your kids to make edible artwork. Think ants on a log!  Cut them into slices and serve them with dipping sauces such as low-fat ranch dressing, hummus, peanut butter or (for fruits) flavored yogurt.  Let your child pick out a new food in the produce department on your next trip to the grocery store.  If you can, grow some vegetables of your own, even if it’s just a cherry tomato growing in a container on your porch next summer.  Kids are more willing to eat food they helped to grow.  Choose a country or type of cuisine and make a thematic dinner, including a new fruit or vegetable or an old stand by served a different way.

Repeat, repeat, repeat.  Foods that are served over and over again eventually before familiar and even comfort food.  Nutritionists tell us that kids usually need to be served a new food 8 – 10 times before they will accept it.

So institute one bite rule for the obvious healthy stuff, hide more in the comfort foods and then move on to the next battle.