Preventing and Treating Vitamin D Deficiency

More people seem to be getting the message that too little vitamin D in our diets can lead to health problems. In addition to being at risk of developing rickets (extreme vitamin D deficiency), children with milder forms of vitamin D deficiency can develop weak bones and muscle weakness.

Why is vitamin D so important?

Vitamin D is a hormone that helps our bodies absorb both calcium and phosphorous, two very important minerals that help keep our bones strong.

Without enough vitamin D, we absorb 85-90% less of the calcium in our diet! And then, to keep calcium levels normal, our bodies pull more calcium out of our bones, causing osteopenia and osteoporosis.

Some experts also think that a low vitamin D level is associated with other conditions that are not linked to calcium and our bones, including some psychiatric conditions. The American Academy of Pediatrics even states that “new evidence suggests that vitamin D plays a vital role in maintaining innate immunity and has been implicated in the prevention of certain disease states including infection, autoimmune diseases (multiple sclerosis, rheumatoid arthritis), some forms of cancer (breast, ovarian, colorectal, prostate), and type 2 diabetes mellitus.”

The role of vitamin D in preventing infections, cancer, or anything else beyond preventing and treating vitamin D deficiency (extraskeletal effects) is far from proven though. In fact, a 2010 investigation by the Institute of Medicine (IOM) didn’t find any evidence to support a role for vitamin D in any other health conditions besides supporting bone health.

Surprisingly to many people, the IOM report also found that most people in North America are already getting enough calcium and vitamin D in their diet and that getting too much can be harmful. They also warned that “the number of people with vitamin D deficiency in North America may be overestimated because many laboratories appear to be using cut-points that are much higher than the committee suggests is appropriate.”

Tests for Vitamin D Deficiency

Although vitamin D testing seems to becoming part of the routine screening tests that some doctors order, it is important to keep in mind that only those at risk for having low levels should be routinely tested.

Are your kids at risk for vitamin D deficiency?

These high risk children can include:

  • exclusively breastfed infants who don’t get a vitamin D supplement
  • babies born to mothers with a vitamin D deficiency, especially premature babies
  • children with chronic kidney or liver disease
  • children with malabsorption syndromes (Crohn’s disease, inflammatory bowel disease, cystic fibrosis, etc.), as vitamin D is absorbed with fats in our diet
  • obese children, because vitamin D is stored in fat tissue and is not readily available for use
  • children with dark skin, who live at high latitudes, and/or spend a lot of time indoors (less vitamin D from sun exposure)
  • children taking certain medications, including antiseizure medications and oral steroids
  • children who simply don’t get enough vitamin D – at least 400-600 IU of vitamin D each day, depending on their age. This might include vegetarians, vegans, and children who simply don’t drink vitamin D fortified cow’s milk, soy milk, or almond milk, etc., or other foods that are high in vitamin D.

If your child falls into one or more of these risk factors for vitamin D deficiency, then talk to your pediatrician about testing his vitamin D levels.

Although different tests are available, the test that is recommended by the AAP and the Endocrine Society is the serum 25(OH)D level (25-hydroxyvitamin D). This actually measures the levels of a prehormone of vitamin D, calcifediol, but is thought to give a good idea of a person’s vitamin D status.

This vitamin D test is preferred over testing 1,25(OH)2D levels, another test that is available, as those levels can be normal or even elevated when someone has a vitamin D deficiency. Similarly, measuring vitamin D levels (the active hormone) has not been found to be helpful. Instead, we use 25(OH)D levels as a marker for vitamin D levels.

Treating Vitamin D Deficiency

Is your child’s vitamin D level low?

That question is a actually a little harder to answer than you might realize. According to the IOM, in discussing cut-points for 25(OH)D levels, or what’s low and what’s normal, “At this time, there is no central body that is responsible for establishing such values for clinical use.”

The serum 25(OH)D level is typically defined as low (vitamin D deficiency) in children if it is below 20 ng/ml. Some experts think that a 25(OH)D level above 16 ng/ml is normal for infants and children though.

Experts do agree that a level below 5 ng/ml is a sign of a severe vitamin D deficiency.

Recommendations for treating children with low vitamin D levels depend on their age, and might include:

  • newborns: 1,000 IU /day vitamin D2 or D3
  • children 1 to 12 months old: 2,000 IU /day vitamin D2 or D3
  • children > 12 months old: 2,000 IU /day vitamin D2 or D3

These vitamin D supplements, together with adequate amounts of calcium, are usually continued for at least 1 to 3 months, at which time the child’s serum 25(OH)D level can be repeated to make sure it is responding to treatment.

“The upper limit for vitamin D is 1,000 to 1,500 IU/day for infants, 2,500 to 3,000 IU/day for children 1-8 years, and 4,000 IU/day for children 9 years and older, adults, and pregnant and lactating teens and women. Vitamin D toxicity almost always occurs from overuse of supplements.”

NIH Vitamin D Fact Sheet for Consumers

The Endocrine Society also advises that some children can take 50,000 IU of vitamin D2 once a week as an alternative treatment for vitamin D deficiency. Since you can definitely get too much vitamin D, be sure to talk to your pediatrician and make sure your child is getting the right dose before starting a treatment regimen for vitamin D deficiency.

Preventing Vitamin D Deficiency

Once you get your child’s vitamin D levels back into a normal range, it is important to take steps so that they don’t drop again.

To prevent vitamin D deficiency, the American Academy of Pediatrics recommends that healthy infants get at least 400 IU of vitamin D each day, while older children – toddlers to teens – get at least 600 IU. This vitamin D should come from some combination of:

  • foods that are naturally rich in vitamin D – salmon, tuna, shitake mushrooms, etc.
  • foods that are fortified with vitamin D – vitamin D fortified milk, orange juice, cheese, yogurt, margarine, and cereal, etc.
  • a vitamin D supplement – with just vitamin D, vitamin D plus calcium, or a children’s multivitamin

What about sunlight? Can’t your kids just spend more time in the sun to boost their vitamin D levels?

Although we all have the ability to make vitamin D when we are out in the sun, it isn’t considered a good source of vitamin D. Intentional, unprotected (no sunscreen) exposure to the sun has risks of sunburn and skin cancer. And it is very hard to judge how much sun exposure is necessary to get adequate amounts of vitamin D. The intensity of the sun’s radiation varies greatly in different parts of the world and at different times of year and will also affect how much vitamin D your body makes.

Other Things To Know about Vitamin D Deficiency

  • Raw milk, in addition to being unprocessed and unpasteurized, is unfortified and has very little vitamin D.
  • Although other foods may be fortified with vitamin D, in the United States, only milk, margarine, infant formula, and “fortified-plant based beverages” are mandated by the FDA to be vitamin D fortified.
  • In addition to low 25(OH)D levels, children with vitamin D deficiency will often have low phosphorous, high alkaline phosphatase, and high parathyroid hormone levels. These levels might be checked and monitored when kids are treated for vitamin D deficiency.
  • Vitamin D2 (ergocalciferol, derived from plants) and vitamin D3 (cholecalciferol, derived from animals) are two major forms of vitamin D. Some experts think that vitamin D3 is more potent than vitamin D2, especially at higher doses. Still, these prohormones are converted to the same active form of vitamin D (calcitriol) in the liver and kidney.
  • Some experts think that 25(OH)D levels between 21 and 30 ng/ml are a sign of vitamin D insufficiency in children, as in adults, and are a sign that the child needs more vitamin D in their diet.
  • Although the use of sunscreen can block the synthesis of vitamin D by blocking UVB radiation and has been blamed for lower vitamin D levels in recent years, many people likely don’t use sunscreen properly and don’t use it consistently enough and so “sunscreen use may not actually diminish vitamin D synthesis in real world use.”
  • Taking high doses of vitamin D is yet another nutrition fad which has been linked to serious consequences. Mega doses of vitamin D have been linked to kidney problems and tissue damage. That makes it important to stay below the upper limit that your child can likely take each day without causing harm, which ranges from 2,500 IU/day for toddlers to 4,000 IU/day for teenagers. Most only need 400 to 600 IU/day though.

Children with severe vitamin D deficiency are often managed by a pediatric endocrinologist or a pediatric nephrologist.

More Information on Treating Vitamin D Deficiency

  • AAP – Vitamin D: On the Double
  • The rise and inevitable fall of Vitamin D
  • Help Your Child Build Healthy Bones
  • NIH Vitamin D Fact Sheet for Consumers
  • Study – American Academy of Pediatrics Clinical Report. Optimizing Bone Health in Children and Adolescents. Pediatrics. Pediatrics Oct 2014, 134 (4) e1229-e1243
  • Study – Institute of Medicine Report. Dietary Reference Intakes for Calcium and Vitamin D. Released: November 30, 2010.
  • Study – The Endocrine Society. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism, July 2011, 96(7):1911–1930.
  • Study – Misra, M. Vitamin D Deficiency in Children and Its Management. Pediatrics, Aug 2008; 122: 398 – 417.

Avoiding Confusion During an Allergy Attack – Adrenaclick vs EpiPen Directions

Whether you have an EpiPen or Adrenacick injector, make sure everyone around your child with allergies knows how to use it.
The FARE Food Allergy & Anaphylaxis Emergency Care Plan provides detailed instructions for all available epinephrine injectors.

The price of EpiPens has been in the news a lot recently.

Most people know that they went Mylan’s EpiPen 2-Pak went from costing about $100 in 2006 to over $600 today and that there has been little or no competition.

One competing device, Auvi-Q was recalled in 2015, but it was fairly expensive too.

Good News and Bad News About EpiPens

Things have gotten better recently.

First, a generic EpiPen 2-Pak is now available. It costs $339.99. While still expensive, it does lower co-pays for many people with good insurance.

The latest news? A generic Adrenaclick injector for $109.99 at CVS pharmacies.

Even better, coupons are available that can make the injectors free for many people.

So what’s the bad news?

The directions for using the EpiPen 2-Pak and the Adrenaclick are not the same. That can cause some confusion. Do you want someone to grab one and not be sure how to use it when your child is having a life-threatening allergic reaction?

That makes it important for everyone to be familiar with both types of epinephrine injectors.

Adrenaclick vs EpiPen 2-Pak Directions

The fact that the Adrenaclick has two caps that you need to remove before use, while the EpiPen only has one, can lead to confusion. Also, the Adrenaclick injector, despite its name, doesn’t actually ‘click’ after you use it, like the EpiPen does.

EpiPen 2-Pak auto-injector directions:

  1. Remove the EpiPen Auto-Injector from the clear carrier tube to find an EpiPen Jr (green label) or EpiPen (yellow label).
  2. Remove the blue safety release by pulling straight up without bending or twisting it.
  3. Swing and firmly push orange tip against mid-outer thigh until it ‘clicks’.
  4. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
  5. Remove auto-injector from the thigh and massage the injection area for 10 seconds.

Remember that the orange end is the needle end! And you know that your child got your dose if you heard the click sound.

Adrenaclick epinephrine auto-injector directions:

  1. Remove the outer case.
  2. Remove grey caps labeled “1” and “2”.
  3. Place red rounded tip against mid-outer thigh.
  4. Press down hard until needle enters thigh.
  5. Hold in place for 10 seconds. Remove from thigh.

With the Adrenaclick injector, the red tip end is the needle end! Do not touch this end or you could unintentionally inject your self. After use, the needle should be visible.

Avoiding Confusion About Your Epinephrine Injector

All of the epinephrine injectors are easy to use. At least on paper.

In the heat of the moment though, when a child is having a life-threatening allergic reaction, it may not seem so easy though.

It will likely be even more difficult if the epinephrine injector you grab is not what you are expecting. Make sure you know how to use your epinephrine injector, both when your pediatrician prescribes it and when your pharmacist dispenses it to you (in case you get a different one, which is allowed in some states).

  1. Read the instructions.
  2. Watch a video.
  3. Use a trainer device.
  4. Be prepared!

It is also important that anyone that watches your child, whether it is a family member or the school nurse, knows how to use your child’s epinephrine injector.

“Individuals and caregivers are often reluctant to use self-injectable epinephrine in anaphylaxis despite instruction to do so.”

Pediatrics March 2007

Other things that can lead to confusion about epinephrine injectors include that you:

  • use an EpiPen or Adrenaclick training pen instead of the real injector with active medication when your child is having an anaphalytic reaction
  • use the real injector when you meant to use the training pen
  • don’t carry your child’s epinephrine injector with you at all times, which is why it is important to get more than one injector each time, allowing you to keep one at school, one at home, and one and travels with your child, etc., eventually allowing your child to carry his or own epinephrine injector at an age-appropriate time
  • forget to move to a higher dose of epinephrine as you child grows, keeping in mind that the Jr (0.15mg) dosing is only for kids under 66 pounds
  • aren’t sure when to use your EpiPen or Adrenaclick injector or are afraid to use it, which can lead to an unnecessary delay in your child getting a lifesaving treatment
  • don’t get a refill if your epinephrine injectors have expired or you actually needed to use one
  • understand that you still need to call 911 after you have used your epinephrine injector, even if your child begins to immediately feel better. Symptoms can return, which is why you are given two doses (2-Pack) of epinephrine.

A good Food Allergy & Anaphylaxis Emergency Care Plan can help avoid much of this confusion. In addition to easy to read instructions on when to give epinephrine, this type of plan should include directions for your child’s epinephrine injector.

When in doubt – you should usually give epinephrine if you have any concerns that your child is having an anaphylactic reaction. It is a safe medicine.

More Information About Epinephrine Injectors

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How To Avoid Peanut Allergies

Infants with eczema are at high risk for developing peanut allergies.
Infants with eczema are at high risk for developing peanut allergies. Photo courtesy of the NIAID.

The worst part of having a severe allergy to peanuts isn’t the high price of EpiPens.

It is that peanut allergies can be deadly, even when you have access to an EpiPen.

And since there is no 100% fool proof way to avoid peanuts and peanut containing foods, doctors have been trying to come up with ways to prevent kids from ever developing peanut allergies.

The first efforts, to avoid peanuts and other high risk foods during pregnancy and early infancy, likely backfired, leading to even more kids with peanut allergies. That’s why recommendations for starting solid foods changed back in 2008, when the American Academy of Pediatrics began to tell parents to no longer delay giving solid foods after age 4 to 6 months and that it wasn’t necessary to delay “the introduction of foods that are considered to be highly allergic, such as fish, eggs, and foods containing peanut protein.”

The latest guidelines are the next evolution of that older advice.

Now, in addition to simply not delaying introducing allergy type foods, as part of a new strategy to prevent peanut allergies, parents of high risk kids are being told to go out of their way to be sure that they actually give their infants peanut-containing foods!

Prevention of Peanut Allergies

Developed by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, with 25 professional organizations, federal agencies, and patient advocacy groups, these clinical practice guidelines recommend that parents:

  1. introduce peanut-containing foods into your infant’s diet as early as 4 to 6 months of age if they have severe eczema, egg allergy, or both (strongly consider allergy testing first)
  2. introduce peanut-containing foods into your infant’s diet around 6 months of age if they have mild to moderate eczema
  3. introduce peanut-containing foods into your infant’s diet in an age-appropriate manner with other solid foods if your infant has no eczema or any food allergy

Keep in mind that it is possible that your baby already has a peanut allergy, so discuss your plan to introduce peanut-containing foods with your pediatrician first. But don’t be in such a rush that you make peanut-containing foods your baby’s first food. Offer a cereal, veggie, fruit, or meat first. If tolerated, and you know that your baby is ready for solid food, and with your pediatricians okay, then consider moving to peanut-containing foods.

And although not always necessary, it is possible to do allergy testing even on younger infants. Testing is an especially good idea if your infant has severe eczema or an egg allergy. For these higher risk kids, referral to an allergy specialist might even be a good idea, where infants can start peanut containing foods in their office (supervised feeding) or as part of a graded oral challenge. Your pediatrician might also consider supervised feeding for your higher risk child who is not allergic to peanuts.

Peanut-Containing Baby Food Recipes

So how do you give a 4 or 6 month old peanut-containing foods?

It’s not like Gerber has any 1st or 2nd foods with peanuts – at least not yet…

So for now, you can:

  • add 2 to 3 tablespoons of hot water to 2 teaspoons of thinned, smooth peanut butter. Stir until the peanut butter dissolves and is well blended. You can feed it to your baby after it has cooled.
  • mix 2 to 3 tablespoons of a fruit or veggie that your baby is already tolerating in 2 teaspoons of thinned, smooth peanut butter.
  • mix 2 to 3 tablespoons of a fruit or veggie that your baby is already tolerating in 2 teaspoons of peanut flour or peanut butter powder.

Each of these recipes will provide your baby with about 2g of peanut protein. Since the goal is to give your child about 6 to 7g a week, you should offer them three separate times.

During the first feeding, it is important to only “offer your infant a small part of the peanut serving on the tip of the spoon,” and then wait for at least 10 minutes to make sure there are no signs of an allergic reaction, such as hives, face swelling, trouble breathing, or vomiting, etc.

Of course, because of the risk of choking, you should not give infants or toddlers whole peanuts or chunks of peanut butter.

More Information on Preventing Peanut Allergies

Ten Things That Aren’t As Scary As Most Parents Think

Being a parent can be scary enough.

Don’t let these every day parenting issues freak you out even more.

Be prepared for when you child eats a bug, has a night terror, or wakes up barking like a seal.

  1. Breath holding spells – in a typical breath holding spell, a young child cries, either from a tantrum or a fall, etc., and then holds his breath (involuntarily) and briefly passes out. Although it sounds scary and the episode might look like a seizure, these kids usually quickly wake up and are fine after. Kids who have breath holding spells are often prone to repeated spells though, so you do want to warm other caregivers so they don’t freak out if your child has one. Eventually, kids outgrow having them.
  2. Febrile Seizures – parents often describe their child’s first febrile seizure as ‘the worst moment of their life.’ Febrile seizures typically occur when a fever rises rapidly, but although they are scary, they are usually brief, stop without treatment, don’t cause any problems, and most kids outgrow having them by the time they are about five years old.
  3. Nosebleeds – a nosebleed that doesn’t stop is certainly scary, but with proper treatment, most nosebleeds will stop in ten to twenty minutes (if not sooner), even if your child wakes up in the middle of the night with a bloody nose for what you think is no reason.
  4. Night terrors – often confused for nightmares, a child having a night terror will wake up in the early part of the night yelling and screaming, which is why parents think their child is having a nightmare. The scary thing though, is that their child will be confused, likely won’t recognize you, and might act terrified – and it all might last for as long as 45 minutes or more. Fortunately, night terrors are normal. Your child likely won’t even remember what happened the next morning. And they eventually stop.
  5. Eating a Bug – “Kids eat bugs all the time. Few if any symptoms are likely to occur.” – that’s a quote from the National Capital Poison Center, who must get more than a few calls from worried parents about their kids eating bugs. Or finding the evidence later – when you see a dead bug in their diaper…
  6. High Fever – pediatricians have done a lot of education about fever phobia over the years, but parents often still get scared that a high fever is going to cause brain damage or hurt their child in some other way. Try to remember that fever is just another symptom and doesn’t tell you how sick your child is.
  7. Playing Doctor – even though it’s natural for young kids to be curious about their bodies, the average parent is likely going to be scared and upset if they “catch” their kids playing doctor. Understand that it is usually a normal part of child development and don’t turn it into a problem by making it into more than it is.
  8. Hives – a child with classic hives might have a red raised rash develop suddenly all over his body. And since hives are very itchy, that child is probably going to be miserable, which can make hives very scary, even though without other symptoms (like vomiting or trouble breathing), they typically aren’t a sign of a serious allergic reaction. The other thing about hives that can be scary is that even when they go away with a dose of Benadryl, they often come back – sometimes for days, but often for weeks. And your pediatrician might not be able to tell you what triggered them.
  9. Croup – your child goes to bed fine, but then wakes up in the middle of the night with a strange cough that sounds like a barking seal, has a hoarse cry, and it seems like he is wheezing. Scary, right? Sure, but if you realize he probably has croup and that some time in the bathroom with a hot shower (getting the room steamy can often calm his breathing), you’ll be ready for this common viral infection.
  10. Choking – while choking can be a life-threatening emergency, most episodes of choking aren’t. In addition to learning CPR and how to prevent choking, remember that if you child “is still able to speak or has a strong cough” then you may not have to do anything, except maybe 911 if he or she is having some breathing difficulties. It is when your child is choking and can not breath at all (and can’t talk and isn’t coughing) that you need to quickly react and do the Heimlich Maneuver while someone calls 911.

Even with a little foreknowledge and preparation, many of these very common pediatric issues are scary. Don’t hesitate or be afraid to call your pediatrician for more help.

For More Information on Things That Scare Parents

Twenty One Things Every Parent Should Know

There is no need to use hydrogen peroxide on cuts and scrapes.
There is no need to use hydrogen peroxide on cuts and scrapes. Use soap and water instead.

You could just parent by instinct, but it is much better to supplement your instinct with a little helpful advice from some of the parents who have come before you.

While some of these things experts figured out through years and years of research, others are simply tips that folks figured out after making mistakes and understanding that there must be a better way to get things done.

  1. Vaccines are safe, necessary, and they work.
  2. Sleep is good. For everyone. Learn to help your baby sleep through the night by the time they are four to six months old.
  3. Three years is not a magic age at which every kid is potty trained. Some take a little longer. The main potty training mistake you can make is to push your kids when they aren’t ready.
  4. Some kids continue to wet the bed at night, even after they are potty trained.
  5. Don’t give aspirin to kids, even teens. It is a risk factor for getting Reye syndrome.
  6. If you still have them, safely dispose of mercury thermometers and syrup of ipecac.
  7. Experts don’t recommend that you use hydrogen peroxide to clean wounds any more. You can usually substitute soap and water instead.
  8. “Starve a fever; feed a cold” is an Old Wives’ Tale, like not drinking milk when your kids have a fever or diarrhea. It is not a real thing. If your child is sick and hungry, let them eat their regular diet. If they are sick and don’t want to eat, encourage them to at least drink a lot of fluids, and add bland foods, until they are ready to eat more.
  9. A green or yellow runny nose almost certainly means that your child has an infection, but unless it has been lingering for weeks or your child has a persistent high fever, then it is likely a viral infection that won’t respond to antibiotics.
  10. When your doctor prescribes antibiotics for your kids, think about whether the prescription is because your sick child needs it or because the doctor thinks you want it. Consider asking if your child might get better without antibiotics.
  11. Don’t force kids to “clean their plates” or eat foods that they really dislike. Picky eaters who are forced to eat are probably more likely to grow up to be picky adult eaters.
  12. Most kids, unless they are missing out on one or more food groups or have a chronic medical problem, probably don’t need a daily vitamin.
  13. Don’t just ask your kids if they are being bullied. Also ask if they ever bully  or see kids getting bullied. Someone is doing the bullying.
  14. All kids are different. Don’t compare them. Or at least don’t compare them too much. But talk to your pediatrician if your child’s growth and development really seems off-track compared to most other children.
  15. Some kids are harder to discipline than others. Try something else or get help if what you are doing isn’t working.
  16. Taking extra unnecessary risks, like hiding a loaded gun in the house, not having a fence around your backyard swimming pool, letting your kids ride a bike without a helmet, or letting them ride an ATV, etc., will increase the chances that your kids get hurt. Think about safety.
  17. Not every kid wants to play or is going to be good at team sports.
  18. Being on a “select” sports team probably doesn’t mean what you think it means. The selection process is just as likely to involve the fact that you can pay to be on the team and take extra lessons or classes, as it is to about your child’s skill level.
  19. For perspective, always remember that no matter how good or talented you think your child is, there is always another kid playing at a much higher level. That’s why so few end up playing in college or at higher levels.
  20. At some point, you child might say “I hate you!” Be ready, and understand that it almost certainly has nothing to do with you.
  21. The ‘free range kids’ movement is the opposite extreme to ‘helicopter parenting.’ Don’t fall for parenting fads.

And don’t believe everything you hear or read about parenting. Kids do come with instructions – good instructions, you just have to know when and where to get them. And who to trust.

Otherwise you could end up making all of the same mistakes that all of the rest of us have already made.

For More Information on Things Parents Should Know

Treating Hard to Control Nosebleeds

Parents usually get scared when their kids get a nosebleed.

Fortunately, most nosebleeds aren’t serious. That doesn’t make them less scary when they are happening though, especially when it is your first or it doesn’t stop right away.

Nosebleeds

There are two things to understand about nosebleeds in kids. They are common and most of the things that you probably know about stopping them aren’t very helpful.

We no longer recommend tilting a child’s head back during a nosebleed, pinching the bridge of their nose, stuffing tissue into their nostrils, or holding a tissue lightly against their nostrils. Although your child’s nose will likely eventually stop bleeding with these methods, it will take a long time and it won’t be from any of those interventions.

Treating Nosebleeds

When your child has a nosebleed, the best treatment advice is to:

  • have your child sit down
  • encourage them to lean forward
  • pinch the tip of their nostrils firmly for five or ten minutes with their fingers or a tissue if it is available (don’t check every few minutes to see if it has stopped)
  • continue to pinch for another ten minutes if it is still bleeding (again, wait and don’t check every few minutes to see if it has stopped)
  • for persistent bleeding, some experts recommend blowing out the clot, spraying a nasal decongestant into your child’s nostril, and then applying firm pressure for ten minutes

If blood is still coming out while you are pinching the soft, lower part of your child’s nose, then you likely aren’t pinching firmly enough or may not be pinching in the right spot. Pinching the bony part doesn’t help.

Keep in mind that it takes at least a few days for blood vessels to heal, so your child  might easily get another bloody nose in the hours or days after a nosebleed. That’s why some kids might get a nose bleed without really doing anything to provoke it.

After a bloody nose, you might encourage your child to avoid blowing out the clot in their nostrils and leave their nose alone.

Treating Hard to Control Nosebleeds

What about if your child has hard to control nosebleeds?

If the nosebleed is hard to control because it just won’t stop after about 20 minutes, then you likely need to seek quick medical attention.

On the other hand, if you can stop your child’s nosebleeds, but they are hard to control because they keep coming back, then ask yourself these questions and share the answers with your pediatrician:

  • Are your child’s nosebleeds seasonal, which could mean that allergies are a trigger?
  • Have you been using a nasal steroid to treat your child’s allergies? Nosebleeds can sometimes be a side effect of using a steroid nose spray, especially if you don’t spray towards the outside of the nostril when you use them.
  • Does your child frequently pick his nose?
  • Have you noticed any other signs of heavy bleeding or easy, large bruising? If not, a bleeding disorder is almost certainly not causing your child’s nose to bleed.
  • Do your child’s nosebleeds increase in the winter, when it is dry in the house?
  • Does anyone in the house smoke? Second hand smoke is an irritant.
  • Has your child been using a nasal decongestant for more than a few days? That can dry out your child’s nasal passages and lead to nose bleeds.
  • Could your child’s head or nose have been hit recently?
  • Did your child stick anything in his nose?

In addition to treating uncontrolled allergies, things that might help chronic nosebleeds include keeping your child’s nails cut short, encouraging your child to not pick his nose, using nasal gel (or Vaseline) or saline spray to keep your child’s nostrils moist (can discourage picking too), using a cool mist humidifier (this can increase mold and dust mites and make allergies worse though), and avoiding second hand smoke.

A pediatric ENT can help your child with chronic nosebleeds when routine treatments don’t work. Although a little painful, cautery with a silver nitrate stick is an option to seal blood vessels in the nose for some kids who keep getting nosebleeds.

What To Know About Treating Hard to Control Nosebleeds

Don’t panic when your child has a bloody nose. Instead, encourage them to sit, lean, pinch, and wait and learn to prevent chronic nosebleeds.

More Information About Treating Hard to Control Nosebleeds

Treating Hard to Control RSV

With a cough, wheezing, and trouble breathing that can linger for weeks, all RSV infections probably seem like they are hard to control, especially since up to 2% of kids, mostly high-risk infants, with RSV require hospitalization.

Still, it’s important to remember that for many kids, RSV is just a cold.

Understanding RSV

Since there is no cure or treatment, it is best to learn to protect your kids from RSV.
Since there is no cure or treatment, it is best to learn to protect your kids from RSV.

The first thing to understand about RSV is that it isn’t a disease.

Instead, RSV, or the respiratory syncytial virus, can cause many different kinds of upper and lower respiratory infections, ranging from the common cold and croup to bronchiolitis and viral pneumonia.

And almost all kids get sick with RSV at some point during the first few years of their life, especially if they are in daycare.

Fortunately, although RSV can cause life-threatening infections, especially in high-risk infants, the great majority of  children get over their symptoms without any special treatments.

And infants who are the most high risk, including premature babies who were born at less than 29 weeks, can get five monthly doses of palivizumab (Synagis) during RSV reason to reduce their chances of getting sick. Infants with hemodynamically significant heart disease or chronic lung disease of prematurity can also get palivizumab.

Treating RSV

Many of the classic treatments for RSV have now fallen out of favor with pediatricians. In fact, the American Academy of Pediatricians now advises against using albuterol breathing treatments, epinephrine, steroids, or chest physiotherapy (CPT) for infants with RSV bronchiolitis.

What’s left?

Not much, except pushing your child to drink and treating cold symptoms as possible.

The AAP even advises against routinely testing kids for RSV. That makes sense, since there is no treatment, kids can sometimes be contagious for 3 to 4 weeks, long after they have returned to daycare without symptoms, and other viruses can cause similar symptoms.

Instead, if your child has symptoms of RSV, especially if she was around someone else with RSV symptoms about two to eight days ago or is simply in daycare during RSV season (usually November to April), then it is safe to assume that your child has RSV.

Also understand that antibiotics have no role in the treatment of uncomplicated RSV infections. RSV is a virus. Antibiotics do not work against viral infections.

Going to Day Care with RSV

Since many kids who get RSV are in day care, the million dollar question often becomes, when can my child with RSV go back to day care?

“Most minor illnesses do not constitute a reason for excluding a child from child care, unless the illness prevents the child from participating in normal activities, as determined by the child care staff, or the illness requires a need for care that is greater than staff can provide.”

AAP Red Book 2015

Although I once had the manager of a day care argue with me that a child needed to test RSV negative before being allowed back into her day care, kids can usually go back, even if they still have cold symptoms, as long as they:

  • don’t have a fever for 24 hours
  • don’t have any trouble breathing
  • are not fussy or irritable

Since these kids will likely be contagious, the AAP recommends that “In child care centers, good hygiene practices should be used by the staff and the children, including frequent and thorough hand washing.”

Treating Hard to Control RSV

If your child has RSV symptoms and isn’t getting better, ask yourself these questions and bring the answers to your pediatrician or seek quick medical attention:

“Some youngsters with bronchiolitis may have to be hospitalized for treatment with oxygen. If your child is unable to drink because of rapid breathing, he may need to receive intravenous fluids.”

American Academy of Pediatrics

  • Do you think your child’s symptoms are hard to control, not because they are getting worse, but rather because they are lingering for several weeks, which can be normal when young kids have RSV?
  • Does your newborn or infant under two or three months have a fever (temperature at or above 100.4F/38C)?
  • Is your child having trouble breathing, such as breathing fast or hard, with chest retractions (chest caving in), nasal flaring, trouble catching his breath, or a non-stop, continuous cough?
  • Do you see any signs that your child isn’t getting enough oxygen, including that “his fingertips and the area around his lips may turn a bluish color?”
  • Is your child dehydrated, with less urine output, dry mouth, or no tears?
  • Does your child have any medical problems that put her at higher risk for a severe RSV infection, including extreme prematurity, having complex heart disease, chronic lung disease of prematurity, or immune system problems?
  • Is your child lethargic, which doesn’t simply mean that he is just playing less, but rather that he is actually hard to wake up and is maybe skipping feedings?

If your child with RSV is getting worse, although there aren’t any special treatments to make the RSV infection go away, supportive care is available to help your child through it, including IV fluids and supplemental oxygen. Those who are most sick sometimes end up on a ventilator to help them breath, and tragically, some infants with RSV die.

What To Know About Treating Hard to Control RSV

RSV is never really easy to control for infants and toddlers, as there is no treatment or cure, but fortunately, most kids do not have severe symptoms that require hospitalizations.

More Information About Treating Hard to Control RSV

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