Is Acute Flaccid Myelitis Contagious?

Do we really know whether or not acute flaccid myelitis is contagious or not?

Many people were surprised by a comment by Dr. Robert Redfield, the director of the Centers for Disease Control and Prevention, in an interview for “CBS This Morning,” during which he said that acute flaccid myelitis:

“doesn’t appear to be transmissible from human to human.”

Wait, then how do kids get it?

Is Acute Flaccid Myelitis Contagious?

Since we don’t actually know what causes AFM, it is certainly possible, although rather unlikely, that it is caused by something that is not communicable.

But remember, the leading theory is that AFM is caused by an enteroviral infection, either EV-D68 and EV-A71, as most kids develop symptoms shortly after they had viral symptoms, and these two viruses are most commonly identified.

And you are typically contagious when you are sick with an enteroviral infection.

So how can the CDC Director say that AFM “doesn’t appear to be transmissible from human to human?”

It is because even if the virus that causes AFM is communicable, you can’t actually catch AFM from someone.

adult child cooperation daylight
Wash your hands to help avoid viral infections. Photo by Andres Chaparro on Pexels.com

Just like polio.

While the polio virus itself is communicable, paralytic polio isn’t. You can’t catch paralytic polio. Instead, you can catch polio, and then you have the small chance that it develops into paralytic polio.

It may not sound like a big difference, but it is.

Just consider what might happen if AFM itself was contagious, and if most of the kids who were exposed to someone with AFM developed AFM themselves…

We would likely see a lot more cases of AFM, especially in clusters in homes, daycare centers, and schools.

Instead, most cases seem to be isolated.

AFM Clusters

But aren’t there reports of clusters of AFM?

“In September 2016, an acute care hospital in Arizona notified the Maricopa County Department of Public Health (MCDPH) of a suspected case of AFM and subsequent cluster of 11 children who were evaluated with similar neurologic deficits; differential diagnoses included transverse myelitis and AFM.”

Notes from the Field: Cluster of Acute Flaccid Myelitis in Five Pediatric Patients — Maricopa County, Arizona, 2016

Yes, kind of.

But they aren’t clusters of epidemiological linked cases.

In Arizona, for example, only four of the 11 children were confirmed to have AFM and “no epidemiologic links were detected among the four patients.”

“In October 2016, Seattle Children’s Hospital notified the Washington State Department of Health (DOH) and CDC of a cluster of acute onset of limb weakness in children aged ≤14 years.”

Acute Flaccid Myelitis Among Children — Washington, September–November 2016

Similarly, at Seattle Children’s Hospital, the ten cases in their “cluster” had nothing in common, except for having prodromal respiratory or gastrointestinal symptoms about seven days before developing AFM symptoms.

It is likely that you see “clusters” at some hospitals simply because they are referral hospitals for a large region.

But even if we don’t know why some kids with these viral infections develop paralysis and other don’t, if they are the cause, then you wouldn’t develop AFM if you never actually had the virus.

“While we don’t know if it is effective in preventing AFM, washing your hands often with soap and water is one of the best ways to avoid getting sick and spreading germs to other people.”

About Acute Flaccid Myelitis

So handwashing and avoiding others who are sick is still the best strategy to try and avoid getting AFM.

And getting vaccinated against polio and using insect repellents can help you avoid other known causes of AFP – polio and West Nile virus.

More on Preventing AFM

5 Rare Syndromes That Parents Should Learn About

Learn when to suspect that your child might have a rare syndrome, like EDS, PANS/PANDAS, or a mito disorder.

I’ve talked about classic and uncommon diseases that parents should learn about before. From acanthosis nigricans to volvulus, they are conditions that are fairly common. Or at least not rare.

There are another group of syndromes that it can be good to be aware of, not necessarily because you will ever know someone that is affected by them, but rather because they are so hard to diagnosis, increased awareness is important.

5 Rare Syndromes That Parents Should Learn About

What are these rare syndromes? They include:

  • Ehlers-Danlos syndromes – now includes thirteen subtypes of connective tissue disorders, at least one of which can cause infants to have repeated, unexplained fractures that can be confused with child abuse
  • Mitochondrial genetic disorders or mito – genetic diseases that can affect multiple organ systems in the body and can cause a variety of signs and symptoms, from developmental delays and muscle weakness to seizures. The type of mutation and whether it is in mitochondrial DNA or nuclear DNA determines the type of mito disorder, of which there are many, including Alpers syndrome, Barth syndrome, Co-enzyme Q10 deficiency, Kearns–Sayre syndrome, Leigh syndrome, MELAS, and Pearson’s syndrome, etc.
  • PANDAS – Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections is characterized by OCD and/or tics that appear or suddenly worsen after a strep infection. With the OCD, these young kids might also have anxiety, including separation anxiety, depression, irritability, regression in their behavior, sleep problems, or school problems, etc. Although it has since been renamed PANS, Pediatric Acute-onset Neuropsychiatric Syndrome, you should still have the “temporal association between Group A streptococcal infection and symptom onset/exacerbations” to have PANS.
  • POTS – teens with Postural Orthostatic Tachycardia Syndrome have dizziness, fatigue, headaches, nausea, difficulty concentrating and other disabling symptoms related to alterations or dysfunction in the autonomic nervous system (dysautonomia). POTS is actually fairly common. What’s rare is for parents and pediatricians to know about POTS, and to therefore get kids diagnosed.
  • Vocal cord dysfunction – often misdiagnosed as asthma, especially exercise induced asthma, and other things, kids with vocal cord dysfunction often have episodes of repeated shortness of breath, chest tightness, wheezing, and coughing – just like asthma. They don’t improve though, even as more asthma medicines are added, which should be a red flag that these kids don’t have asthma and could have vocal cord dysfunction instead.

Have you ever heard of these disorders? No one would be surprised if you hadn’t.

Although a few are indeed rare, even when children do have them, it often takes years and years and visits to many different doctors before many of these kids finally get a diagnosis. That can mean years and years of unnecessary treatments and more importantly, the missed opportunity to get the proper treatment and hopefully relief for your child’s symptoms.

Why don’t all doctors learn more about these conditions so that they can be sure to recognize them as early as possible?

It’s not that simple. For every teen you every see with POTS, there will likely be dozens with vasovagal syncope or orthostatic hypotension. Same goes with the Ehlers-Danlos syndromes, which can sometimes be confused with the more common hypermobility spectrum disorders, which might just cause kids to have some extra aches and pains.

Tips for Getting a Diagnosis for These Rare Syndromes

How can you get a quick, or relatively quick diagnosis if your child has one of these syndromes? A little luck and a lot of increased awareness. This can also help avoid getting diagnosed when your child probably shouldn’t.

“Vocal cord dysfunction is an asthma mimic. Diagnosis of this condition requires a high index of suspicion if unnecessary treatments are to be avoided.”

Varney et al on The successful treatment of vocal cord dysfunction with low-dose amitriptyline

It can especially help to understand that:

  • Children with EDS often score 6 out of 9 on the Breighton scale.
    Children with EDS have hypermobility and often score 6 out of 9 on the Beighton scale. (Photo by Cattalini et al CC by 4.0)

    you might suspect that your child has one of the Ehlers-Danlos syndromes if they seem to be “double jointed,” often complain of growing pains, have a lot of sport’s injuries, poor wound healing, and/or skin that is hyper-extensible.

  • mitochondrial disorders are rare and children often don’t have classic signs or known genetic defects that make getting a diagnosis easier. There are checklists of signs, symptoms, and physical exam findings to look for, testing that can be done, and family history to look for, that may help if you suspect that your child has a mito disorder. Why would you suspect that your child has a mito disorder? They might have unexplained low muscle tone (hypotonia), muscle weakness, poor growth (failure to thrive), seizures, and lactic acidosis.
  • there aren’t always easy blood tests that help to make these diagnoses. Even when there are, like in the case of PANS/PANDAS, an elevated strep titer, some health care providers will make a diagnosis with a titer that isn’t really elevated or isn’t rising. Or in a child that has had no evidence of a strep infection. You should suspect PANDAS when a younger child (before puberty) suddenly develops (abrupt onset) obsessions, compulsions, and/or tics.
  • since many teens have issues with dizziness and fatigue, to make a diagnosis of POTS, they should have a real tilt test which demonstrates that their heart rate goes up at least 30 to 40 beats per minute within 10 minutes of going from a supine (lying down) to a standing position. The problem is that many health care providers do the tilt testing improperly, getting heart rate and blood pressure measurements at the wrong time. The easiest way to do a tilt test (active stand test) is to have the child lie down for a good 10 minutes, and check their heart rate and blood pressure. Then have them stand up (being careful they don’t faint) and check them again immediately, noting the differences.
  • although vocal cord dysfunction can be triggered by the same things and have the same symptoms as asthma, the treatments are greatly different. Instead of asthma inhalers, kids with vocal cord dysfunction learn breathing techniques and might get voice therapy. Other clues that a child might have vocal cord dysfunction include normal pulmonary function tests, that they have stridor, instead of wheezing, and that episodes come and go more quickly than a typical asthma attack.

With a prevalence of about 1 in 5,000 people, the average pediatrician might never see a child with EDS or a mito disorder.

Pediatricians are much more likely to see kids with PANDAS, POTS, and vocal cord dysfunction. More awareness  of all of these syndromes can help make sure that kids get a quick diagnosis and proper treatments.

A referral to a pediatric specialist or team of specialists can also be helpful if you suspect that your child has any kind of rare or unexplained syndrome.

What to Know About Getting a Diagnosis for These Rare Syndromes

Your pediatrician can help if you suspect that your child has any of these difficult to diagnose conditions.

More on Getting a Diagnosis for These Rare Syndromes

Get Control of Your Child’s Allergy Triggers

Identifying your child’s allergy trigger or allergy season won’t make them away. It can help you learn to avoid or control them though, or at least help get prepared by starting your child’s allergy medicines before he is exposed.

What’s triggering your child’s allergies and asthma?

Is it the cat?

The roses she loves to smell?

The dust on all of the stuffed animals in her room?

The Cottonwood tree blooming in the yard next door?

How do you know?

Identifying Allergy Triggers

Roses are not a common allergy trigger.
Roses are not a common allergy trigger.

If your other kids are dog lovers, they are probably voting for the cat, but depending on the time of year, her pattern of symptoms, and where you live, there could be plenty of candidates.

One thing you can check off your list – the roses.

Allergies are typically caused by pollen from trees, grasses, and weeds – not other types of flowering plants, like roses, geraniums, or begonias, etc. These “allergy-friendly” plants don’t produce much pollen. Other plants with flowers that are said to be fairly non-allergenic include orchids, pansies, petunias, snapdragons, and zinnias, etc.

“Brightly colored flowers that attract bees and other insects or humming birds are generally not allergenic.”

Michael J. Schumacher, MB, FRACP, The University of Arizona

In general, plants with wind-borne pollen can trigger allergies.

Are your child’s allergies better after it rains? Since heavy rains can lower pollen counts in the air, that could be a hint to a seasonal allergy trigger.

What about when it is dry and windy? Does that make your child’s allergies worse? Since pollen is carried by the wind, a dry, windy day will likely mean that there is more pollen in the air, which is another hint to a seasonal allergy trigger.

Do your child’s year round allergies quickly get better when he is away from home for a few days or weeks? That could be a hint to something inside your house being a trigger, although if he traveled far away, to another area of the country, it could simply mean that he wasn’t exposed to the same pollen in the air.

Understanding Allergy Triggers

Year round, or perennial allergy symptoms, are likely caused by things inside your home.

If your child’s allergies only seem to be bad at very specific times of the year, then pollen from grasses, trees, or weeds could be the trigger. Which pollen is high in your area when your child’s allergy symptoms are acting up?

Allergy testing is always an option if your child’s allergies are hard to control, either skin testing or a blood test.

Indoor Allergens That Trigger Allergy Symptoms

Year round allergy symptoms can often be caused by things in your home:

  • Cat and dog dander
  • Dermatophagoides farinae and pteronyssinus (dust mites)
  • Mice (mouse allergens/mouse urine proteins)
  • Cockroach saliva, feces, and body parts (cockroach allergens)

While allergy testing can help you figure out which to blame, if you don’t have any indoor pets and can eliminate mold in the house, then maybe you can blame dust mites.

Weeds That Trigger Allergy Symptoms

Most people think of ragweed as the classic weed that can trigger seasonal allergies. Often described as being “packed with pollen,” each ragweed plant produces up to one billion pollen grains each season! These ragweed pollen grains are carried by the wind and can trigger allergy symptoms from early to mid-August through September and October – fall allergy season.

Others weeds that commonly trigger allergies include:

  • nettle
  • mugwort
  • Russian thistle (tumbleweed)
  • plantain
  • Rough marsh elder
  • Rough pigweed
  • Sheep sorrel

Again, if necessary, allergy testing can help you figure out to which weed your child is allergic, but if their allergies peak in the fall, it is likely triggered by weeds.

Trees That Trigger Allergy Symptoms

Which trees are most likely to trigger allergy symptoms?

It depends on where you live, but in the spring, mountain cedar, pecan, elm, maple, birch, ash, oak, and cottonwood, are common offenders.

If you are allergic to tree pollen, you can expect symptoms in late winter to early spring.

Grasses That Trigger Allergy Symptoms

While many people don’t think of summer as a typical allergy season, that is actually when grass pollen is in the air.

Do you know which grasses are commonly grown in your area?

Bermuda grass, Timothy, Kentucky Blue, Johnson, Rye, or Fescue? Are your kids allergic to any of them? If so, their allergy symptoms will probably act up in the late spring and early summer.

Molds That Trigger Allergy Symptoms

Depending on where you live, molds can either cause seasonal symptoms (colder climates) or they can be a cause of year round symptoms.

And you can expect outdoor mold spore counts to be extra high when it is warm and humid.

Inside, mold grows best in parts of the house that are cool and damp, with common suspects including:

  • Cladosporium herbarum
  • Penicillium notatum
  • Alternaria alternata
  • Aspergillus fumigatus

Have you seen any of these names on your child’s allergy test results? Although it is considered part of our natural environment, you can keep mold from growing inside your home.

What To Know About Allergy Triggers

Identifying your child’s allergy trigger or allergy season won’t make them  away. It can help you learn to avoid or control them though, or at least help get prepared by starting your child’s allergy medicines before he is exposed.

More Information about Allergy Triggers

Treating Hard to Control Poison Ivy

While poison ivy isn’t contagious, it can make you miserable if you don’t learn to avoid it and treat poison ivy rashes properly with anti-itch creams and steroids.

Poison ivy growing on a tree, ready to give your kids a rash.
It is better to learn to avoid poison ivy than to get a rash and have to get it treated. Photo by Vincent Iannelli, MD

It is usually not hard to identify a child with a poison ivy rash, especially a classic case of poison ivy, which might include a child with a known exposure to poison ivy after a camping trip, hike in the woods, or day at the lake, who a few days later develops a red, itchy rash all over his body.

The problem is that many parents don’t remember the “known exposure,” especially if it is the child’s first poison ivy rash.

The Poison Ivy Rash

Aerial roots on the stems can help you identify poison ivy, and yes, they can trigger a rash too.
Aerial roots on the stems can help you identify poison ivy, and yes, they can trigger a rash too. Photo by Vincent Iannelli, MD

After exposure to the leaves, stems, or roots of a poison ivy plant, children develop symptoms of poison ivy within 8 hours to a week or so, including:

  • an intensely itchy rash
  • red bumps that often may be in a straight line or streaks, from where the poison ivy plant had contact with your child’s skin
  • a rash that appears to spread, mostly because the rash appears at different times depending on how big or small a dose of the urushiol oil that area of skin got, with the rash appearing first on the spots that got exposed the most
  • vesicles and blisters that are filled with fluid

Keep in mind that children exposed to poison sumac and poison oak, other members of the genus Rhus or Toxicodendron, can get these same symptoms that we generically refer to as poison ivy symptoms.

(Using medical terminology, these children develop rhus dermatitis or allergic contact dermatitis, an intensely pruritic, linear, erythematous, papulovesicular rash after exposure to the urushiol oil in poison ivy.)

Treating Poison Ivy

It seems like everyone has their favorite treatments for poison ivy.

These basic treatments for poison ivy are usually going to help control the itch, and might include:

  • oral antihistamines (Benadryl or Atarax)
  • modified Burow’s Solution
  • Calamine lotion
  • Aveeno oatmeal baths
  • over-the-counter or prescription topical steroid creams

Is that all you need?

While these treatments might provide temporary relief and might be enough for very mild reactions, those with more moderate or severe symptoms will likely require systemic steroids.

Does that mean a steroid shot?

That might be what your doctor suggests or what some parents request, but keep in mind that it might wear off too soon, leading your child’s poison ivy symptoms to flare up again (rebound rash). That’s why most experts recommend a longer, tapering course of oral steroids instead of a single shot. A steroid dose pack is also often avoided as treatment for poison ivy, as the dose might be too low and it typically doesn’t last long enough.

Since the poison ivy rash might not go away for as long as three weeks, getting treated with systemic steroids can be an especially good idea if you have a moderate or severe case.

Avoiding Poison Ivy

A classic poison ivy plant in the 'leaves of three, let it be' configuration.
A classic poison ivy plant in the ‘leaves of three, let it be’ configuration. Photo by Vincent Iannelli, MD

Since very few people are actually immune to poison ivy, it is best to learn to avoid getting exposed to it in the first place.

You can start with the old adage, ‘leaves of three, let it be,’ but you really have to look at a lot pictures of poison ivy to get good at avoiding it. And to be safe, learn to avoid the places where poison ivy grows – along tree lines, around lakes and ponds, along trails, and in wooden or wild areas, etc.

Or at least do your best to avoid the plants by wearing long pants, a shirt with long sleeves, and gloves, etc., to avoid skin contact even if you are around poison ivy while hiking, playing along a creek, or fishing near a lake.

What can you do if you have been exposed to poison ivy? If you can rinse the exposed area with rubbing alcohol, like within 10 minutes, then you might avoid a reaction. After that, the oil in poison ivy, urushiol, will likely be stuck and trigger a rash. Of course, you don’t want to be applying rubbing alcohol to a large area of your child’s skin though or allow your child to use it if they will be unsupervised. And be sure to wash it off afterwards.

Commercial products might be more useful (and safer) to help you avoid poison ivy reactions and  include:

  • Ivy Block – was an over-the-counter barrier lotion that was supposed to prevent poison ivy, but unfortunately, it isn’t being made anymore
  • Tecnu Original Outdoor Skin Cleanser
  • Tecnu Extreme Poison Ivy & Oak Scrub
  • Zanfel Poison Ivy Wash

Although it is best to use the products immediately, within 10 to 30 minutes after exposure to poison ivy, if used anytime before you get a rash, you might decrease your symptoms. And if you get lucky, you might not get any symptoms at all.

Myths and Facts About Poison Ivy

Would you recognize this is poison ivy? It will still trigger a rash...
Would you recognize this as poison ivy? It will still trigger a rash… Photo by Vincent Iannelli, MD

As common as poison ivy is, there are many myths and misconceptions about it, including that:

  • poison ivy is contagious (false) – scratching doesn’t spread poison ivy, although it may seem that way as the rash spreads to new areas over the days and weeks after being exposed. That’s only because some areas of a child’s skin that had less exposure to the poison ivy plant than others will get the rash later, not that they are continuing to spread it by scratching.
  • you can get poison ivy from your dog (true) – although not as common as direct contact with a plant, indirect contact, like if you touch the oil from poison ivy that got on your dog’s fur or on your clothing, could trigger a reaction
  • it is easy to spot poison ivy (false) – poison ivy plants are often found growing among other plants, can trigger reactions year round, even when they don’t have any leaves (the stems  and roots can trigger a reaction too), and even dead poison plants can trigger a reaction, which can make it extremely hard to simply use the ‘leaves of three, let it me’ advice to spot plants.
  • birds help spread poison ivy (true) – ever wonder why poison plants grow along tree lines? Birds and small mammals eat the poison ivy berries and then poop out the seeds, allowing new plants to grow wherever the birds commonly hang out, including tree lines, around lakes and ponds, and your garden.
  • it’s easy to get rid of poison ivy plants (false) – poison ivy plants are very persistent and can be hard to get rid of
  • goats like to eat poison ivy (true) – well, goats like to eat everything, but a goat in your yard will likely eat up all of the poison ivy plants.
  • it is easy to identify poison ivy (false) – many other plants mimic the ‘leaves of three, let it be’ pattern, like Virginia creeper and Boxelder
  • burning poison ivy plants is dangerous (true) – the oil that triggers the poison ivy rash can vaporize, meaning exposure to the smoke from a burning plant can cause severe reactions.

And remember that your pediatrician can be helpful if you think your child has poison ivy. (true)

What To Know About Hard to Control Poison Ivy

While poison ivy isn’t contagious, it can make you miserable if you don’t learn to avoid it and treat poison ivy rashes properly with anti-itch creams and steroids.

More About Hard to Control Poison Ivy

Treating Hard To Control Headaches

It can be frustrating when your kids have regular headaches, including migraines, but fortunately, there are many things you can do to both prevent and treat your child’s chronic headaches.

Does your child get headaches?

Are they easy to control?

Headaches

Headaches, including migraines, are much more common in kids than most parents imagine.  In fact, one study showed that up to 8% of kids have migraines, with many starting to have headaches by age 7 or 8 years.

Treating Headaches in Kids

In addition to treating headaches when they happen, it is important to teach your kids to get SMART and prevent their headaches:

  • Get plenty of Sleep each night.
  • Never skip Meals.
  • Be physically Active and exercise each day.
  • Learn ways to Relax and reduce any extra stress in their life.
  • Avoid things that you know Trigger their headaches.

If this doesn’t work and your child’s headaches are bothersome, you can consider treating them with a standard, age-appropriate pain reliever, such as acetaminophen or ibuprofen.

Treating Hard To Control Headaches

If your child has chronic headaches, ask yourself these questions and share the answers with your pediatrician:

  • Does your child have any signs of symptoms that might indicate that he needs immediate medical attention, including severe headaches that are getting worse, high blood pressure, a recent head injury, seizures, fever, or headaches that routinely wake your child up in the middle of the night?
  • Are your child’s headaches interfering with daily activities, including school, sports, or social activities?
  • Do headaches, especially migraine headaches, run in the family?
  • Does your child routinely have symptoms of allergies, in addition to headaches, with a runny nose and congestion, which could be a sign of allergy headaches?
  • How does your child describe her headache pain?
  • Does your child have any other symptoms with the headache, such as anorexia, nausea, vomiting, photophobia (light hurts their eyes), phonophobia (loud sounds bother them), or osmophobia (smells bother them)?
  • Can your child sense when a headache is about to begin, with with an aura, including symptoms like slow or slurred speech (dysarthria), vertigo (sense of spinning), or changes in their vision?
  • What does your child do during a headache?
  • Do you think that your child is having migraine headaches, tension type headaches, or allergy headaches, etc.?
  • Have you been giving your child pain medicines for her headaches on most days (more than 15 times a month), which can cause rebound or worsening headaches?
  • Have you been giving your child a triptan medicine for her headaches on most days (more than 10 times a month), which can cause rebound or worsening headaches?
  • If stress is a major trigger for your child’s headaches, have you considered seeing a counselor or child psychologist for extra help?
  • Have you tried keeping a symptom diary to try and identify headache triggers, such as caffeine, chocolate, weather changes, or stress, etc.?

What’s next if your child is still having bothersome headaches?

The FDA has approved a few medications (triptans) that can stop migraine headaches in kids, including:

  • Axert (almotriptan) – FDA approved for children between the ages of 12 and 17 years
  • Maxalt (rizatriptan) – FDA approved for children between the ages of 6 and 17 years

Zofran (ondansetron) can also be helpful if your child has nausea and vomiting with her headaches.

Lastly, a daily medication might help prevent your child from getting headaches in the first place. These preventative migraine medications can include Periactin (cyproheptadine), Elavil (amitripyline), Topamax (topiramate), Depakote (valproic acid), propanolol, or clonidine.

A pediatric neurologist can help manage your child with hard to control headaches. Other treatments for chronic headaches can include biofeedback, guided-imagery, cognitive behavioral therapy, and select nutritional supplements.

What To Know About Treating Hard To Control Headaches

It can be frustrating when your kids have regular headaches, including migraines, but fortunately, there are many things you can do to both prevent and treat your child’s chronic headaches.

More Information On Treating Hard To Control Headaches

Treating Hard to Control Vomiting and Diarrhea

Even when they don’t linger, it can be frustrating for parents to treat their kids with vomiting and diarrhea. Get the latest treatment recommendations to help you get through these very common infections quickly.

Kids get vomiting and diarrhea for many reasons, but it is most often caused by a stomach virus.

Whatever the cause, even if it is something your child eat or food poisoning, you will want to know how to best manage your child’s symptoms to help them feel better quickly and prevent them from getting dehydrated.

Vomiting and Diarrhea

Although most people associate vomiting and diarrhea with the “stomach flu,” the flu virus doesn’t usually cause vomiting and diarrhea.

Instead, there are a number of other viruses, bacteria, and parasites that do, including:

  • rotavirus – a vaccine-preventable disease
  • norovirus – the “cruise ship virus,” but very common elsewhere too
  • Salmonella, Shigella, E. coli – food poisoning, animals
  • C. diff – associated with recent antibiotic use
  • Cryptosporidium – drinking contaminated water, swimming pools, water parks

If necessary, especially when diarrhea is associated with severe symptoms or is lingering, stool tests can be done to figure out the specific cause. Fortunately, diarrhea and vomiting often goes away on its own fairly quickly and these tests aren’t necessary. What will likely be necessary is keeping your child well hydrated until these symptoms stop.

Treating Vomiting and Diarrhea

For most kids with vomiting and diarrhea, you can:

  • continue breastfeeding on demand
  • continue their normal diet (feed through the diarrhea), including baby formula or milk, if they just have diarrhea and no vomiting or only occasional vomiting, giving extra fluids every time your child has diarrhea (about 3 ounces if your child is under 22 pounds and about 6 ounces if they are over 22 pounds)
  • forget about eating and concentrate on drinking if your child has a lot of vomiting, but start by offering very small amounts of fluid, perhaps starting with a teaspoon (5ml) every 5 or 10 minutes, and then slowly working your way up to a tablespoon (15ml) and than an ounce (30ml) or two over a few hours
  • take a break from drinking for 30 minutes if your child has a set back and begins vomiting again, and restart at 5ml, slowly working your way back up again as tolerated
  • watch closely for signs and symptoms of dehydration, including weight loss, decreased urine output (fewer wet diapers or going to the bathroom less often), no tears, or dry mouth with no saliva or spit, etc.

In general, when talking about fluids, we mean an oral rehydration solution, like Pedialyte. If your older child won’t drink Pedialyte, you can offer something like Gatorade, but keep in mind that sports drinks have more sugar, so can sometimes make diarrhea worse.

But do you really make your child eat and feed through the diarrhea if he doesn’t want to? Of course not. The idea is that you don’t restrict your child’s diet if they want to eat. If they are complaining of a stomach ache, just don’t feel good, or feeding them their regular diet makes the diarrhea or vomiting worse, then move to more bland food.

Treating Hard to Control Vomiting and Diarrhea

What if your child continues to have vomiting and diarrhea?

You should still avoid treating your younger child with over-the-counter remedies to stop diarrhea, including those with loperamine (Imodium) or bismuth subsalicylate (Kaopectate).

A prescription medication, Zofran (ondansetron), might be appropriate for some children with persistent vomiting who are at risk of getting dehydrated.

If your child has persistent vomiting and diarrhea, ask yourself these questions and share the answers with your pediatrician:

  • Does your child have any symptoms that might require immediate medical attention, such as high fever, bloody diarrhea, severe headache, severe abdominal pain, or signs of moderate to severe dehydration?
  • Has your child with chronic diarrhea (diarrhea for more than four weeks) been losing weight, had fever, or regular stomach pains?
  • Does your otherwise well toddler have chronic, watery diarrhea even though no one else has been sick, a possible sign of Toddler’s diarrhea?
  • Do you have any pets or contact with pets that could put your child at risk for a Salmonella infection, including turtles, lizards, snakes, and frogs?
  • Has your child visited a farm or petting zoo, which puts him at risk for a Salmonella or E. coli infection?
  • Did your child recently take an antibiotic, which puts him at risk for a C. diff infection?
  • Has your child been drinking raw milk or other high risk foods?
  • Has your child traveled recently, which puts him at risk for traveler’s diarrhea?
  • Did you put your child on the BRAT diet (bananas, rice, applesauce, and toast) even though they were eager to eat?
    Have you tried giving your child a probiotic?
  • Does your child now only have diarrhea after drinking milk, perhaps a sign of a temporary lactose deficiency?
  • Is your child better, with much less vomiting, but you are just frustrated that the diarrhea hasn’t gone away yet?
  • Is your child better, with much less vomiting, but you are just frustrated that she is still vomiting at least once each day?

While you should certainly call your pediatrician if your child’s symptoms are lingering, remember that almost everything about the idea of the “24 hour stomach flu” you have heard is probably wrong. In addition to the fact that it isn’t caused by the flu virus, the symptoms typically last more than 24 hours, at least in kids. The vomiting may get better in 24 hours, but diarrhea can easily linger for a week or two.

It is also important to keep in mind that most causes of vomiting and diarrhea are very contagious and can easily spread through the whole house if you aren’t careful. Remember to always wash hands, rinse fruits and vegetables, clean and disinfect contaminated surfaces, and don’t share food or drinks, etc. If you just do it when your kids are sick, it will be too late, as many illnesses are contagious even before you show symptoms.

What To Know About Treating Hard to Control Vomiting and Diarrhea

Even when they don’t linger, it can be frustrating for parents to treat their kids with vomiting and diarrhea. Get the latest treatment recommendations to help you get through these very common infections quickly.

More Information On Treating Hard to Control Vomiting and Diarrhea

Treating Hard To Control Asthma

Does your child have asthma?

Are his asthma symptoms easy to control or are they getting in the way of doing routine things, like sleeping through the night or playing outside with friends?

What Triggers Your Child’s Asthma?

As with many other childhood conditions, it is often better to avoid asthma flareups instead of trying to treat them.

That doesn’t necessarily mean it is easy though.

Still, you might try to avoid common asthma triggers, such as:

  • allergies – dust mites, pet dander, mold, pollen, etc.
  • exercise
  • infections
  • smoke
  • pollution
  • weather changes

Keep track of your child’s symptoms to see if you can identify any triggers.

Asthma Treatments for Kids

The most common treatment for asthma symptoms are the quick-relief medications, including albuterol (ProAir, Ventolin, Proventil) and levalbuterol (Xopenex). Either with a nebulizer, inhaler with a spacer, or inhaler alone, they can help when your child is coughing and wheezing.

If your child has severe or frequent asthma symptoms or attacks, the next treatment step is to use a long-term control medication, starting with an inhaled steroid (Alvesco, Asmanex, Flovent, Pulmicort, Qvar) and moving to a combined inhaled steroid and long acting beta-agonist (Advair, Dulera, Symbicort) if necessary.

Other asthma treatments can include:

  • oral steroids – often used short term for asthma flares with quick-relief medications
  • leukotriene modifiers – Singulair (montelukast) is a once-a-day pill that can be used to prevent both allergies and asthma in some kids

An asthma action plan can help make sure you know how and when to use your child’s asthma medications.

Treating Hard To Control Asthma

What do you do if your child’s asthma medicines aren’t working?

If your child continues to have regular asthma symptoms or attacks, ask yourself these questions and share the answers with your pediatrician:

  • Is your child really using his inhaler? Non-compliance is the most common reason for kids to have poorly controlled asthma. Remember, long-term control medications are used every day, even when your child doesn’t have any asthma symptoms. They prevent asthma attacks and asthma symptoms that can be treated with the as need use of your child’s quick-relief medications.
  • Is your child using his inhaler correctly? If not, his asthma medicine might not be making it to his lungs where it needs to go to work.
  • Is your child with exercise-induced asthma using his quick-relief inhaler before exercise?
  • Does your child need a step-up in therapy? Long-term control medications are available in a variety of strengths and your child may need a higher dosage if she is still having asthma symptoms. Or she may need to move from an inhaled steroid to a combined inhaled steroid and long acting beta-agonist inhaler.
  • Would allergy testing help you identify your child’s triggers?
  • Does your child have acid reflux?
  • Could stress be triggering your child’s asthma symptoms?
  • Does your child really have asthma? Both vocal cord dysfunction and exercise-induced laryngeal obstruction are asthma mimics that can be misdiagnosed as asthma.

A pediatric allergist and/or a pediatric pulmonologist can help your child with hard to control asthma.

What To Know About Treating Hard To Control Asthma

Asthma can be a life-threatening condition, so be sure to seek extra help if your child has difficult to control symptoms, especially if you have already tried many of these classic asthma treatments.

For More Information About Treating Hard To Control Asthma

Treating Hard To Control Allergies

Allergies (hay fever or allergic rhinits) are common in kids.

That makes it a good idea to learn how to control your child’s allergies.

What Triggers Your Child’s Allergy Symptoms?

There are several good reasons to try and figure out what your child’s allergy triggers are, including that it can help you:

  1. avoid the trigger – stay away from cats if your child is allergic to cats
  2. minimize the trigger – control dust mites in your home if that is a trigger
  3. know to give your child her allergy medicine before she will be exposed – start medicines before fall allergy season if she is allergic to ragweed

That doesn’t mean your child needs an allergy test though. You can often figure out what triggers your child’s allergies if you are mindful of the pattern of her symptoms (year round vs seasonal), what she is doing or exposed to when they worsen, and by checking pollen counts on both good and bad allergy days.

Allergy Medicines for Kids

Unfortunately, simply trying to avoid allergy triggers isn’t usually enough.

Most kids with allergies also take one or more of these medicines, many of which are now available over-the-counter, without a prescription:

  • short acting antihistamines – Benadryl (can be sedating)
  • long acting antihistamines – Allegra, Claritin, Zyrtec
  • non-antihistamines – Singulair
  • steroid nasal sprays – Flonase, Nasacort, Nasonex, Omnaris, Rhinocort
  • antihistamine nasal sprays – Astelin, Astepro, Patanase
  • allergy eye drops – Pataday, Zaditor

And to work best, your child should likely start his allergy medicines before his allergy season and take them every day.

Treating Hard To Control Allergies

So what do you do when these allergy medicines don’t control your child’s allergies?

The first thing you likely want to do, and something many people overlook, is to make sure that your child’s symptoms are really caused by allergies. Remember, just because your child has a runny nose, it doesn’t mean that he has allergies. Or even if he often has allergies, it doesn’t mean that allergies are causing every runny nose. If your child has a runny nose and congestion and allergy medicines aren’t working, then he may just have a cold.

If your child does have allergies and they are just hard to control, then you might want to:

  • review your allergy trigger control methods (allergy proof dust covers on mattresses, no mold in house, keep windows closed in the car, etc.)
  • consider if you are triggering your child’s allergies even more, for example, dust mites and mold like humidity, so a humidifier in your child’s room would not be a good idea if your child is allergic to dust mites or mold
  • make sure your child is taking the correct dose of his allergy medicine
  • make sure your child is taking the correct medication for his allergy symptoms, keeping in mind that antihistamines don’t treat congestion, but Singulair (montelukast) and steroid nasal sprays do
  • try a different allergy medicine, although tachyphlaxis reportedly doesn’t occur with antihistamines – they shouldn’t become less effective over time
  • try a combination of medicines, for example, a long acting antihistamine plus a steroid nasal spray
  • try a different combination of medicines, for example, Singular plus an antihistamine nasal spray
  • make sure your child is able to avoid second hand smoke
  • consider that your child could have vasomotor rhinitis or nonallergic rhinitis
  • ask about allergy testing, which can be done by your pediatrician (blood tests at almost any age) and/or a pediatric allergy specialist (blood or skin tests)

A pediatric allergist can also be helpful in diagnosing and managing your child’s allergies, especially if you think your child needs to start oral (sublingual immunotherapy) or shot (subcutaneous immunotherapy) allergy preventative treatments.

What To Know About Treating Hard To Control Allergies

Allergies can be hard to treat and control in kids, but they can often be managed if you understand how to avoid common allergy triggers and use allergy medicines properly.

For More Information On Treating Hard To Control Allergies

Treating Hard to Control Reflux

Acid reflux isn’t just for babies, so it is important to learn to recognize GERD symptoms in older children and teens too.

Acid reflux is common, especially for newborns and infants.

Many parents are surprised to know that reflux can affect older kids too though. Fortunately, reflux is temporary for most of these kids and can be easily treated.

It can be even easier to treat younger kids, most of whom don’t need any treatment if they are just messy and don’t have true acid reflux disease.

Happy Spitters and Reflux Symptoms

Children who spit up have acid reflux or more specifically gastroesophageal reflux (GER).

Many babies spit up or have reflux.
Many babies spit up or have reflux, but most are just “happy spitters” and don’t need treatment. Photo by Ryan Dickey (CC BY 2.0)

They may not have acid reflux disease though (GERD), with other associated signs and symptoms, such as:

  • refusing to eat
  • recurrent vomiting
  • weight loss or poor weight gain (failure to thrive)
  • irritability or trouble sleeping
  • respiratory symptoms, such as a chronic cough, hoarse voice or cry, or hard to control asthma, etc.
  • Sandifer syndrome – reflux plus head tilting and back arching

Without any of these symptoms, your baby who spits up, even if it is very frequent and it seems like they spit up a large amount each time, is likely what is classically called a “happy spitter.” If they are just messy, they don’t need any treatment and you can wait until they outgrow their reflux.

Remember – “Spit Happens.”

Older children with acid reflux might complain of heartburn, chest pain, or say that they have a sour taste in their mouth (sour burps).

Lifestyle Changes for Reflux

Once you recognize that your child has GERD and needs to be treated, you might start with these lifestyle changes:

  • avoiding milk and dairy products for two to four weeks if you are breastfeeding an infant with GERD
  • changing baby formula to an extensively hydrolyzed protein (Nutramigen, Gerber Extensive HA, Alimentum) or amino acid–based infant formula if your formula fed baby has GERD
  • thickening your baby’s formula (typically about one tablespoon of rice cereal per every one to two ounces of formula) vs switching to a baby formula for reflux (Enfamil AR or Similac Sensitive R.S.)
  • making sure you aren’t overfeeding your baby, including that you don’t re-feed your baby right after they spit up
  • avoiding seated and supine (on his back) positions after feedings, although you shouldn’t put your baby down prone (on his stomach) if he is going to fall asleep (risk factor for SIDS)
  • helping older children with acid reflux lose weight if they are overweight and making sure they don’t smoke or drink alcohol
  • encouraging older children to avoid acid reflux triggers, especially caffeine, chocolate, foods with acid, and spicy foods

When can you expect your infant’s reflux to go away? In most babies, reflux symptoms peak at about 4 months and go away by the time they are 12 to 18 months old. In older children, reflux symptoms generally go away after a few months of appropriate treatment.

Acid Reflux Medicines

If lifestyle changes aren’t working, your child with reflux likely needs medicine to treat his reflux.

These acid reflux medications include:

  • antacids – may be okay in older children with very rare symptoms, but not for routine use
  • histamine-2 receptor antagonists (H2RAs) – such as Zantac (ranitidine) – works quickly, but may stop working over time (tachyphylaxis)
  • proton pump inhibitors (PPIs) – such as Prevacid (over-the-counter for adults) and Nexium (Nexium packets are FDA approved for infants) – considered more potent and superior to H2RAs but may take up to four days to start working
  • prokinetic agents – rarely used because of side-effects

In general, if your child’s symptoms improve or go away within two weeks of taking an acid reflux medication, then you should likely continue it for at least two to three months.

Treating Hard to Control Reflux

What do you do when lifestyle changes and reflux medicines don’t work or symptoms return after you stop your child’s reflux medicine?

First, make sure you are giving the right medicine, the right dosage of medicine, and are giving it at the right time, keeping in mind that PPIs should be giving 30 minutes before a meal.

Next, consider if there are any other lifestyle changes that you can try. For example, you might encourage your older child with persistent reflux to eat smaller meals more frequently, avoid a bedtime snack, and you may even elevate the head of his bed by about 30 degrees.

Lastly, you might make sure that your child really does have reflux.

Just because your baby is fussy and wakes up a lot at night, it doesn’t automatically mean that he has reflux. It could instead be colic, or be related to a food intolerance or allergy, with breastfeeding mothers needing to go on a more restrictive diet or infants drinking a hydrolyzed formula might need to switch to an elemental formula (Elecare, Neocate, or PurAmino).

Older kids with difficulty swallowing (dysphagia), which is often blamed on acid reflux, might have post-nasal drip caused by allergies or a sinus infection, etc.

And even if truly spitting up, instead of GERD, a child might have any number of other conditions instead of GERD, from an intestinal obstruction to a metabolic disorder.

It is usually at this point, when classic acid reflux treatments aren’t working, that a referral to a pediatric gastroenterologist would be a good idea.

What To Know About Acid Reflux

Acid reflux in kids is usually temporary and can often be controlled with lifestyle changes and medications, but unfortunately, acid reflux symptoms are not always caused by reflux, leading to some treatment failures.

For More Information on Acid Reflux

Treating Hard to Control Bedwetting

Although bedwetting can be hard to control, it is easier if your child understands that it is not their fault and that they will almost certainly eventually outgrow it and stay dry at night.

All kids wet the bed when they are younger.

When do they stop?

Bedwetting Basics

Although parents typically understand that their kids will become potty trained sometime around age three years, they often have unrealistic expectations for when they will stop wetting at night.

So the first thing to understand about bedwetting (nocturnal enuresis) is that it is consider a normal part of development to continue to wet the bed up until about age six years. That’s the age when most kids can stay dry all night.

But even after age six years, many kids still wet the bed. In fact, at age eight years, up to eight percent of kids still wet the bed. Fortunately, there is a 15% chance that these kids will outgrow their bedwetting each year.

Treating Bedwetting

In addition to waiting it out, classic treatments for bedwetting often include:

  • protecting the mattress from getting wet by using a plastic cover under the sheets
  • make wearing pull-ups seem routine and not a punishment
  • limiting the amount of fluids your child drinks in the evening
  • severely limiting the amount of fluids your child drinks right before bed
  • making sure your child goes to the bathroom right before going to bed
  • sticking to a good bedtime routine

Most importantly, make sure that your child knows that it is not his or her fault that they wet at night. Staying dry at night is just another developmental milestone that kids have to reach. Unfortunately, like many milestones, you will likely have to wait until your child reaches this one and stops wetting at night.

Usually bedwetting stops by puberty.

American Academy of Child and Adolescent Psychiatry

If your child is getting older and is tired of waiting, especially if he is approaching the age of sleepovers or overnight camping trips, there are  other options to treat bedwetting, including the use of bedwetting alarms and prescription medicines, like DDAVP (desmopressin) tablets.

DDAVP can be an especially good option for sleepovers, etc., as it only works to stop wetting on the nights your child takes it. It is a synthetic version of a natural hormone, antidiuretic hormone (ADH), that normally reduces urine volume at night in our bodies.

Treating Hard to Control Bedwetting

Why is your child continuing to wet the bed at night?

Maybe he is just a deep sleeper. Maybe he has a small bladder. Maybe bedwetting runs in the family and she will just have to outgrow it, like other family members have.

Although most children eventually outgrow wetting the bed, if you think your child’s bedwetting should have already stopped, you should ask yourself these questions and share the answers with your pediatrician:

  • Has your child ever been dry at night for more than a few weeks or months or has he always wet the bed?
  • If the bedwetting is a new issue, have there been any changes in your child’s life?
  • Is your child constipated?
  • Is your child losing weight?
  • Does your child wet during the day?
  • Does your child avoid going to the bathroom during the day, holding their urine for long periods of time (voiding dysfunction)?
  • Is your child drinking any caffeine during the day?
  • Does your child snore very loudly at night? Some people think that bedwetting can be associated with sleep apnea.
  • Have you tried waking your child an hour or two after he has gone to sleep and having him go to the bathroom?
  • Are you relying on alternative treatments for bedwetting, such as hypnosis, psychotherapy, acupuncture, chiropractic, or medicinal herbs, which have been proven to not work?
  • Have your tried using a star chart to encourage and reward nights that she stays dry?
  • Although they only work half the time, did you try using a bedwetting alarm?
  • Did you try DDAVP (desmopressin), thinking it would cure your child’s bedwetting, but not understanding your child would likely wet again once they stopped taking it?

A pediatric urologist can also be helpful for your child with hard to control bedwetting.

What To Know About Treating Hard to Control Bedwetting

Although bedwetting can be hard to control, it is easier if your child understands that it is not their fault and that they will almost certainly eventually outgrow it and stay dry at night.

More Information About Treating Hard to Control Bedwetting