Category: Pediatric Conditions

Treating Hard to Control Reflux

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

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

Treating Hard to Control Warts

Unfortunately, there are no quick and easy ways to treat warts.

In fact, because there are no quick and easy ways to treat warts, many pediatricians suggest that parents simply wait it out, and let the warts go away on their own.

Common Wart Treatments

If you don’t have the patience to wait for a wart to go away on its own, which can take months to years, you can try:

  • OTC topical liquid or gel wart remover treatments with salicylic acid
  • OTC wart remover treatments with salicylic acid on a pad
  • OTC wart remover treatments that freeze warts
  • duct tape

Your pediatrician might also try:

  • cryotherapy – “prescription strength” wart freezing, which may have to be repeated multiple times
  • cantharidin – not FDA approved in the US, but this blistering agent is often applied to warts to induce them to go away

And of course, your pediatrician might also simply recommend that you wait it out for a few more months or years, as the warts should eventually just go away.

But why not treat the warts if treatments are available? Many experts say that at best, standard wart treatments only work half of the time. And they can be painful or leave scars.

Treating Hard to Control Warts

Again, treating warts is often hard, even in the best of circumstances. Warts can be even harder to treat if they are around your child’s nails (periungal warts) or on the bottom of their feet (plantar warts).

Plantar warts can be hard to treat.
Plantar warts can be hard to treat. Photo by happyfeet34 (CC BY 2.0)

Still, if you are not getting anywhere, you should ask yourself these questions and share the answers with your pediatrician:

  • Does your child really have warts?
  • Did you follow the directions on the label carefully?
  • Are you gently rubbing away hard skin from the surface of the wart with a pumice stone or emery board each week?
  • Are you softening the skin on and around the wart by soaking the area in warm water for at least 5 minutes before your wart treatments?
  • Did your child’s wart mostly go away and then come right back in the same spot?
  • Did your child’s wart completely go away, but new warts came up in different places?
  • Did your child get a much bigger wart around the site of a previously treated wart (a ring wart)?

A dermatologist can treat your child’s truly resistant warts with cryotherapy, cantharidin, higher strength salicylic acid paste than is available OTC, yeast injections, electrosurgery, or pulsed dye laser therapy, etc.

What To Know About Treating Hard to Control Warts

Although multiple wart treatments are available, warts are not easy to treat and so it is not unreasonable to just leave them alone if they aren’t bothering your child.

More Information About Treating Hard to Control Warts

Treating Hard To Control Eczema

Eczema or atopic dermatitis very commonly affects kids.

Few conditions are as frustrating for parents and pediatricians, because even when properly treated, you can expect eczema to flare up from time to time after it gets better. Eczema is even worse when it isn’t properly treated though.

What Triggers Your Child’s Eczema?

Like other things that are supposed to have triggers, like asthma and migraines, it is often hard to figure out what triggers a child’s eczema.

Dress in soft, breathable clothing and avoid itchy fabrics like wool, that can further irritate your eczema.

National Eczema Association

Common eczema triggers to avoid might include:

  • harsh soaps and cleansers, shampoos, and body washes, including those with fragrances
  • food allergy triggers – milk and eggs
  • environmental allergy triggers – dust mites and animal dander
  • low humidity
  • temperature extremes – either getting too hot or too cold
  • skin infections

And anything else that might make your child’s skin dry and itchy.

Eczema Treatments for Kids

Although there is no cure for eczema, it is usually possible to control your child’s eczema, including getting rid of all or most of her eczema rash and decreasing how often your child has eczema flares.

These basic treatments include:

  • using lukewarm water for daily baths and showers
  • using a soap substitute or cleanser that is unscented, fragrance-free, and dye-free – Cetaphil, Dove, Aveeno
  • using a tar-based shampoo if your child’s scalp is red and itchy – T-Gel
  • daily use of moisturizers, especially within a few minutes of taking a bath or shower (soak and seal therapy)
  • prompt use of a moderate strength prescription topical steroid (like traimcinolone acetonide 0.1% cream) as soon as your child has a flare, with red, rough itchy skin
  • as needed use of oral antihistamines to help control itching during flares – Benadryl
  • keeping your child’s finger nails short to minimize damage from scratching

A written eczema action plan can make sure that you understand how and when to do each of these treatments.

Best Moisturizers for Eczema

Everyone seems to have their favorite eczema moisturizer.

Which is best?

The best moisturizer is probably the one that your child will use and which works to keep his skin from getting dry. In general though, ointments are better than creams, which are better than lotions.

Some favorites include Aquaphor (too thick and greasy for some people), Vanicream Moisturizing Skin Cream, CeraVe Moisturizing Cream, Eucerin Original, and Cetaphil Moisturizing Cream.

Whichever moisturizer you use, be sure to apply it to your child’s skin within three minutes of his soaking in a bath or shower so that you can seal in the moisture (soak and seal therapy).

Treating Hard To Control Eczema

What to do you do when basic treatments aren’t working?

Although a pediatric dermatologist can evaluate your child to see if she needs a systemic medication, phototherapy, or other treatment, most kids with hard to control eczema simply need more education to make sure they are using standard treatments correctly.

  • Is your child bathing correctly?
  • Are you putting on the right moisturizer, using enough moisturizer, and using it often enough?
  • Is your soap too harsh?
  • Are you afraid to use a topical steroid?
  • Are you applying a steroid over a moisturizer, which can make it less effective?
  • Could you be doing more to avoid triggers?
  • Could stress be triggering your child’s eczema?

What’s next?

A Staph skin infection might be a problem. In addition to oral antibiotics, weekly dilute bleach baths might help if this is an issue for your child.

Your child with hard to control eczema might also benefit from:

  • using more moisturizer over his entire body – don’t spot treat the areas that you think are a problem
  • using a thicker moisturizer – put your jar of Aquaphor in the freezer or refrigerator if your child doesn’t typically like using a moisturizer or complains that it stings or burns
  • a prescription barrier cream to control itching – Atopiclair, MimyX
  • a prescription topical Clacineurin Inhibitors – Elidel, Protopic
  • a 504 school plan
  • changing your laundry routine – wash new clothes, use mild, dye free laundry detergent and rinse twice after washing
  • using sunscreen and rinsing after swimming in a pool or excessive sweating, applying a moisturizing quickly afterwards
  • allergy testing to better identify triggers

You might also talk to your pediatrician about wet wrap therapy. With this treatment, you have your child take a bath or shower, applying a topical steroid to the affected areas and a generous amount of moisturizer to the rest of your child’s skin. Next, cover the area in wet cotton clothing or a wet dressing, and lastly, dress your child in dry cotton clothing, removing them all once the clothing dries out. You can then repeat the whole process or start again the next night, continuing until your child’s eczema is under better control.

Wrap therapy can be done with wet pajamas if you have to cover a big area, tube socks with the end cut off if you just have to do his arms, or cotton gloves for hard to control hand eczema. Some experts even recommend using a chilled wet dressing, putting the wet clothes in the refrigerator for a short time before using them on your child.

If you are at the point of considering wet wrap therapy, seeing a pediatric dermatologist might also be a good idea.

What To Know About Treating Hard To Control Eczema

While eczema can usually be controlled and most kids eventually outgrow having eczema, you may need some help to really understand how to really manage your child’s eczema effectively.

More Information About Treating Hard To Control Eczema

Treating Hard to Control Acne

Does your teen or pre-teen have acne?

Does he want to get it under control? Will he actually follow a daily regimen your pediatrician prescribes?

Acne Treatments for Kids

While treating your child’s acne on you own with an over-the-counter product can be a good way to start, there are so many products, you do want to make sure you are using the right ones. In general, you should likely start with:

  • products with benzoyl peroxide (BP), which might include OTC 5-10% BP wash for your child’s back or chest
  • a gentle, soap free, pH-balanced cleanser to wash your child’s face twice a day or a salicylic acid cleanser
  • a facial toner, only if necessary to remove excess oil or makeup

When those regimens aren’t working, your pediatrician can prescribe stronger acne medicines, usually in a step-wise fashion, including:

  • a topical retinoid –  Tretinoin (Retin A), Adapalene (Differin), or Tazarotene (Tazorac)
  • a combination topical product – BP/clindamycin (BenzaClin), BP/adapalene (Epiduo), BP/erythromycin (Benzamycin),  tretinoin/clindamycin (Ziana)
  • oral antibiotics – doxycycline, monocycline, tetracycline

If your child isn’t tolerating these medicines, like if it is causing his skin to become dry, make sure he is also using a moisturizer and washing with a mild soap substitute, like Dove. Starting with the lowest strength medicine can also be helpful, perhaps even just using topical medicines every other day until your child gets used to them.

Treating Hard to Control Acne

What do you do if your child’s acne isn’t getting better?

Ask yourself these questions and discuss the answers with your pediatrician:

  • Has your child started puberty yet? If not, talk to your pediatrician or a pediatric endocrinologist to see why he or she has such bad acne.
  • Are you avoiding picking up an acne prescription because of the cost? Ask your pediatrician about lower cost alternatives.
  • Is your child really using his acne medicines each day?
  • Is your child correctly using his acne medicines each day, avoiding spot treating problem spots and using a pea-size amount of cream or ointment to cover his whole face? Teach her to use the 5-dot method of applying acne cream – with a small pea-size amount of cream, place dots of the cream on their forehead (1), cheeks (2, 3), nose (4), and chin (5). Rub the cream in until, keeping in mind that they are using too much if you can see or feel any left over cream.
  • What kind of acne does your child have? Comedonal (whiteheads and blackheads) and inflammatory acne (classic zits or pimples) are treated differently.
  • Does your child frequently touch or rub his face, which can make acne worse?
  • If using makeup, is it oil-free and noncomedogenic?
  • Is your child overdoing washing, using a harsh soap or astringent, thinking that dirt is making her acne worse?
  • Does your child use a non-comedogenic sunscreen, remembering that a sunburn will make her acne worse in the long run?
  • Does your child have severe acne, which should probably be treated with a combination of oral antibiotics plus topical retinoids with BP, with or without topical antibiotics?
  • Did you give the medicines enough time to work or have a relapse because you stopped them too soon? Acne often worsens before it gets better and oral antibiotics are often continued for months and months,  with a goal of being tapered and stopped after about three to six months.
  • Does your child need a step-up in therapy? Ask your pediatrician if you need to add on a new medicine, switch to a combination product, or move to a higher strength product.
  • Have you considered adding hormonal therapy (combination oral contraceptives) for your pubertal daughter with severe acne, such as Ortho-Tri-Cyclen, Estrostep, or Yaz?

Lastly, even with worry about possible side effects, oral isotretinoin (Accutane, Amnesteem, Sotret, and Claravis) is still a good option for teens with severe, refractory, and scarring acne. At this point, and perhaps even before, an evaluation by a dermatologist would be a good idea.

What To Know About Treating Hard to Control Acne

There are no quick fixes for acne, but your pediatrician can offer you a step-by-step regimen of topical and oral acne treatments.

More Information On Treating Hard to Control Acne

Treating Hard To Control Constipation in Kids

Constipation is very common for kids.

Since your kids will almost certainly become constipated, at least briefly, at some point in their lives, it is important to understand how to recognize the symptoms of constipation.

Symptoms of Constipation

How do you know if your child is constipated?

In addition to grunting and stomach pain, more traditional signs and symptoms of constipation include having:

  • fewer than two bowel movements in a week
  • bowel movements that are small, hard, and like little balls
  • bowel movements that are very big and hard and which may frequently clog the toilet

Most importantly, your constipated child will have bowel movements that are painful and difficult to pass. Very big bowel movements might also lead to small rectal tears and bleeding (usually some bright red blood on the toilet paper when wiping, not blood that fills the toilet bowl).

Not surprisingly, large painful bowel movements commonly lead kids to avoid going to the bathroom, creating a viscous cycle of worsening constipation that can become chronic. Your child with chronic constipation may eventually develop encopresis, having soiling accidents that you mistake for diarrhea. Or because they are holding their stool, they might also hold their urine and develop multiple urinary tract infections or just have urine accidents.

What about grunting and straining? If your baby grunts, strains and even cries briefly, but then passes a soft bowel movement each day, then she probably isn’t constipated (Infant Dyschezia).

Young Children with Constipation

It is often most obvious when young children get constipated, as you are still changing diapers or helping them use the potty.

Keep in mind that:

  • you should talk to your pediatrician if you think that your newborn baby is constipated (not pooping can be a sign that newborn babies aren’t eating enough) or if your child has had constipation problems since he was born (sign of Hirschsprung disease) or is constipated and isn’t gaining weight (Celiac disease)
  • exclusively breastfeeding infants, especially before they start solid foods, once they are gaining weight well, are unlikely to get constipated, but they may only have their soft bowel movements every few days or weeks
  • infants sometimes get constipated when they start rice cereal or other baby foods
  • toddlers sometimes get constipated when they start potty training – this is an especially important time to make sure your child doesn’t get or stay constipated, or it will interfere with potty training

Again, be aggressive if your child becomes constipated when potty training. It is easy to imagine that your toddler is not going to want to have regular bowel movements on the potty if he associated them with pain.

Children with Constipation

Although it is typically harder to recognize, because you likely don’t know how often they are going to the bathroom, constipation is common in older children too.

Common times to develop constipation might include:

  • when they start kindergarten, especially if they don’t feel comfortable going to the bathroom at school
  • after going to camp, on a trip, or any other situation where their diet and routine might have changed
  • after a brief illness, especially if they took or are taking a medication that might have constipation as a side effect
  • during a period of stress, such as starting a new school, moving to a new house, bullying, or social changes (divorce, death in the family, etc.) at home

It is so common, you might even want to watch for constipation at those times, especially if your child has had issues with constipation in the past.

Hard To Control Constipation

Most parents know how to treat simple constipation – more fluids, more fiber, stool softeners, and the occasional glycerin suppository or pediatric enema (the last treatments should likely only be used when nothing else is working and your child is uncomfortable).

But what do you do when that’s not enough?

To help treat kids with hard to control constipation, it usually helps to:

  • make long term changes to your child’s diet, including more fluids (especially water), less fat,  and more fiber, as kids with constipation may have a diet high in fat and low in fluids and fiber
  • make long term changes to your child’s behavior, encouraging him to sit and try to go to the bathroom after breakfast and dinner, but not making him sit until he goes
  • encourage your child to be physically active
  • continue your child’s daily maintenance constipation medicine (usually polyethylene glycol (PEG), lactulose, Milk of Magnesia (magnesium hydroxide), or mineral oil) until he is having a soft stool each day for several months and continues having a daily soft stool as you gradually decrease (over several months) and then stop the medicine (stopping a laxative as soon as kids begin having regular bowel movements is the biggest mistake that parents typically make when their kids are constipated)
  • consider a clean out regimen over a few days if your child is very constipated, using high dose polyethylene glycol or magnesium citrate, which unfortunately might cause some diarrhea as a side effect of getting a lot of hard stool out

What do you do if your child relapses? You usually just start over, especially if the relapse is because you stopped one or more of your child’s constipation treatments.

If your child relapses even though you had been consistent and had been continuing all of his previous treatments that had been working well, you might consider:

  • switching to an alternative to cow’s milk, like almond or soy milk, as some people think constipation can be due to a cow’s milk protein allergy, plus they will likely be lower in fat than cow’s milk
  • increasing the dose of stool softeners and make sure that you don’t stop them too soon
  • avoiding treatments that have not been found to be helpful, including very high fiber diets, prebiotics or probiotics, biofeedback and other alternative treatments
  • avoiding suppositories and enemas, as oral constipation medicines are just as effective and will be better tolerated by your child

Your pediatrician and/or a pediatric gastroenterologist can be helpful if your child has hard to control constipation. In fact, up to 25% of the visits to a pediatric gastroenterologist are for constipation.

For More Information on Constipation