Generic baby formula

Sylvia wants to know: “Can I use generic baby formula?  I use generics for myself all the time, but get nervous about the idea with my baby.  (He only eats one thing – I want it to be good for him!)  Are generic formulas ok?  Do I just need to make sure it has the same nutrition info as the well-known brand?”

Generic formulas adhere to the same industry standards as the name brands, and are essentially the same. When you buy the name-brand products, you’re paying more for a label, and you’re paying more for their extensive promotional efforts and giveaways.

I almost always buy generics—including medications, when they’re available. (Except for JIF peanut butter. Mmmmm, Jif!) It’s a myth that brand-name products are superior, a myth allegedly maintained by false or misleading advertising campaigns. There have been times in the past when new developments in baby formula first appeared in the name-brand products, most recently the addition of the essential fatty acids ARA and DHA. At this time, however, the generics have entirely caught up, and you don’t need to spend extra to get the second best product available.

(I forgot Coca-Cola. OK, for the record, all other brands of cola are nasty, especially icky store brands. Mmmmm real Coke!)

Almost all formulas fall into one of these groups, with very little variation within the group:

1. Standard cow’s milk based formulas, like Enfamil Lipil or Similac Advance or almost any store brand. These are fine, the standard second best thing to feed your baby.
2. Partially hydrolyzed cow’s milk formulas. A few brands partially “digest” their milk proteins, supposedly making the formulas easier on the tummy. There’s very little data to support their use, but they’re fine if you want to try one, like Gentlease or Carnation Good Start.
3. Soy formulas, including many generics, Isomil, and Prosobee. There are very few, rare medical reasons to use these; many babies with genuine cow’s milk allergies can’t tolerate soy, and have to use a genuinely hypoallergenic formula. Still, if you’d like to avoid cow’s milk, go for it. These are probably fine.
4. Reduced-lactose formulas (Similac Sensitive, Lactofree). These are just silly—there is no such thing as lactose intolerance in babies, and these formulas are only there to pander to fears and misinformation. If your child is genuinely allergic to milk, these won’t help.
5. Hypoallergic formulas, like Alimentum or Nutramigen, are for babies with genuine milk allergies. This isn’t common, but for those babies these products are essential. There are no generics of these formulas, which are very expensive.
6. Spittin’ formulas, like Enfamil AR or Similac RS, add modified rice starch that thickens somewhat in the stomach, preventing spitting. They seem to help some, but keep in mind that almost all babies spit up sometimes, and most don’t need any medicine or special formula. There are no generics of these moderately-priced formulas.

(I like genuine Ivory soap, too. Smells nice.)

If you’re looking to save a few dollars, generic baby formula is fine. There’s another alternative, too, for those of you making plans for after your baby is born: the bestest “formula” ever happens to be the cheapest, too. Nurse! Genuine Momma’s Breast® is one brand name that’s worth every penny!

Fever part 4: The Fever Action Plan

In prior posts, we’ve covered what a fever is, and why the body runs a fever, and how to tell if a fever is something serious to worry about. Putting all of this together in one practical plan has been the goal of this series. We want to keep children healthy and safe, and avoid unnecessary Emergency Room visits—while looking out for occasions when a child might really need evaluation right away. So here it is, what you’ve been waiting for, The Pediatric Insider fever “action plan.” Clip and save, or even better, share this with friends to bring more eyeballs to my blog. You found it here first!

What to do if your child feels like he has a fever

1. If your child looks very ill—he’s unresponsive, having trouble breathing, or has a blue or grayish color—call 911 or bring him to the nearest emergency room.

2. If the child has not reached his four month birthday, measure the fever with a thermometer, rectally. If the number is 100.4 F or higher, call your child’s pediatrician for instructions. Fevers in very young babies are far more likely to be caused by a serious problem, and usually need to be evaluated right away. Even if the measured temperature doesn’t show that your baby has a fever, call your pediatrician if your child seems unwell.

3. If your child has a poor or abnormal immune system, or has a disease that you’ve been told predisposes to serious infections, call your physician. You should also contact your physician if your child has a fever and has not been immunized—these kids are at much higher risk for serious bacterial infections that may need urgent evaluation and therapy.

The remainder of this action plan is only for normal, otherwise healthy and immunized children 4 months of age or older.

4. (Optional) Measure the temperature in an appropriate way with a thermometer. There is no reason to check a rectal temperature on an older child. An axillary (armpit) or temporal artery temperature is a good enough estimate. (I haven’t found ear thermometers, pacifier thermometers, or skin thermometer strips to be accurate) If you don’t have a thermometer handy, it is not essential to measure the temperature; but it can be handy for monitoring to keep track of the temperature trend, especially if the fever lasts more than a day.

5. If you child feels ill (achy, or just “blah”), give a dose of fever-reducing medicine such as acetaminophen or ibuprofen. You’re giving the medicine to help your child feel better—not necessarily to reduce the fever—but it will probably help the fever drop, too.

6. After the fever decreases, see how your child feels. If he’s still feeling ill, contact your physician for instructions or bring him to the doctor. If he’s looking and feeling better, see how he’s doing in the morning and call your pediatrician for a non-emergency appointment within a few days for evaluation if the fever or other symptoms persist.

Fever itself can be an unpleasant symptom, often accompanied by chills and aches. Parents should treat fever with medicine not because the fever itself is harmful, but to help the child feel better. Even if the fever medicine doesn’t reduce the temperature back to normal, it will help how your child feels. It’s also easier and more accurate to judge just how sick a child is after the fever has been brought down.

During a fever, you’ll also want to offer your child extra fluids. It doesn’t matter what Junior drinks, as long as it’s wet. Milk and other dairy products are fine during a fever (even an extremely high fever isn’t nearly warm enough to “curdle” milk.) Jello, applesauce, pudding, ice cream, and Popsicles are all also good choices. For little babies, encourage frequent nursing or offer an extra bottle. If your child doesn’t feel like eating, that’s OK—as long as he’s drinking, he won’t get dehydrated.

“Fever phobia” is an unwarranted fear that fever is really going to harm your child. In the past, fevers could often have been a harbinger of a truly devastating illness. Nowadays, almost all of the serious fever illness are easily prevented with vaccines and simple hygiene. The few serious fever illnesses that still occur are far more easily recognized and managed. Though fever ought to be treated if it makes your child feel bad, it’s nothing to be afraid of. Protect your child with vaccines, look out for the few red flags that we’ve discussed, and help your child stay comfortable when the occasional fever strikes.

Previous posts in this series:

Part 1: What is it?

Part 2: Why?

Part 3:  Dispelling fever phobia

The best parenting advice you’ll ever get from a two word post

Be patient.

Fever part 3: Dispelling fever phobia

Worry about fevers is the most common reason for an urgent call or visit to a pediatrician. Parents worry about fevers because it makes their child look and feel ill, but also because they’re concerned that the fever means there is a serious medical problem going on, or that the fever is going to harm their child.

Historically, fever did once mean that something terrible could be going on. One of the most common causes of fever world-wide, malaria, is no longer seen in the developed world thanks to improved mosquito control. Likewise, many other serious fever illnesses have become rarities thanks to improved sanitation (like typhoid fever, plague, and dysentery.) Vaccinations now protect against most of the more serious bacterial infections (including meningitis and blood poisoning), as well as many viral infections that had been so devastating in the past (like polio and measles.) Other potentially serious infections have now become easy to identify and treat (scarlet fever, pneumonia, kidney infections.) Compared to a century ago, we are far more able to access reliable health care that can accurately diagnose and treat almost any illness. So while it made sense for parents 100 years ago to worry that a fever could mean the death of their child, this fear is not justified today.

If your child does have a fever, how can you tell if it’s caused by something serious?

In the past, a general rule was that the height of the fever predicted how serious the underlying problem was—so a fever of 105 was far more of a worry than 101. But in a fully vaccinated, otherwise healthy child, this “rule” doesn’t hold true. Even a 105 fever in a healthy child is quite unlikely to be from any serious condition. The best way to determine how likely it is for a child to have a serious medical issue causing a fever isn’t to look at the number on the thermometer, it’s to see how the child acts when the fever goes back towards normal. Give a dose a fever-reducer, wait 30 minutes, then see how Junior feels. If he’s doing much better, it’s very unlikely that you have a serious infection to worry about. We’ll cover this in more detail in the next (and last) installment of my fever series.

The government pokes me in the eye. Again.

Remember HIPAA? That’s the “Health Insurance Portability And Accountability Act” of 1996, a fabulously convoluted and incomprehensible pile of stink that was supposed to make health information more private, while at the same time allowing individuals to more easily change health insurance plans. After numerous revisions, clarifications, and doodling in the margins, we’ve got a system in place that:

• Costs billions
• Prevents doctors, hospitals, and labs from communicating
• and creates (1.5 million links!) a Byzantine, sprawling industry of consultants, lawyers, and bureaucrats to monitor enforcement and create new rules. None of this improves health care in any way.

From the patient’s perspective, the only tangible impact of this monster is a steady stream of unreadable, paper-wasting lawyer-scribble in the form of “privacy notices.” Oh, and you get to sign a few more forms when you go to the doctor.

From my perspective, HIPAA is  a hugely expensive waste of time squatting uninvited between me and my patients, a hideous, stinking uninvited guest that only gets bigger and more stinking every year. (As an example—the current Economic Recovery Act includes tweaks that requires providers to track every disclosure of health information that’s been used for any purpose—for three years. See, that will help with the economic recovery by employing even more administrative pygmies and consultant-weasels. Not that I am bitter.)

But get this: HIPAA might just have been a preview for a whole new set of rules and regulations being foisted on the healthcare industry by the nameless rule-makers. You haven’t heard much about this—yet—but get ready for the “Identity Theft Red Flags Rule.” Since it lacks a snappy abbreviation like HIPAA, let’s call it the “Screwing Physicians and Empowering Weasels” Act, or SPEW for short.

The rule was announced in 2007 by the Federal Trade Commission (FTC) as a way to protect consumers against identity theft when dealing with financial institutions and creditors. Fair enough, those businesses handle zillions of dollars in increasingly complex transactions, and identity theft is a genuine threat. But after the rule was announced, and the period of public comment ended, the FTC told physician groups that it was going to consider the term “creditor” in a very broad sense, including any business that defers payment. That’s right—since doctors will allow you to leave without paying, while we wait for payment from your insurance company, that makes us a creditor. No matter that we don’t charge interest, or that we’re only extending “credit” to cover a medical bill for  a few weeks. We get the same rules and oversight and paperwork as the megabanks, though of course no bail-out money to pay for all of the consultants, employees, and time its going to take to do this. Since no one guessed that SPEW would apply to physicians and hospitals, we had no chance to review the rules or suggest any modifications to make them work in our industry.

The SPEW rules are so vague that no one knows what we are really supposed to do—a boon to the consultants and lawyers who leaped so happily into HIPAA-chummed waters a few years back, and are salivating over a new opportunity to make sure that even less of your health care dollar is actually spent on health care. The rule requires health businesses like mine to develop and conduct an identity risk assessment, followed by implementation of an identity theft program to identify, detect, and respond to potential risks. We’ve got to have a plan in place stating how we’ll respond to alerts of potential misuse of identifying information. What, exactly, does all of this mean? I found one example I could understand: The FTC suggests, among other steps, that to comply with this rule we should check photo ID at every encounter. I hope your baby has a driver’s license.

SPEW, like HIPAA, is a hugely misguided effort by your government run amok. It will add layers of complexity and cost to every medical encounter, further burdening physicians and distracting us from providing medical care. It’s one more completely unnecessary poke in the eye, one more straw on the back, and one more nail in the coffin for the few physicians left who still enjoy practicing medicine.

Preventing the dreaded yuck

The dreaded tummy bug: vomiting, diarrhea, misery. Holly wanted to know, if one child gets it, what’s the best way to prevent it from knocking out the rest of the family?

In medical lingo (you know, we can’t use normal words like normal people), the dreaded tummy bug is known as “gastroenteritis.” Most commonly, it’s caused by a number of different viruses. Sometimes, it’s called a “stomach flu”, though it has nothing at all to do with influenza. The common symptoms are nausea followed by vomiting followed by diarrhea, usually in that order, and usually all occurring within a day or so. Sometimes there’s a fever, or some abdominal pain, but that typically isn’t severe.

Vomiting or diarrhea, though seldom both, can also be caused by food poisoning. When a family catches this, everyone gets sick at the same time—how special! With an infectious (usually viral) gastroenteritis, one person gets it, then another, then another, then it’s time to move to a different house, or at least burn all of your clothes and sheets.

If you can’t afford to do that, it might be more practical to follow these steps for prevention:

1. Wash your hands.
2. Wash your hands when you leave the bathroom.
3. Wash your hands before you eat.
4. Wash your hands again.
5. Wash your child’s hands.
6. Wash your child’s hands when she leaves the bathroom…
7. …you get the idea.

Purell or a similar brand of alcohol-based hand sanitizer can protect against many infectious, but if your hands are “visibly soiled” you need to do a thorough wash with lots of sudsy soap and running water. What kind of soap doesn’t matter (antibacterial or medical soaps are not more effective than ordinary soap), but hand washing technique is important. You need running water and friction as you rub, and it ought to take as long to wash your hands as it takes to sing “Happy Birthday.” And blow out the candles.

Fever part 2: Why?

Normal body temperature is regulated in an area at the base of the brain called the hypothalamus. By the release of hormones and neurologic signals, the hypothalamus can instruct the body to raise its temperature (by gearing up heat-producing metabolic pathways), or lower the temperature (by shivering. sweating, and increasing blood flow to the skin.) Conceptually, we think that the hypothalamus has a very sensitive temperature “set-point”, and that it continuously monitors the temperature of the blood to make adjustments in the body, keeping the temperature as close to the set-point as possible.

Fever occurs when the hypothalamic set-point is temporarily changed. This can occur via a variety of mechanisms, often involving molecules called “pyrogens” than can be released by a variety of immune cells in the body. Pyrogens are also found as components of certain bacteria.

“Hyperthermia” occurs when the body’s temperature rises above normal, but it is different from fever. In fever, the hypothalamus’ set-point is altered, and the body “wants” to get to the new set temperature by using normal physiologic mechanisms. In hyperthermia, excess heating occurs because heat from the environment is so high and sustained that it overwhelms the body’s ability to cool itself off. Think of a football player in full gear in August—it might be 100 degrees out, and if dehydration occurs there won’t be any sweat left to cool the body off.  The hypothalamus wants to cool off, but there isn’t any way to do this. In hyperthermia, the body’s temperature can get so high that tissue damage occurs. The best way to avoid hyperthermia is to consume plenty of fluids, and to get out of the hot sun at the first signs of heat illness (often nausea, headaches, and warm & dry skin.)

Unlike in hyperthermia, during a fever there is no outside source of heat, and the body cannot heat up enough to cause itself damage. As long as a child or adult with a fever stays well hydrated, the fever itself will not cause any harm, though it can make the person feel lousy.

So what’s the point of a fever—why does the body have mechanisms in place to raise the set-point? There is evidence that fever may be beneficial in fighting at least some infections. Fever allows white blood cells to proliferate faster, and helps them migrate through tissue better. It also increases the virus-fighting ability of interferons, and may decrease the ill effects of some bacterial toxins. It’s also thought that an overly warm environment may be less hospitable to bacteria that have developed in a way to thrive best at normal body temperatures. However, despite these observations there isn’t strong data that fevers overall really change the outcome of most infections, at least in the developed world where general health, nutrition,  and access to health care is good.

If fever is at least theoretically helpful in fighting infections, should we be using medicines to reduce fevers? I think so. Fever does cause some tangible ill effects in people, especially children. It increases fluids losses (contributing to dehydration), and increases metabolic energy demands. More importantly, though, it makes people feel bad. People with fevers can be achy and miserable. In my mind, helping the child feel better trumps any theoretical benefit from allowing the fever to continue untreated.

Most commonly, fever is treated by using medications to lower the hypothalamic set-point back towards normal. This is how ibuprofen and acetaminophen work. Alternatively (or in addition), parents can try to help their children reduce excessive heat by using cool (not cold) packs, or bathing in tepid water (never cold water, and never alcohol.)

Fevers occur when the body decides to reset the temperature at a higher level, most commonly as part of fighting an infection. It may serve a useful purpose, though the evidence for a practical benefit in most circumstances is sparse. Ordinary fevers can’t hurt anyone, but if your child feels bad with a fever, using medicine to help him feel better is a good idea.

When is a belly ache “real”?

Holly asked: “My almost-3-year-old twins have recently started telling me on occasion that their tummy hurts. It almost seems like it’s a catch-all phrase for any malaise, but I also think that they have figured out that a statement like that brings on immediate attention. So far, in every instance, either food or a distraction has resolved the issue, but I did wonder if there’s way to recognize when the complaint should be taken seriously – absent the obvious symptoms like fever.”

I love this question. It speaks to something I consider my main goal as a doctor: teaching parents to become self-reliant, and teaching them how to teach their own children to become self-reliant. It’s a circle-of-life thing, without the smarmy Elton John soundtrack, sort of a recursive zen way of looking at what I consider the point of my life as a parent and a pediatrician. Teach parents how to deal with belly aches in a way that helps their own children deal with their own belly aches, that’s been a good day.

I wrote a chapter, called “Communication Remedies,” about this in Solving Health and Behavioral Problems from Birth through Preschool. It’s sort of a whole philosophy of parenting, plus a practical guide to dealing with things like common headaches and belly aches. Here’s an excerpt:

Any body complaint can be caused by social stresses or psychology. Think especially about this sort of problem when a preschooler complains about any of the following symptoms:

• Belly ache
• Dizziness
• Headache
• Tiredness
• Sleep problems

I’ll go more into the various causes of these problems in other chapters, but it is important to not always assume any of these has a “medical” cause. More frequently, there are both biologic and psychological issues at work, and to help a child feel well parents should be prepared to look for the stresses that are contributing to the symptoms.

A good scheme for listening and responding to a child’s complaints follows these steps:

1. Listen right away. Don’t force a child to get your attention with more dramatic or painful symptoms. When a child complains of a headache, it’s best to quickly listen.

2. Listen with attention. Show with body language that you are listening and interested.

3. Try an “explore question”. Often, a quick “How was school today?” type of question will get you to the root of the problem. If you don’t ask, they won’t tell.

4. Encourage the child to discuss the symptoms. Ask a few brief clarifying questions to allow the child to discuss the pain for a few moments. This allows the child to talk with your attention, which is therapeutic. This step should not last longer than 30 seconds or so. Use open-ended questions like:

• Tell me about the pain.
• Where does it hurt?
• What does it feel like?
• Why do you think it hurts?
• What could I do to help it feel better?

Avoid yes/no or leading questions:

• Does it hurt right here?
• Does your throat hurt too?

5. Touch the child. Touch is powerful and important. Try a kiss in the middle of the forehead for a child’s headache. You’ll be amazed how well it works.

6. Attack the problem. You need a firm, confident plan. It may include medicine (for example, a safe antacid for belly pain, or acetaminophen for a headache), comfort measures (hugging a heating pad), or resting in a certain way (“Lie here on your side for five minutes.”) The plan should always include specific steps and be time-limited.

7. Confirm the child is better. Use a statement, not a question. Say “I am glad you’re starting to feel better.” This is a special phrase: it does not imply that the pain is all gone, it is reassuring, and it helps children feel better by making their parents happy. It’s magic.

8. End the encounter. Gently change the subject and encourage your child to play, with a specific suggestion.

• Good: “I’m glad you’re starting to feel better. Go play with your sister.”
• Better: “I’m glad you’re starting to feel better. Go play dress up with your sister.”
• Best: “I’m glad you’re starting to feel better. Let me help you get your cowboy vest on to play dress up with your sister.”

I’m sometimes asked, “What if it is really serious?” Families will not miss a serious illness by first following the scheme above. If the problem is something to worry about, children will show you with their behavior that they’re truly ill. If after a few days symptoms persist in an otherwise well appearing child, consider a trip to the doctor.

Reassuring factors: (these are clues that pain is not caused by a serious medical problem):

• Pain in a vague location, or pain right in the belly button.
• Symptoms that are difficult to describe or talk about.
• Symptoms that only occur on school days, or are especially bothersome the few days after a school vacation.

Concerning factors: (clues that should raise your concern)

• Associated symptoms like fever, vomiting, diarrhea, or weight loss.
• Symptoms that wake a child from sleep.

Many symptoms have no definite medical cause, but are still stressful and upsetting to children. Watch how children act to help determine if immediate medical concern is justified, and listen to what they say to find ways to help alleviate the symptoms.

Fever part 1: What is it?

The normal human body temperature is thought to average 98.6 F. We all remember this from elementary school, and I’ll bet many of you remember the old glass thermometers, the one your mom used with the little red line right at 98.6. If you could top that, you got to stay home! But, like so many things we were told in elementary school, the truth is more complex and murky.

The classic 98.6 is based on a book by Carl Reinhold (sometimes his name is given as “Carl Reinhold August Wunderlich,” a wonderful name that I hope comes up in casual conversation this week). In 1868 he published The Course of Temperature in Diseases, in which he hand-calculated the averages of about a million measurements in 25,000 patients, coming up with 37 C (=96.8 F). He also declared that based on his observations, 38 C (100.4 F) was the upper limit of the normal temperature, essentially defining “fever” for the first time. It turns out that his thermometers weren’t calibrated very well, and were probably off by at least 1 or 2 degrees, but he gave it a good try—especially considering that his thermometer was a foot long, and took twenty minutes to register a stable measurement. (I don’t know where he put that in his patients, and I’m not sure I want to know.) More recent research pegs the average temperature at 98.2 F, but even this varies at least one degree between individuals. One’s own temperature can also vary at least one degree based on the time of day (normal temperatures are lowest first thing in the morning, unless you’re ovulating.) There is also evidence that carefully measured temperature averages vary between human races and genders (women tend to run hotter than men—no surprise there.) Thought it’s not technically correct, 98.6 F (37 C) still remains widely accepted as the “normal” human body temperature for everyone at any time.

If 98.6 F is the traditional (though inexact) definition of “normal”, then what’s a fever? There isn’t a universal definition. Most pediatricians consider a rectal temperature above 100.4 to be a fever; in adults, the number 100 is more often used, usually referring to an oral temperature (though in the elderly, normal “resting” temperatures may considerably lower than 98.2 F). Measuring rectal temperatures becomes more difficult past a few months of life, so often an armpit, oral, or forehead temperature is measured. To be clear in communicating with your pediatrician, say the number that the device recorded, followed by the method you took it: “Junior was 100.8 degrees measured orally.” Don’t add or subtract degrees to “correct” the temperature, just tell us what the number is. In most cases outside of the newborn period, the exact number is not actually very important, but we do like to have a general idea of how high the fever was.

Fever occurs in children most commonly from infections, but can be a result of many other rarer problems (such as adverse reactions to medicines, inflammatory arthritis, cancer, and thyroid disease). Fever can also occur as part of “heat stroke,” when dehydration combined with exposure to heat overwhelms the body’s capacity to control its temperature. Victims of heat stroke feel warm and dry—not sweaty—and are often delirious or sleepy.  This is a true medical emergency that can lead to kidney failure, brain damage, and death. It’s the only health condition where fever itself contributes to harm.

This is the first post in a little series I’m writing on fevers. In future posts, we’ll explore what fevers are for, why parents don’t need to fear fevers, and a super-simple “pediatric insider” action plan for parents to follow when their child runs a fever. Stick around!

Out, damn’d snot

“Out, damn’d snot! out, I say!—One; two: why, then ’tis time to do’t.—Hell is murky.—Fie, my lord, fie, a soldier, and afeard? What need we fear who knows it, when none can call our pow’r to accompt?—Yet who would have thought the child to have had so much snot in him?”

Macbeth Act 5, scene 1, 26–40. Adapted.

One of the joys of being a pediatrician is that I can still make jokes about snot. I get all serious sometimes during the physical exam, asking a six year old to turn up their nose for a careful look. Then I make a concerned “Hmmmmm noise”—you know, create some comedic tension—then, a pause, followed by one of my best one-liners: “Ewww! Boogers!”

It cracks them up. Really.

Shannon asked me to write about whether the fancy-pants new high-tech nasal aspirators are any better than the old fashioned ones at de-snotting kids. The truth is, I have no idea. But there are plenty of other booger-tidbits I’d be happy to share—so join me for what promises to be the most revolting post of 2009, a journey of mucus and fun!

Snot is nasal mucus, made by specialized cells lining the nose, sinuses, and the entire respiratory tree. It’s mostly water, plus specialized proteins called mucins that help create its wonderfully sticky character. Mucus also contains disease-fighting antibodies and chemicals that can tear apart infectious particles. Not only does it help prevent and treat infections, but it also keeps the nasal linings happy and moist, and humidifies inhaled air. Its sticky surface traps pollens, infectious particles, and airborne pollutants, sort of like built-in fly paper. Under ordinary circumstances, a person makes—and swallows– about a quart of it a day.

The most common “chief complaint” for visits to a pediatric office is nasal congestion, most often caused by an upper respiratory infection, or “the common cold.” The snot, especially early on in the cold when it’s clear and watery, is loaded with infectious viral particles. That’s why colds are so common: they make your nose runny and irritated, so you rub it, then touch a doorknob, and then the virus can easily spread to the rest of the family and everyone else in the classroom. Towards the end of a cold, snot will get thick and dark and lovely yellow-green (especially the stuff in that first morning tissue.) By then, the mucus isn’t infectious anymore. Rather than being loaded with virus, it’s filled with dead and dying infection-fighting cells and sloughed debris from your nose. It’s a misconception (unfortunately perpetuated by many doctors, I know) that green snot at the end of a cold means that there’s some kind of infection that needs antibiotics. ‘Taint true, though if thick persistent all-day mucus lasts longer than 10-14 days at the end of a cold, you might have a sinus infection brewing. It’s the duration of symptoms that helps distinguish a cold from sinusitis, not the color of the boogers. And no, you don’t need to bring in a sample for your pediatrician to examine. Really. Thanks.

Excessive snot could be caused by other things. Allergies can make your nose run, though more commonly allergies cause swelling of the lining of the nose, causing a congested feeling without much actual extra mucus. When you cry or have irritated, teary eyes, the tears drain into your nose through little ducts, which makes your nose run too. And a three year old who shoves a lego up her nose is going to get one heck of a snotty discharge in a few days. About once a year I see a toddler with a “cold”—but a cold that oddly enough only leads to nasal discharge from one nostril. If your child has two nostrils, but only one of them is runny, take a look up there. You might just find a toy you thought was missing.

Too much snot causes a few problems. In the short-run, it might make it hard for your child to get comfortable, and can interfere with sleep. More importantly, nasal mucus that just sits there in the nasal cavity is a warm and inviting media for bacteria, and can eventually lead to secondary bacterial infections like ear infections and sinusitis. So both for symptom relief and for the prevention of these infections, it’s a good idea to at least try to get the boogers out of there.

What about cold medicines? The short answer: they don’t work. Some contain antihistamines that may make your child sleepy—that’s not a bad thing, as long as it’s safe—but none actually decrease mucus accumulation . Topical decongestants like Afrin do work, but are potentially addictive and shouldn’t routinely be used in children.

So a more creative approach is needed. Traditional, effective advice includes giving the child extra fluids, humidifying the air, and sitting in a steamy bathroom. These will all keep the mucus nice and runny rather than thick and sticky. You can also put a few drops of saline solution in the nostrils, or even better use a nasal saline irrigator to wash out the boogies. Loose, watery mucus can also be sucked out with a traditional bulb aspirator.

You say you want something fancy, something high-tech, something to casually whip out to the oooohs and aaaaahs of the envious playgroup crowd? This electronic marvel boasts twelve different tunes it can play to distract your honey while her nose is sucked out. (Got to be at least 12. Junior would certainly complain if the same tedious song were played during each episode of nose-sucking. I’m surprised there isn’t a built-in MP3 player.) Or the Nosefrida, manufactured in Sweden, which apparently lets you inflate your baby’s head much like a carnival balloon. I can’t believe I’m raising three kids without it!

I have no experience with these newer nose-suckers, so please, if you get one, post a review. Anyone who posts gets double points if you include a photo—of the kid, not the snot. I really can live without seeing that!