Can getting cold give you a cold? A win for Grandma!

The Pediatric Insider

© 2015 Roy Benaroch, MD

Grandma says, “Bundle up or you’ll catch cold!”

Research just published in the Proceedings of the National Academy of Sciences explains why Grandma may have been right.

A team from Yale University looked at rhinovirus–the most common of the common cold viruses—and the immune response in mice. They found some solid science:

Mouse airway cells infected with mouse-adapted rhinovirus 1B exhibited a striking enrichment in expression of antiviral defense response genes at 37 °C relative to 33 °C, which correlated with significantly higher expression levels of type I and type III IFN genes and IFN-stimulated genes (ISGs) at 37 °C.

In other words, when the nose is at the ordinary body temperature (37 C = 98.6 F), there is a more-robust immune response than when the nose is cold (33 C = 91.4 F). Cold temperatures allow the rhinovirus to replicate and spread more easily.

Does this mean you ought to put a muffler on your pet mouse this winter? Maybe so. And maybe your children, too!

How to treat congestion in babies

The Pediatric Insider

© 2013 Roy Benaroch, MD

Life isn’t easy for babies. You can’t talk, and to get anywhere you have to wave your arms around and hope someone carries you. Perhaps worst of all, when you’ve got a cold your little nose gets so stuffy, it’s miserable.

Face it: no matter how smart your baby is, she probably hasn’t figured out how to blow her nose. Are there any practical ways to help unstuff congested baby?

• Keep the room humid, using a cool-mist humidifier or a warm vaporizer. Moist air prevents mucus from getting stick and sticky and harder to move.

• Try using a few drops of nasal saline. You can buy a little bottle at the drug store, or make it yourself.  Squirt or drip a few drops of this up each nostril to loosen mucus. You can repeat this as often as you’d like.

• A nasal bulb aspirator can help pull out at least some of the mucus. Remember, first squeeze it, then gently press the tip against the nose opening, then let go so it sucks out the yuck.

• Gently inclining the bed can help, but it’s not a good idea to routinely let babies sleep in a car seat, bouncy seat, or other device that holds them upright.

• Vapor-rubs like “Vicks” might help some with congestion, though good studies haven’t been done, especially in young babies. If you want to try a product like this, it’s essential that your baby NOT be able to eat or lick any of the rub. It’s very toxic if ingested.

Fortunately, even the most congestion baby usually feels much better in a day or two. If your congested baby is acting ill, having trouble nursing, having any trouble breathing, or isn’t improving in a few days it’s a good idea to head to the doctor.

Infections now, or infections later: Does day care keep children healthier in the long run?

The Pediatric Insider

© 2011 Roy Benaroch, MD

Tracy has a good question: “My 4 year old is not in day care – he stays with Granny. I heard that once you get a cold, you never get that cold again, and I am worried he isn’t exposed to enough germs now to keep him healthy later. Should we be trying to infect him with more colds now that he has the luxury of staying in PJs all day instead of hitting him with all these new viruses when he does start school?”

For many viral infections, it’s true: you get it once, you won’t get it again. Think about chicken pox, measles, or hepatitis A—suffer through the infection, or get the vaccine, and you’re pretty much protected for life. Second infections or breakthrough disease after vaccination can happen, but it’s uncommon. This doesn’t hold true for bacterial infections like pneumonia, whooping cough, or ear infections, but for many viruses immunity can last the rest of your life.

But the common cold isn’t caused by one virus, or even one family of viruses. Common cold symptoms occur with hundreds of kinds of rhinoviruses, coronaviruses, and the recently-discovered metapneumovirus, to name just a few. Each cold may earn you immunity from one variety of one virus, but there are plenty more of them lurking out there.

What about the cumulative effect of the dozens or hundreds of viruses kids in day care? Do day-care kids earn lasting protection from enough viruses to keep them healthier once they’re in school? And does that mean that kids who spent more time in their PJs with Granny will get sicker once they start kindergarten?

A study published in December 2010 tried to figure that out. Researchers followed about 1300 families in Canada over eight years to record the frequency of infections in children through their years of day care and school. They looked at upper respiratory infections, ear infections, and “tummy bugs” that caused vomiting and diarrhea. Their conclusion was actually quite satisfying: children, whether or not they attended day care, suffered through approximately the same number of infections over the course of the study. But day-care kids got more of their infections when they were younger, especially when they first started in group care, while kids who didn’t attend day care got more infections later when they started school. The piper gets paid, either way: get your infections over with early, or get them later.

It’s reassuring to know that overall, neither group of children was really sicker than the other. Whether or not children attend group care when they’re young doesn’t seem to affect the total number of infections, but rather only the timing of their infections. Parents can choose whether their children will get more infections now or later, but the total number of infections is going to be about the same either way.

Zinc supplements for the common cold

The Pediatric Insider

© 2011 Roy Benaroch, MD

The Cochrane Collaboration is a very well-respected international non-profit whose 28,000 volunteers review the best, solid evidence to help determine if medications or other health interventions really work. They are, in short, da bomb.

When Cochrane speaks, people listen.

Cochrane last week released a review of studies examining the effectiveness of zinc supplementation on preventing and treating the common cold. They found that there was good evidence that zinc taken early, during the first symptoms of a cold, can lessen the duration and severity of illness; furthermore, zinc taken daily during cold season can reduce the frequency of these annoying infections.

There were only 15 good quality studies to look at, involving a total of about 1400 patients. Because the studies varied in how much zinc was given, in what form, and how often, no conclusion could be drawn about the best dosing strategy. Nor could any conclusions be drawn about using zinc in children. Still, the evidence tantalizing, and more research is needed to pin down these details.

Zinc is fairly well-tolerated and safe. The most common side effects reported were an unpleasant taste and nausea. There is no particular reason to think zinc in reasonable doses would be unsafe in children or adults.

If you want to try zinc, there are drops, lozenges, and pills to choose from of varying strength and composition. Follow label directions for dosing. For these products to work to treat the cold, you have to start them quickly, and take them frequently throughout the day.

One other warning: the Cochrane review was looking at genuine, therapeutic doses of zinc. Many other zinc products are produced and marketed as “homeopathic”—meaning there isn’t any actual zinc in the bottle. Homeopathy is literally nothing. It’s a kind of witchcraft that relies on the nonexistent magical memory of water. Don’t waste your money on anything labeled “homeopathic.” If you want to try zinc, choose a genuine zinc product that measures the dose in milligrams, not in magic memories.

Humidifier versus dehumidifier smackdown!

The Pediatric Insider

© 2010 Roy Benaroch, MD

Shannon wrote in, “I just recently read in a magazine that a humid environment as opposed to a dry environment is more hostile to viruses. It sounds a little counter-intuitive to me, however, if it’s true would it be best to run my children’s humidifiers all winter long to stave off the flu and other viruses as this article recommended? I tend to run them more in the winter anyway because my kids tend to have more runny noses or their nasal passages are drier and bloodier. What are your thoughts?”

I’m not sure the viruses, themselves, would even care. Viruses are just little teeny packets of genetic material, with a small handful of protein. They’re not cells, so they won’t “dry out”, and I doubt that their survival would depend much on humidity.

I would guess, though, that a dry environment might make it easier for viruses to invade the nasal lining to make your children sick. Viruses can’t penetrate normal intact skin, and even moist surfaces like the lining of a mouth or nose does a pretty good job repelling these little monsters (the viruses, I mean, not the children.) But once the lining of a nose gets dried out and develops cracks and fissures, the viruses can grab hold and jump right in.

By preventing dry air with a humidifier, you’ll also keep whatever mucus is around nicely wet and runny—that’s good, because thin and runny mucus is less likely to plug up noses and sinuses and get infected with bacteria. Thick and sticky mucus just sits there, an inviting bacterial playground. Thin and runny mucus drains, carrying infection away.

If you do run a humidifier all winter, you’ve got to keep it clean. That warm, moist environment can also become a playground for mold. Once a week, take the humidifier apart, wipe it down with diluted bleach (1 capful per gallon) and let the pieces dry before re-assembling.

What kind of humidifier is best? The ultrasonic ones are easiest to clean, so those get my vote. The kind with the big fabric wicks are just about impossible to clean well, and the ones that use a heating coil could cause burns when Junior pulls it over onto her head.

More articles about mucus, which has apparently become a favorite topic at my blog. Momma would be proud:

Out, Damn’d Snot

Control your mucus

Too many colds

A cold lasts longer than you think

Cough and cold medicines don’t work, updated here

Great study, but wrong conclusion: The Vapo Rub fail

The Pediatric Insider

© 2010 Roy Benaroch, MD

A study due for publication in December, 2010 claims to show that Vick’s Vapo Rub can help your child fight through the common cold. Though it was funded by the manufacturer (Procter and Gamble), it’s a good study—but if you read it carefully, there are some big red flags that say “Beware!” I don’t agree with the author’s conclusions, and I don’t agree with headlines in the media extolling the virtues of Vick’s. The study was well-designed, but the authors themselves found a fatal flaw that renders their results meaningless.

The study design was solid, and cleverly tried to prevent parents from being able to skew the results. 138 kids from age 2-11 years with at least moderate coughs were recruited. Children with more-specific causes of cough, like asthma, were excluded; and the children were not allowed to take other kinds of medication that might suppress a cough. The group was divided into thirds: one group received no treatment at all, one group received plain petrolatum (similar to Vaseline), and one group received Vick’s Vapo Rub. The parents were given a glass jar in an opaque bag with their study drug (or an empty jar, if they were in the no treatment group), along with a second jar that contained Vapo Rub in all three groups. When the families began treatment, they were instructed to first rub Vapo Rub under their own noses—then rub the study medication on their child’s chest. By putting Vapo Rub on the parents, the hope was that parents would not be able to tell whether they had put plain petrolatum or Vapo Rub on their child’s chest.

The next day, parents filled out a questionnaire, recording how well, or how poorly, their child did. The kids who received Vapo Rub did the best, especially when their ability to sleep was judged. That’s what the mainstream and medical press are reporting. But sometimes it pays to read the study a little bit further.

Thought the authors tried to prevent the parents from knowing what treatment group they were in, 90% of the parents correctly “guessed” what their child had been treated with the night before. I don’t know if the parents were able to smell past the Vick’s on their own noses, or if they didn’t follow directions, or if the approximately 50% of children in the Vapo Rub group who developed skin irritation gave it away—but in any case, this was essentially an unblinded study. Almost all of the parents knew whether their child was treated with Vick’s or the placebo—and that could certainly account for the observed differences in how the children did.

It’s human nature. The placebo effect has been documented in almost every clinical study that’s been done. People who are given what they think is medicine expect to get better, or expect their kids to get better, and will honestly judge that they did get better. Even if the “medicine” is itself just a placebo. Our own expectations influence our perceptions. If study participants are aware of whether they’re taking placebo or the study drug, clinical studies of medications are worthless.

There are other reasons to think twice before using Vick’s Vapo Rub. It can be quite toxic—according to the discussion section of this new study, an 8 tsp dose can kill a child. Much smaller doses are probably safe, but have occasionally been linked to seizures (children with seizures were excluded from the study.) In children less than two, Vick’s can cause serious lung irritation and breathing troubles.

When deciding whether to try a treatment, parents and physicians ought to weight the risks and the benefits. This study, in which the participants were inadvertently unblinded, allows us to draw no conclusions about whether Vick’s actually works. We do know that there are genuine risks. I’d stay away from Vicks, especially in younger children, until there is better proof that it actually works.

If you do want to try Vick’s Vapo Rub, follow the directions carefully. Do not put any near your child’s mouth, and do not use it in children less than two. Keep it way out of the reach of children and pets.

Short questions on cramps, SIDS, lumps, spatulas, and suckers

The Pediatric Insider

© 2010 Roy Benaroch, MD

A quick-fire post! Time to clear out the inbox…

Michelle: “Is it possible for girls to have cramps before (about a year or so) they start their period?”

I don’t think that’s likely, at least not that far beforehand. Constipation, stress, poor diet (too much processed food, not enough fresh fruits/vegs/water), not enough exercise, and lactose intolerance would be far more likely.

L asked: “Why do some children develop knots in the leg after immunization injections?”

They’re called “sterile abscesses”, which isn’t a great name—they’re not really abscesses at all. The knots are caused by a local inflammatory reaction, and they’re more likely to occur if the needle was too short or if the child jerked away. The knots don’t really mean anything, and don’t interfere with the way the vaccine works. Expect them to gradually go away in a few months.

Sheri: “My 6 1/2 month old recently started sleeping on his stomach. I put him down on his back half swaddled with his arms out for every sleep. He cries, moves around and eventually rolls over on his stomach for the rest of the night. I know this increases his risk of SIDS but I can’t stop him from rolling over. Can I stop worrying?”

Yes. Stop worrying. The “back to sleep” campaign, which has reduced SIDS by about 50%, encourages parents to put babies on their backs to sleep—but never included any instructions to keep babies on their backs. Once your child can roll to him stomach, leave him there. You don’t have to stand aside his crib all night with a spatula, flipping him back over.

Melissa: “Hi- I was wondering what your opinion was on all of the antibacterial products that are available now and so widely used.”

No good studies have been able to confirm that antibacterial-coated products have been able to reduce infections. I doubt they could have any net effect on the germs that children are exposed to, with the single exception of alcohol-based hand sanitizers. Those have been shown to reduce infections among health care works and in day cares. You want to avoid infections? Try:

• Good handwashing
• Frequent use of alcohol-based hand sanitizers
• Vaccines against preventable illnesses like influenza
• Keeping your children away from sick children
• A good night’s sleep

Antibacterial surfaces, special vitamin supplements (including those “developed by a teacher” or sold by olympians), herbs, wands, sprays, magic air ionizers, and plenty of other gizmos and elixirs are big money-makers for some, and big money-wasters for others. Don’t be a sucker.

Control your mucus

The Pediatric Insider

© 2010 Roy Benaroch, MD

Germs love warm, sticky mucus. If you want to spread them around, spray your coughs and sneezes like a cropduster. Alternatively, you could sneeze or cough on your own hands, then smear the ick on doorknobs. Either way, the germs win.

At the height of last year’s novel-H1N1 epidemic, researchers in New Zealand wanted to see if people in public places were taking public health advice seriously. Dozens of medical students surreptitiously watched people in a hospital, shopping mall, and a train station to see how they sneezed and coughed, observing and taking notes on 384 mucus-producing events. The results, as reported here:

• 65% covered their mouths and nose with their own hands, ensuring their ability to wipe their infectious germs on the next unsuspecting doorknob or stranger.
• 27% didn’t cover anything at all—they just let ‘er rip!
• 3% sneezed into tissues or handkerchiefs.
• 1% sneezed or coughed into their own elbows, Dracula-style. This is what my kids were taught to do in kindergarten. It looks weird, but it prevents snot from spraying without getting a child’s hands covered with infectious goo.

So: the vast majority of people observed in this study did nothing to prevent the spread of disease. Somehow, I’m not surprised.

We could all do a better job at keeping our germs to ourselves. Some simple, effective steps:

• Stay home if you’re sick, and keep your kids home if they’re sick.
• Get your family vaccinated against influenza, and encourage your friends and neighbors to do this too. The more of us who are vaccinated, the better protection we all have.
• Wash hands frequently, and use an alcohol-based hand gel between washings.
• Finally: Be in control of your mucus! Teach children to sneeze into their elbows, and use a tissue to prevent your germs from spreading. And throw away those tissues afterwards—don’t just wad them up somewhere.

We’re all in this together, folks. Let’s do what we can to stay a bit healthier and less sticky this winter.

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!

A cold lasts longer than you think

Here’s a simple question: how long should symptoms of a common cold last? Three days? How about five? Maybe a week?

A study published in January, 2008 sought to answer that question. School-age children were followed for several months, and kept records of the onset and duration of common cold symptoms like fever, congestion, cough, sneezing, and runny nose. During the study period, 81 colds occurred. The investigators also collected mucus from the kids during their colds to test it for viruses and bacteria.