Posted tagged ‘day care’

To prevent ear infections, you have to prevent colds

February 25, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

“My toddler keeps getting ear infections. There’s got to be a way to help with this. What can we do to prevent them?”

It’s frustrating, I know. Ear infections—doctors call them “otitis media”, because we need fancy-pants names for ordinary things—are very common, and account more antibiotic prescriptions than any other pediatric infection. Why do kids get so many of them?

If you stick your finger in your ear, it won’t go very far. Which is probably a good thing. If your finger were oddly thin and pointy, though, you’d be able to reach down your own ear canal to touch your eardrum (doctor-speak: “tympanic membrane”), a little flimsy sheet of tissue that closes off the end of the outer ear parts and separates the ear canal from the middle ear. Ordinarily, on the other side of the eardrum is a small, open, air-filled space through which sound waves can be transmitted with the help of three interlocking little bones.  The important thing to remember is that this middle ear cavity is sealed off on all sides, and is supposed to be filled with ordinary air. There is a little drainage tube on the bottom which can allow tiny droplets of normal mucus to drain out of the middle ear into the nose. All of this works pretty well, most of the time.

Until the drainage tube (doctor-talk, “Eustacian tube” or “Auditory tube”) gets clogged up. Then the middle ear space fills with nice warm mucus. That sits there. And you can guess what happens: bacteria love warm, stagnant mucus. Party time = infection in the middle ear = Mommy, my ear hurts!

What causes congestion that clogs up the drainage tube? Usually, a common cold virus. Junior gets the dreaded yuck, gets all snotty, the tube clogs, and normal mucus can’t drain. That leads to ear infections.

Little kids get far more ear infections than adults. They get far more colds, especially if they’re enrolled in group care. They’re not very good at blowing their little noses and clearing out mucus. But most importantly, that drainage tube of theirs is oriented horizontally, and it’s thin—the net effect being, it doesn’t drain well. They’ve basically got lousy gutters, and the mucus builds up behind them, especially when there’s a lot of snot around.

Ear infections do run in families, probably because some families tend to have even worse middle ear anatomy that predisposes to more infections. Parental smoking is also a big-time contributor to ear infections, because that contributes to chronic congestion and poor drainage. Sometimes, chronic nasal allergy causes nasal congestion, poor drainage, and at least some ear infections. But by far, the biggest contributor to ear infections are ordinary common cold viruses. In fact, during an ordinary cold young children will develop an ear infection about half of the time.

So what can be done to prevent ear infections? The only really practical strategies are to try to prevent the spread of cold viruses:

  • Avoid group care, if possible
  • Stress the importance of handwashing
  • Practice good cough and sneeze hygiene—we should cough into our elbows, not our hands!

In addition, try to avoid second-hand smoke, and make sure that your children are up-to-date on their immunizations. Though there is no one immunization that will prevent all or even most ear infections, some infections can be prevented by making sure that your child has had the pneumococcal conjugate and influenza vaccines.

Related posts:

Weekend ear pain action plan—you do NOT have to rush to the ER, but you ought to help your child feel better when there’s a suspected ear infection

How many ear infections are too many?

Diagnosing ear infections requires an exam

What to do if your child seems to get too many colds

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Idiotic attendance policies, part 2: The preschoolers

June 4, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

I’ve written about stupid school policies before—schools that set up carrots and sticks to prevent even genuinely sick kids from staying home. Dumb, dumb, dumb. But it did give me the opportunity to write, “If absences are outlawed, only outlaws will have absences.” I’m not sure exactly what that means, but it seems wise. Someone ought to put it on a bumper sticker.

Now I’m noticing more and more little kids being sent home (and often sent to my office) for equally dumb reasons. I don’t know why, but while the high schools seem to want to keep genuinely sick kids in the classrooms, child care centers for little ones want to send them home for next-to-nothing illnesses. Both extremes aren’t helping keep kids healthy.

The AmericanAcademyof Pediatrics has tried to offer guidance about sensible, science-based pre-school policies to protect the health of children. They’re summarized in this book, also available at Amazon. Owners and operators of preschools and government bodies that make health policies really ought to read that book, and keep it under their pillows at night to help absorb its wisdom. Instead, they seem to be making things up.

School exclusion rules ought to be designed to protect the health of children and staff. Children, in general, ought to stay home if:

  • They can’t comfortably participate
  • Their presence poses a health risk to themselves or others
  • Their presence requires more support than the staff can offer

The AAP has specific suggestions for certain health problems that may surprise you. They certainly run counter to what I’m seeing from day cares in my community. Some of their recommendations:

Kids with the common cold, even if there is green snot, don’t need to be excluded from school. This is because the period of highest infectivity is before symptoms become obvious. Once a child has obvious cold symptoms, they’re no longer very contagious anymore—no matter the color of their snot. As long as they’re comfortable, they can go to school.

Fever, itself, isn’t a reason to keep kids home. Now, most kids with fever are uncomfortable—those kids shouldn’t go to school, since they can’t participate. But some kids with fevers, especially those with viral infections, feel just fine after a dose of ibuprofen. Excluding these children is unlikely to reduce the spread of disease, since most viral infections are spread by children who have no symptoms at all.

Pink eye? This seems to be the biggest boogeyman at preschool. Like the common cold, pink eye is contagious, but there is no evidence that treatment of pink eye reduces the spread of the bacteria or viruses that cause this common infection. The symptoms are quite mild, and will resolve in 5-6 days with or without treatment. The schools freak out, but kids do not go blind from garden-variety pink-eye, and most of them feel fine. As with other illnesses, if the child really feels bad she ought to stay home. Note that there are rare, more-serious occasional outbreaks of more-serious pink eye caused by adenovirus, so a classroom with multiple cases of severe pink eye needs to be reported to public health authorities. But the vast majority of pink eye that’s referred “emergently” to my office are very mild, nearly symptom-free infections.

Infections that really ought to stay home are those that include diarrhea that can’t be contained in a diaper or requires frequent changes, or vomiting. These symptoms really can’t be managed safely or comfortably in a group care setting.

Wrongheaded day care policies probably drive a lot of my business. Many centers seem to require a “note from a doctor” to return to school. Still, wrong is wrong. What we need is a more sensible approach to group care and school illnesses, rather than knee-jerk policies that keep children and parents home or send them to my office. Sick kids ought to stay home, but most kids with mild illnesses who feel pretty well can go to school safely.

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

March 6, 2011

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.

Mild belly aches and vomiting

September 27, 2008

Holly posted, “My 4 year old has recently been complaining of ‘tummy aches’ during different times of the day. She hasn’t been ill, running a fever, or consuming anything out of the ordinary. She has vomited several times in the last few days. Once she has emptied her stomach, she seems to feel fine. Later, however, a tummy ache returns. Are there any OTC meds ok to give a 4 year old that can help settle an upset tummy? Since no other symptoms of illness are apparent, how many days of occasional vomiting should be dealt with at home before calling the doctor’s office? Since no one else at home is getting sick, is it ok to send her to school?”

Ways to settle an upset tummy begin with some non-medical approaches, like making meals small, and staying away from foods that are rich in fat or protein. Sips of things like clear liquids or cola seem to help. A few studies have looked at ginger as a treatment for nausea, at it is probably effective—but I’m not sure you’ll get a four year old to gnaw on ginger. Most ginger ales contain only artificial flavors, not real ginger root.

A few safe OTC remedies include antacids like Maalox or Mylanta, or a medication for nausea called Emetrol. Pepto-bismal can soothe an upset stomach and help with nausea, but there are some people who advise against its use in children because it contains an aspirin-like ingredient. In the past, taking aspirin during an infection with influenza or chicken pox was associated with a serious liver condition called Reye Syndrome. Though the ingredient in Pepto has never been linked to Reye Syndrome, some people are still leery of it.

As long as she’s overall feeling well, I don’t think a trip to the doctor’s office is warranted for several days. But if this persists, she should be seen. Since she’s vomiting a few times a day, the most likely diagnosis is a viral infection. It would be best to keep her out of school for the protection of the other children until she is well. I know this isn’t always possible for working families, but keeping her home is the best way to prevent sickness from spreading to other children.