Thrush: out of the mouth of babes

Cottage cheese like curds coat the inside of your baby’s tongue and inner cheeks. What is this white stuff that won’t wipe off? Not breast milk, not formula, it’s thrush.

Thrush, fancy medical name Oral Candidiasis, is caused by an overgrowth of yeast, called Candida. Although not painful, it may cause discomfort akin to having a film of cotton coating the inside of the mouth.

We all have Candida on our bodies. Usually we have enough bacteria on our bodies to suppress the growth of Candida, but in cases when there is less than usual bacteria such as in young babies or for kids who are on antibiotics, Candida can emerge. For older kids on inhaled steroids for asthma, failure to rinse out the mouth after medication use also promotes an environment conducive to thrush.

To treat thrush, we usually prescribe Nystatin, an anti-fungal/anti-yeast medication, which works topically. Parents apply the medicine to the inside of the baby’s mouth after feedings four times per day. Use Nystatin until thrush is no longer visible for 48 hours. A course takes one to two weeks to complete. An oral medication called fluconazole (brand name Diflucan) may also be prescribed.

Watch out. Thrush may be thriving on mom’s breasts or on pacifiers or bottle nipples. Mothers can apply the same medicine to their breasts after breast feeding. Scrub pacifiers, bottle nipples, and any other object that goes in to a baby’s mouth extra well with hot water and soap or use the dishwasher.

Thrush that persists despite proper treatment can signal an immune system problem. So if your child’s thrush is not resolving in the expected time, let your child’s health care provider know.

A newborn’s tongue may always look slightly white. This “coated tongue” in young babies could be residual breast milk or formula and does not need treatment. If you are not sure, bring him in to see his health care provider for proper diagnosis.

Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®

Two Peds goes undercover at your local pharmacy

Picture the Mission Impossible theme song in your head… da da da DUM DUM da da da DUM DUM dadada…dadada…dadada…DA DA! Keep this background music playing as you read.

Recently, Two Peds in a Pod went undercover as two unsuspecting moms surveying the scene on the shelves of a local chain pharmacy, seeking to uncover what medicines, ointments, and therapies avail themselves to the unsuspecting consumer. Today we break open the case.

All medication labels have an “active ingredient” list. This list contains the actual medicine that acts on your child’s body to hide symptoms or cure a condition. Read this list carefully so that you know what you are actually giving your child. For example, Flu-Be-Gone claims it “cures the aches and cough of flu and helps your child sleep better.” In order to know just what is actually in Flu-Be-Gone, you need to read the active ingredients. Included might be acetaminophen (brand name Tylenol), a fever reducer and pain reliever, and diphenhydramine (brand name Benadryl), allergy medicine that has the common side effect of causing drowsiness and has some mild anti-cough properties. Notice neither active ingredient actually kills the flu germ. Additionally, you may already have these two medications in your medicine cabinet, or you might have already given your child diphenhydramine recently and giving Flu-Be-Gone would overdose your child.

Also note, diphenhydramine is everywhere. If you see the word “sleep” or “PM” in the name of a product, you will usually find diphenhydramine in the active ingredient list.

Now, let’s hone in on your choices for the anti-itch therapy, hydrocortisone. When your child’s health care provider advises treating an itchy bug bite, poison ivy, or allergic rash with hydrocortisone, make sure that the ACTIVE INGREDIENT in the product is “hydrocortisone 1%.” Hydrocortisone comes as a cream, ointment, spray, or stick (looks like a glue stick) and can have aloe, menthol, or other ingredients thrown in as well. Don’t bother with anything less than maximum strength. Regular strength is 0.5% and is generally ineffective. Also, keep in mind that while ointment is absorbed a bit better, it is more greasy/messy than cream.

Don’t be fooled into thinking products with the same brand name contain similar active ingredients. Also, do not depend on your doctor to necessarily know the difference between the all the formulations.We noticed that the same brand name pain reliever, such as Midol, can have different active ingredients depending on which one you choose. Midol Teen contains acetaminophen, Midol liquid gels contains ibuprofen, and Midol PM contains acetaminophen and diphenhydramine.

Let’s talk bellyache. Did you know that kids should not take adult pepto bismol because it has a form of aspirin in it? Aspirin may cause Reye’s syndrome, a fatal liver disorder. However, we did see a product called Children’s Pepto Bismol and guess what the active ingredient is? It is calcium carbonate, which is the SAME active ingredient as in Tums, and is safe to give kids. However, watch your wallet: the children’s pepto bismol that we found cost $6.00 for a box of 24 tablets. The TUMS that we found cost $4.50 for a bottle of 150 tablets of the same stuff, just in slightly higher dose. Check with your child’s doctor but in most cases, the kids can take the adult dose.

Also, be aware that cold and cough medicine have not been shown to treat colds successfully or even to actually relieve symptoms in most kids. In fact these medicines have potential for harmful side effects, accidental overdose, or accidental ingestion and are just not worth giving your children. However, we found tons of cold and cough medicines marketed for children. Here are the three most commonly used active ingredients:

If you see “suppressant” you will likely find “dextromethoraphan” in the active ingredient list.
If you see “expectorant” you will likely find “guaifenesin” in the active ingredient list.
If you see “decongestant” you will likely find “phenylephrine” in the active ingredient list.

Many products combine two or all three of the above. We ask, even if these ingredients did work well in kids and were not potentially dangerous, what is the POINT of combining a cough suppressant with an expectorant? Can you really have it both ways?

( Remember, that Mission Impossible theme is still playing in the background.)

A few other tidbits. “Dramamine,” used for motion sickness, gets broken down in the body to diphenhydramine, that allergy medicine that we already talked about. So look at cost differences when choosing a motion sickness medicine. Both have the same side effect: sleepiness.

Many cough drops contain corn syrup and sugar. This is the same stuff lollipops are made of, so just call a candy a candy and keep your child’s throat wet with the cheaper choice, if you choose to do so.

Finally, we found one “natural children’s cough medicine” which claimed that it is superior because of its “all natural ingredients.” The first active ingredient listed? Belladonna. Sure it’s natural because it comes from a plant. So does marijuana. Just because it’s “natural” doesn’t mean it’s safe. Belladonna can cause delirium, hallucinations, and death and in fact has been used in high doses as a poison! Leave the cough medicine on the store shelf, and read our post about other ways to soothe a cough.

Bottom line: remember always to check the “active ingredient” list when buying any over-the-counter medication for your children.

As we were wrapping up our mission, one of the pharmacy employees came over to us, raised an eyebrow at our clipboard, and asked, “Can I help you ladies with anything?” We were tempted to answer “YES, can you help us take notes?” but we just smiled and said “No, we’re fine, thanks. Just checking out what’s available.”

So now, we will don our stethoscopes and come out of hiding, go back into our offices and onto our website. Thanks for tuning in to this episode of Two Peds in a Pod…. Da da da, DUM DUM da da da, DUM DUM dadada…dadada…dadada…DA DA!!!

Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®

Acetaminophen FYI

All acetaminophen (e.g., Tylenol) will soon be made at the same concentration, the Consumer Healthcare Products Association announced recently. In the past, manufacturers made most infant formulations more concentrated (thicker) than children’s formulations so parents would not need to give as much liquid to babies. However, this difference in concentration was the source of much confusion and accidental overdoses. Now all acetaminophen will be made the same concentration (160mg per 5ml ). Watch for these changes to hit the shelves as early as this summer.

You may also see other changes if the Federal Drug Administration implements the advice received from an advisory panel earlier in the week. Recommendations include adding weight based dosing guidelines for infants six months to two years of age and for medicine to come with measuring devices clearly marked in milliliters in order to ensure more accurate dosing.

Stay tuned.

Naline Lai, MD and Julie Kardos, MD
©2011 Two Peds in a Pod®

Car safety update

The American Academy of Pediatrics issued an updated policy on car child restraints earlier this week.

The highlights:

– babies/toddlers ride backwards in a rearfacing carseat until two years old

– kids ride in booster seats until the car’s seat belt fits correctly- usually at 4’9″ and between ages 8-12 years of age

– kids ride in the backseat until at least 13 years of age

Please see the complete policy and the reasons behind it on the AAP website.

Naline Lai, MD and Julie Kardos, MD
©2011 Two Peds in a Pod®

Ear tubes: who needs ’em?

Remember that funny Sesame Street sketch when Ernie has a banana in his ear and his buddy Bert keeps asking Ernie why he has a banana in his ear? Ernie answers, “I can’t hear you Bert, I have a banana in my ear!” Ernie’s hearing loss was easily remedied by removing the banana. Temporary hearing loss produced by infection and fluid in the middle ear is remedied by removing the infection and fluid. Ear tubes (myringotomy or tympanostomy tubes) inserted into the eardrum will allow clearing.

Back when we were in training (sixteen years ago, but who’s counting?), Dr. Lai and I were taught any child with persistent fluid in her ears for three months, three ear infections in six months or four ear infections in one year was a candidate for ear tubes by an Otolaryngologist (Ear, Nose Throat Doctor).

Now the recommendations for ear tubes have been modified. One large study from 2007 showed toddlers who have ear tubes placed early because of persistent fluid in their middle ears fared the same developmentally as kids who delayed receiving ear tubes, eleven years later. So how do we decide who needs tubes and who doesn’t?

To understand the need for tubes, lets first look at anatomy. Imagine you are walking into someone’s ear. When you first enter, you will be in a long tunnel. Keep walking and you will be faced with a closed door. This door is the ear drum. Next, open the door. You will find yourself in a room with a set of 3 bones. Look down. In the floor of the room there is an opening to a drainage pipe. This room is called the middle ear. This is where middle ear infections occur.

During a cold, fluid can collect in the room and promote bacterial infection. Think of the sensation of clogged ears when you have a cold. Usually the drainage pipe, called the eustachian tube, drains the fluid. But, if the drain is not working well, or is overwhelmed, fluid gets stuck in the middle ear and become infected. Otolaryngologists give the fluid a different way to escape by placing artificial drainage tubes in the ear drum (the door). The reason young kids get so many ear infections compared to older kids is because the positioning of the eustachian tube in young children does not allow adequate drainage. Also, young children get many more colds —up to 10 per year. Tubes buy time until a child’s anatomy changes with age and a child contracts fewer colds.

An operation to insert ear tubes is very brief, yet still has a baseline small risk of anesthesia. Then the ears must be kept dry because the tubes give the “outside” a direct link to the “inside” of the ear. Kids have to prevent pool water from entering their ears by wearing ear plugs. Many kids don’t like to wear the plugs and it’s difficult to get them to fit properly.

In the past, one way doctors used to stall surgery in kids with reocuring infections was to start daily antibiotics. We gave this antibiotic for several months at a time to lower the ear infection rate. However, with the increased concern about antibiotic resistant “super germs,” this practice is falling out of favor. As for other medications, antihistamines and decongestants have not shown to help treat or prevent ear infections.

So when is it appropriate to try to hold off on surgery, even in the child who has suffered several bouts of ear infections? If a child has normal hearing despite the history of ear infections, and has been developing language normally, then one option is to continue treating the ear infections with antibiotics as they come and make sure ear pain is adequately controlled by using oral or topical medication. The same holds true for children with persistent middle ear fluid.

Current recommendations are for health care providers to check on kids with fluid every 3-4 months for signs of hearing loss or changes in ear anatomy until the fluid subsides. But no longer does the presence of persistent fluid without any hearing loss demand immediate surgical consultation.

Because all children are different, they may need different management even with the same ear infection and fluid history. Start asking your pediatrician about tubes not only if your child has suffered from more than three ear infections within six months, but also if your child shows of hearing difficulty, delayed talking, or any developmental delay (which can be signs of hearing loss). Your child’s health care provider may need the additional input from an audiologist as well as an otolaryngologist.

Julie Kardos, MD with Naline Lai, MD
©2011Two Peds in a Pod®

Flu vaccine coverage

The bad news is that influenza is now circulating in all 50 states. The good news is that according to the Centers for Disease Control, the vaccine covers all currently circulating strains.

The best news: the ground hog predicts an early spring.

For the latest in updated flu information www.cdc.gov

Julie Kardos, MD and Naline Lai, MD

Stay healthy: how to prevent illness this winter

Reporter Melanie Cutler interviews Two Peds in a Pod for Five Tips to Keep Your Child Healthy This Winter in the online news source Newtown.Patch.com.

Waxing philosophically: ear wax and eew

Babies are gooey. Spew tends to dribble out of every orifice and the ear is no exception. Devin’s mother tipped her four month old baby’s head sideways in the office the other day and asked me what to do about the oily, yellow wax smeared around the opening of his ear canal.

Some say wax evolved to help keep bugs and other debris from reaching deep into our ear canals. Case in point: one of my least favorite memories during residency was when I picked out pieces of a cockroach entrapped in the wax of a child’s ear. The amount of wax you see on the outside is not indicative of the actual amount inside the ear canal. Chances are, the wax is not hard and does not block the ear drum. Even if there is a large amount of wax, it is unlikely to greatly affect a baby’s hearing. Equally normal is that some babies and children don’t seem to produce any ear wax. If you are concerned about your child’s ear wax, have your pediatrician take a peek with a light.

Despite the copious amount of wax on the outside, Devin’s ear canals were clear. “But the wax is simply disgusting,” said Devin’s mom, “Can I clean his ears? “

“Yes”, I answered. “Wipe off what you see, doesn’t matter if you use a wash cloth or cotton swab. The special shaped cotton swabs with the safety tips are unnecessary. Anything you see is fair game. Rest assured, you will not go too deeply into the ear canal if you only scrape off what is visible.” Dr. Kardos goes one step further and tells her patients: if you can get the wax with a wash cloth, it’s fair game. Otherwise, leave it alone.

Now suppose your pediatrician does say the wax should be removed. Place an over-the-counter solution such as Debrox in the ears (children and adults can use the same formulation) – three to four drops one or two times a day (during sleep is easiest for babies and toddlers) for a few days. The solution softens wax. For maintenance, mineral oil and olive oil are favorite remedies. Place one drop daily in ears. In the office some pediatricians can use a water irrigation system (like a water squirter in your ear) to wash out the wax. The worst side effect is that the child’s shirt sometimes gets wet. Irrigation is a very effective for removing wax in a school-aged or teenaged child who complains of difficulty hearing.

If you find you are constantly cleaning your baby’s waxy ears, take heart. At least there won’t be any roaches “bugging” them.

Naline Lai, MD with Julie Kardos, MD

What? That’s not what we said: Real Simple Magazine

Take a look at the February 2011 issue of Real Simple magazine. We are two of the experts cited on page 124. The good news is that some of our thoughts on the essentials of a medicine cabinet were integrated into a photo-essay piece. The bad news is that children’s cough medicine is listed as a component of the medical cabinet. While the other contributors to the piece may encourage use of over-the-counter cold and cough medications, we discourage use.

Of concern, safety and effectiveness of cough and cold medicine has never been fully demonstrated in children. In fact, in 2007 an advisory panel including American Academy of Pediatrics physicians, Poison Control representatives, and Baltimore Department of Public Health representatives recommended to the U.S. Food and Drug Administration (FDA) to stop use of cold and cough medications under six years of age.

Thousands of children under twelve years of age go to emergency rooms each year after over dosing on cough and cold medicines according to a 2008 study in Pediatrics . Having these medicines around the house increases the chances of accidental overdosing. Cold medications do not kill germs and will not help your child get better faster. Between 1985 and 2007, six studies showed cold medications didn’t have significant effect over placebo.

So why are children’s cough and cold medicines still around? A year after the advisory panel published their recommendations, FDA advised against using these medications in children younger than two years but data about these medications in older children is still rolling in. FDA continues to advise caution with these medications. The producers of cold medicines said at that point they would launch new studies on the safety of medication for those two to twelve years of age. In the meantime pharmaceutical companies stopped manufacturing cold medicine products for those under two years of age and changed the labels to read “for four years old and above.”

Yes, watching your child suffer from a cold is tough. But why give something that doesn’t help her get better and has potential side effects? There is plenty to do besides reach for cold medicine. Give honey for her cough if she is over one year of age. Run a cool mist humidifier in her bedroom, use saline nose spray or washes, have her take a shower with you, and teach her how to blow her nose. Break up that mucous by hydrating her well- give her a bit more than she normally drinks.

If you have young children and want to make your medicine cabinet truly “real simple” then take out the over the counter cough and cold medication.

Closure: there is no link between the MMR vaccine and autism

It’s confirmed. Dr. Wakefield was a fraud. Recently, on January 5, 2011, reporter Brian Deer published a report in the British Medical Journal exposing more flaws in the Wakefield study- the study which proposed a link between Measles, Mumps, and Rubella vaccine (MMR vaccine) and autism. Of note:

Lawyers who were trying to win a law suit for parents who believed that the MMR caused their children’s autism paid Wakefield to do the study.
Wakefield falsified his findings. The medical records of all 12 children in the study were inconsistent with Wakefields’s data.
Almost half of the children in the study already showed signs of developmental abnormalities before they received the MMR vaccine. Therefore, the MMR vaccine did not cause their disabilities.
Rather than randomly choosing the children for the study, Wakefield obtained most of his subjects through an anti-MMR campaign group.
Ten out of twelve other authors of Wakefield’s paper have withdrawn their support of the paper.

To read about the original study and the controversy around it, please see our earlier post, “Do vaccines cause autism?” For more information about how vaccines work, please read “How vaccines work.” To learn signs of early communication delays in your infant, please see “How do I know if my baby has autism?”

Too bad it’s too late for some children. Since Wakefield published his paper, measles cases have steadily risen in the UK. Hopefully the damage caused by Wakefield’s 1998 paper will be mitigated by more parents who vaccinate their children.

Julie Kardos, MD with Naline Lai, MD