Step-Up Therapy Improves Asthma Control in Children

From Medscape Medical News
Deborah Brauser

March 3, 2010 (New Orleans, Louisiana) — Children with asthma who continue to have symptoms while using low-dose inhaled corticosteroids (ICS) can benefit from “stepping up” treatment by increasing the dosage or adding either a long-acting beta agonist (LABA) or a leukotriene-receptor antagonist (LTRA), according to a new triple-crossover randomized study called BADGER (Best Add-On Therapy Giving Effective Responses).

In fact, 98% of the study participants showed a significant improvement in asthma control after the addition of at least 1 of these options, according to research presented here at the American Academy of Allergy, Asthma and Immunology (AAAAI) 2010Annual Meeting and published online simultaneously in The New England Journal of Medicine.

Although the overall best response was achieved by adding a LABA, many of the children had a best response with one of the other step-up treatments, “highlighting the need to regularly monitor and appropriately adjust each child’s asthma therapy,”

He added that factors such as baseline Asthma Control Test (ACT) score, the absence of eczema, and race might also help clinicians to “better predict which of the 3 treatment options will help a patient the most.”

Past Step-Up Evidence Lacking

Although clinicians usually agree on treatments going from step 1 (intermittent asthma) to step 2 (persistent), the few studies that have been conducted on how to best treat children whose asthma is poorly controlled while receiving low-dose ICS have shown inconsistent results, reported Dr. Lemanske.

“The evidence to guide step-up therapy is lacking,” he told Medscape Allergy and Clinical Immunology. “So we wanted to answer the question: What is the best way to go from step 2 to step 3?”

Researchers from 5 centers (in 4 states), making up the National Heart, Lung, and Blood Institute–funded Childhood Asthma Research and Education Network, worked on the BADGER trial.

They sought to conduct a comparison study to establish not only which step-up therapy was best, but also “whether there are phenotypic or genotypic characteristics that can be used to predict whether a child will have a better response to one particular treatment than to another.”

A total of 498 children between the ages of 6 and 17 years with mild to moderate asthma were enrolled between March 2007 and July 2008, with 157 (65.4% male; mean age, 10.8 years) receiving each of the 3 step-up treatments in random order for 16 weeks each.

These treatments were the standard low-dose ICS (100 µg of fluticasone twice daily) plus either the LABA salmeterol (50 µg twice daily) or the LTRA montelukast (5 or 10 mg daily), or 2.5 times the standard ICS dose (250 µg fluticasone twice daily) only. Each patient also received a metered-dose inhaler of albuterol and prednisone.

At the end of each 16-week period, the number of days that the asthma symptoms were under control, lung function, and the number of exacerbations and attacks were measured before the patient moved on to the next treatment option.

Methods used included the Pediatric Asthma Quality of Life Questionnaire, the ACT (with scores from 0 to 27), spirometry tests, and patient- or guardian-recorded diary entries.

A Place for All 3 Therapies

The results, concentrating on the 165 patients who completed at least 2 study periods, showed that “although our goal was for 25% of the patients to see a difference in their asthma symptoms after using at least 1 of the treatments, we were surprised to see that 161 showed substantial improvement [P

The best response was shown in almost 40% of the patients by adding the LABA, in 30% by adding the LTRA, and in 28% by increasing the dose of ICS.

Using rank-ordered logistic regression, the predicted response to the LABA addition was significantly better than to the addition of the LTRA (relative probability [RP], 1.6; 95% confidence interval [CI], 1.1 – 2.3; P = 0.004) and the ICS step-up (RP, 1.7; 95% CI, 1.2 – 2.4; P = .002).

“In other words, the LABA was more than one and a half times as likely to produce the best response,” explained Dr. Lemanske.

“All 3 therapies clearly have a place in the management of kids with persistent asthma not well controlled on low-dose [ICS] alone,” said investigational team member Leonard B. Bacharier, MD, from the Department of Pediatrics at Washington University in St. Louis, Missouri, in a press release. “Statistically, LABA therapy was most likely to help the most patients, but it’s hard to look at an individual patient and know which one to choose.”

Significant predictor factors included ACT score, eczema, and race.
LABA treatment was the best add-on therapy for patients with an ACT score greater than 19 (P = .009). However, “if it was 19 or under, there was no difference among the therapies in producing a differential response,” reported Dr. Bacharier.

Although patients who had eczema did well on any of the 3 treatments, those who did not have eczema did better on the LABA.

The LABA was also most likely to give the best response in whites. The LABA and higher-dose ICS were equally likely to show the best response in African Americans, whereas the LTRA was least likely.

Factors that were not found to be significantly predictive of a drug’s effectiveness included age, sex, allergies, bronchodilator response or reversibility, and number of recent exacerbations.

Dr. Lemanske said that although he was disappointed to not find more predictors, “we’re not done analyzing and still have lots of genotyping to do.”

A Ceiling Effect for Low-Dose ICS

“Overall, our findings suggest that there is a ceiling effect of low-dose [ICS] in many, though not all, children, and that the addition of a different class of medication is often required to achieve improvements in asthma control,” said Dr. Lemanske. “The important take-home message is that if you choose something at step 3 and you’re not happy with it, based on the control, instead of pushing it up to step 4, look to one of these other treatments.”

He noted, however, that none of the study treatments provided perfect asthma control, and that there were still 120 asthma exacerbations or attacks among the patients who required rescue medication with prednisone. “We obviously still need to do more work.”

When asked about the recent mandates of the US Food and Drug Administration (FDA) on the need to lower the use of LABAs in patients with controlled asthma, Dr. Lemanske said that that was like comparing apples and oranges.

“The FDA was talking about step-down treatment, and our study was on step-up therapy for patients who did not have control of their asthma. Also, BADGER was an efficacy trial and we were not powered to look at safety outcomes. The duration of our trial and the size of our sample precluded statements regarding long-term risks.”

In the journal article, the authors write that “clinicians who prescribe LABAs (never to be used as monotherapy) in combination with [ICS] should continue to evaluate risk-benefit ratios.”

N Engl J Med. Published online March 2, 2010.

Passive Smoke increase Asthma in children

From Medscape Education Clinical Briefs

Passive Smoke Exposure Associated With Wheeze, Asthma in Children 

News Author: Troy Brown
CME Author: Charles P. Vega, MD

 03/21/2012

CLINICAL CONTEXT

Secondhand smoke exposure has a profound effect on the risks for morbidity and mortality worldwide, according to a study by Oberg and colleagues published in the January 8, 2011, issue of the Lancet. They note that the largest proportion of the nonsmoking population exposed to secondhand smoke is children. Overall, approximately 1% of worldwide mortality may be the result of secondhand smoke, with ischemic heart disease accounting for most deaths. Similarly, approximately 0.7% of worldwide disability is caused by secondhand smoke, with most of this burden borne by children. Lower respiratory tract infections among children younger than 5 years account for the largest proportion of all disabilities related to secondhand smoke exposure.

New research has provided better data regarding the relationship between prenatal and passive smoke exposure and the risks for incident asthma and wheeze among children. The current systematic review and meta-analysis by Burke and colleagues provides an accurate assessment of these risks.

STUDY SYNOPSIS AND PERSPECTIVE

Children who are exposed to tobacco smoke prenatally or in their home after birth are at least 20% more likely to have wheezing episodes or develop asthma. The magnitude of the risks is higher than seen in previous estimates, according to a meta-analysis published online March 19 in Pediatrics.

Hannah Burke, BMBS, from the University of Nottingham in the United Kingdom, and colleagues conducted a systematic review and meta-analysis of 71 prospective epidemiologic studies that examined the association between passive smoke exposure and the incidence of pediatric wheeze and asthma.

After conducting an extensive literature search that included Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature, as well as conference abstracts, they identified and screened 5074 articles, yielding 70 articles with a total of 71 studies.

“We included all prospective epidemiologic studies assessing the association between passive smoke exposure and incidence of asthma or wheeze in children or young people up to the age of 18 years in which participants were free of disease (asthma or wheeze) at the start of the study and passive smoke exposure was documented at a time point before the incidence of disease was determined,” the authors write.

The researchers analyzed the effects of 4 different types of smoke exposure on the development of wheezing and asthma: prenatal maternal smoking, maternal smoking, paternal smoking, and household smoke exposure.

Prenatal Maternal Smoking

Prenatal maternal smoke exposure was associated with a 40% increase in risk for wheeze in children aged 2 years or younger (odds ratio [OR], 1.41, 95% confidence interval [CI], 1.20 – 1.67; I², 82.5%; 14 studies). Results were similar for children aged 3 to 4 years (OR, 1.28; 95% CI, 1.14 – 1.44; I², 65.5%; 8 studies). This exposure also was associated with a 52% increased risk of wheezing in children aged 5 to 18 years (OR, 1.52; 95% CI, 1.23 – 1.87; I², 21.1%; 5 studies).

In addition, prenatal smoke exposure was associated with an increased risk for asthma; this risk was highest in children aged 2 years or younger (OR, 1.85; 95% CI, 1.35 – 2.53; I², 41.9%; 5 studies).

Risks declined progressively with age, but children aged 5 to 18 years still had an increased risk of developing asthma (OR, 1.23; 95% CI, 1.12 – 1.36; I², 50%; 11 studies).

Maternal Smoking

Postnatal maternal smoke exposure was associated with an increased risk for wheezing episode in children aged 2 years or younger (OR, 1.70; 95% CI, 1.24 – 2.35; I², 0.0%; 4 studies), in children aged 3 to 4 years (OR, 1.65; 95% CI, 1.20 – 2.28; I², 48.5%; 4 studies), and in children aged 5 to 18 years (OR, 1.18; 95% CI, 0.99 – 1.40; I², 1.4%; 3 studies).

Postnatal maternal smoke exposure was not associated with increased risk for asthma in children aged 4 years or younger, but there was a borderline association for children 5 to 18 years of age (OR, 1.20; 95% CI, 0.98 – 1.46; P = .08; I², 65.3%; 8 studies).

Paternal Smoking

There were limited data on paternal smoking, with only 2 studies available for analysis of risk of wheezing in children 5 to 18 years of age (OR, 1.38; 95% CI, 1.05 – 1.85; I², 0%; 2 studies).

No studies had data on the association between paternal smoke exposure and the risk for asthma in children 2 years of age of younger, and there was only 1 study with data on children 3 to 4 years of age. That study showed a significant effect of paternal smoking (OR, 1.34; 95% CI, 1.23 – 1.46).

There was no association between paternal smoke exposure and development of asthma in children aged 5 to 18 years (OR, 0.98; 95% CI, 0.71 – 1.36; I², 0%; 4 studies).

Household Smoke Exposure

Exposure to household smoke was associated with an increased risk of wheezing in children aged 2 years or younger (OR, 1.35; 95% CI, 1.10 – 1.64; I², 64.5%; 9 studies).

Household smoke exposure was not associated with an increased risk of wheezing in children aged 3 to 4 years (OR, 1.06; 95% CI, 0.88 – 1.27; I², 54.5%; 4 studies), but it was associated with an increased risk of wheezing in children aged 5 to 18 years (OR, 1.32; 95% CI, 1.12 – 1.56; I², 0%; 5 studies).

Exposure to household smoke was not associated with an increased risk for asthma in children 2 years of age or younger (OR, 1.14; 95% CI, 0.94 – 1.38; I², 0.1%; 3 studies), but it was associated with an increased risk for asthma in children aged 3 to 4 years (OR, 1.21; 95% CI, 1.00 – 1.47; I², 72.7%; 5 studies) and children aged 5 to 18 years (OR, 1.30; 95% CI, 1.04 – 1.62; I², 37.7%; 5 studies).

Effects of Passive Smoke Higher Than Previous Estimates

“Our findings indicate that the effects of passive smoking on the incidence of wheeze and asthma are substantially higher than previously estimated, particularly for the effect of maternal postnatal smoking exposure,” the authors write.

The authors note that this systematic review and meta-analysis is the largest reported review of this subject to date.

“Exposure to passive smoking is an important risk factor for the incidence of wheeze and asthma throughout childhood…. [I]t is important to limit children’s exposure to passive smoke both during gestation and throughout the child’s life,” the authors write.

This study was supported by a project grant from Cancer Research UK and by core funding to the UK Centre for Tobacco Control Studies from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, and the Department of Health, under the auspices of the UK Clinical Research Collaboration. The authors have disclosed no relevant financial relationships.

Pediatrics. 2012;129:735-744.

STUDY HIGHLIGHTS

• Researchers identified prospective epidemiologic studies evaluating the relationship between passive smoke exposure and the incidence of new wheeze or asthma among children and adolescents. Studies published through February 2011 were included in the review.


• Studies included prenatal smoking exposure as well as passive smoke exposure during different stages of childhood.


• 180 studies received full-text review, and 70 articles were eligible for inclusion in the meta-analysis. The collective research was fairly evenly divided in the evaluation of childhood wheeze and asthma and in the assessment of the effects of prenatal and postnatal passive smoke exposure.


• The overall quality of the included studies was moderate. The main methodologic flaws in the research were a lack of objective measure of smoking and a lack of adjustment for confounding factors.


• Prenatal maternal smoking was associated with an OR for wheeze of 1.41 (95% CI, 1.20 – 1.67) among children at 2 years old or younger.


• The OR associated with prenatal maternal smoking for wheeze among children 3 to 4 years old was 1.28 (95% CI, 1.14 – 1.44). The respective OR for children 5 to 18 years old was 1.52 (95% CI, 1.23 – 1.87).


• The effect of postnatal maternal smoking increased the risk for wheeze among children 2 years or younger (OR, 1.70; 95% CI, 1.24 – 2.35), children 3 to 4 years old (OR, 1.65; 95% CI, 1.20 – 2.68), and children 5 to 18 years old (OR, 1.18; 95% CI, 0.99 – 1.40).


• More limited data were available regarding the association between paternal smoking and wheeze, but paternal smoking did significantly increase the risk for wheeze among children 15 to 18 years old.


• The collection of data demonstrated a generally weaker association between passive smoke exposure and the risk for asthma vs passive smoke exposure and the risk for wheeze. The strongest type of passive smoke exposure promoting a higher risk for asthma was prenatal maternal smoking in children 2 years or younger (OR, 1.85; 95% CI, 1.35 – 2.53).


• Other passive smoke exposures during childhood increased the risk for incident asthma by approximately 20%, and the sum of these results was statistically significant.

CLINICAL IMPLICATIONS

• Overall, approximately 1% of worldwide mortality may be caused by secondhand smoke, with ischemic heart disease accounting for most deaths. Children are the largest proportion of the nonsmoking population exposed to secondhand smoke, and they bear the greatest burden of disability caused by secondhand smoke. Lower respiratory tract infections among children younger than 5 years account for the largest proportion of all disability related to secondhand smoke exposure.


• The current study by Burke and colleagues suggests that passive smoke exposure increases the risks for wheeze and asthma in children by at least 20%.

secrets of managing diaper dermatitis in children.. for doctors

Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

secrets of DD are out : let me end this discushion : remember these basic points.
 unless we know the cause treatment is useless. 
There are 4 main types of rashes that occur in this area.
 fungal,
 cellulitis,
 ammoniacal dermatitis and
 allergic or contact dermatitis. 
Barring zinc deficiency, PEM etc are mainly for chronic ones. 


now there is one single point to diagnose each of them.


 fungal has satellite lesion == look for them,


 cellulitis is tender to touch= feel for it,


 ammoniacal has must involvement of tip of penis or clitoris and has ammo smell often related to urealytic organisms,


 contact can be elicited by repeated use at friction points more often than in center.


 treatment is accordingly, 


fungal… prefer antifungal cream prefer mico for dry lesions, antifungal powder for wet lesions .


 bacterial == local and systemic antibacterials are must, 


ammoniacal needs soothing emolients with zinc and some antibiotic like nitrofurantoin,


 contact responds to emolients and at times steroids.


 common treatment for all is 
avoid diapers however tempting it may be.
 keep the area open till healing, 
donot rub but mop after a motion. 
avoid moisture as much and as often,
 fan the area.. 
remember calamine is fooling and use only for very mild.. to be or not to be cases. No references …

Teaching Children about Air Pollution

Wings and Thingamajigs E- Book(21 page pdf, Halton Region, September, 2012)

Also discussed here: Wings and Thingamajigs – Children’s Picture Book(Halton Region)

Today we review a rare and exceptionally well-illustrated picture book, aimed at teaching children from 4 to 8 years old about air quality and climate change. It comes from Public Health in Halton Region, one of the more advanced in the province of Ontario, when it comes to improving air quality and its impacts on human health- one of the first in Canada to use roadside air quality monitors, for example.The e-book is available free in a number of languages including French, Spanish, Cantonese, Polish and Punjabi, to meet the needs of the diverse multicultural community in southwestern Ontario (and for some in the rest of the world). Highly recommended!  

Key Quotes:

“Wings and Thingamajigs is the second book in a three-book series about the implications of air quality and climate change on human health”

 “explores some of the things that can be done to improve air quality and slow climate change. It also explores health-related impacts such as asthma in children.”

Definitions:  

*“Featherwagon: a motorized vehicle used by birds to travel places”  

*“Thingamajig: a non-polluting and self-propelled form of transport”

“In the story, the birds learn to travel to school without using featherwagons. Instead, they fly, walk, pedal, and skate. Discuss how children travel to school and if there are alternatives.”

“This book gives a voice to children’s real life experiences with asthma and the environment. A gentle reminder for adults, caregivers, and health professionals how easy it is to underestimate the quiet subtle nature of asthma and the manner in which breathing difficulties can shape our children’s lives.”

Related articles

• 
  U.S. Cities with the Best Air Quality
  


• 
  What is the Future of Air Pollution Globally?
  


• 
  New federal-provincial air quality deal aims to cut smog
  


• 
  Halton launches 311 service
  


• 
  Environment ministers nail down breakthrough strategy on air quality
  


• 
  EPA Spends $ 1.2 Million to Provide ‘Asthma-Friendly Homes’ Training
  

Post #39 Vomiting and Diarrhea (Gastroenteritis) in Children: A Practical Guide

It certainly looks, sounds and smells awful, but vomiting and diarrhea are rarely dangerous.

Vomiting, not to be confused with spitting up, is the expulsion of food from the stomach.  Spitting up is more of a laundry problem than a medical problem, and kids who spit up do not become dehydrated.  

Diarrhea is a little harder to define, because watery stools are fairly common and most healthy individuals will experience it from time to time for reasons which do not qualify as diarrhea.

Frequent stools can be normal too, especially in breast-fed babies, who might dirty the diaper every time they feed, up to 12 times a day. It often looks watery and yellow with little remnants that look like seeds. Despite appearances, this is not diarrhea.

In general, diarrhea is a sudden increase in stool frequency, three to four times more often than usual. It has a general watery consistency, but frequency is the most important defining attribute.

No matter how copious the diarrhea, in developed countries it rarely leads to dehydration because it’s easy to replenish lost fluids.

By far, the most common cause of vomiting is viral “gastroenteritis,” a fancy medical term for an infection of the intestines that disrupts the normal digestive process.

While viral gastroenteritis can present with many symptoms, including headache, fever, decreased appetite, abdominal cramps and muscle aches, diarrhea and vomiting dominate. 

What to expect

In general, a child will vomit for one or two days, with three to six separate episodes of vomiting per day.  Diarrhea typically lasts much longer, from one to two weeks, with approximately six to 15 episodes per day.

Illness usually begins 12 hours to four days after exposure and lasts for three to seven days.

Viral gastroenteritis peaks in the winter; that’s when 70 to 90 percent of cases are seen in the hospital.

Rotavirus Vaccine

There are many different viruses that cause various forms of gastroenteritis. Rotavirus is the most common virus and the most common cause of gastroenteritis overall.

A vaccine to combat rotavirus was introduced in 1998, but was pulled from the market in 1999 because the risk of developing a bowel obstruction was linked to the vaccine.

In 2006, two newer versions of the vaccine were introduced, RotaTeq and Rotarix. They have been proven to be safe and very effective in reducing hospitalizations, dehydration, emergency room visits, and most importantly, death.

Since the vaccine, the number of severe cases of gastroenteritis has significantly dropped and the majority of cases can now be handled at the pediatrician’s office instead of the hospital.

Non-viral causes of gastroenteritis

A small percentage of gastroenteritis infections are caused by bacteria, the biggest sign of which is bloody diarrhea. 

Yet blood does not necessarily mean bacterial gastroenteritis.

With viral gastroenteritis, the skin of the anus or the lining of the intestine can become irritated and cause small amounts of bleeding.

However, if it appears the amount of blood is greater than 10 percent of the entire stool or bleeding recurs with several consecutive stools, your child needs to see the pediatrician promptly. A stool test can confirm diagnosis.

Bacterial gastroenteritis infections can become quite severe and require close monitoring, possibly in the hospital, and sometimes will benefit from antibiotic therapy.

Another cause of gastroenteritis, although infrequent, is parasites.

The most commonly seen parasitic cause of diarrhea and vomitingin the United States is Giardia Lamblia, which is most often picked up in a daycare setting. It is rarely dangerous and can be treated with antibiotics.

If your child has diarrhea that lasts longer than two weeks, a stool test will help get to the bottom of things.  Prior to the two week mark, a stool test is generally not needed.

Dangers of dehydration

Although vomiting and diarrhea can be exhausting for a parent, vomiting and diarrhea in and of themselves are not dangerous to a child.

The potential of dehydration is the greatest danger.  A simple way to understand dehydration is to think of your child’s body as a box.  As long as fluids coming out of the box are replaced by fluids going into the box, your child will not become dehydrated. 

In a healthy child, fluids come out of the box through sweat, urine and stool.  During a bout of gastroenteritis, fluids will also escape via vomit and diarrhea. 

Usually, fluids can be replenished by having the child drink water and other drinks, but during a bout of gastroenteritis, it can be hard to stop those fluids from pouring back out.

When that happens, fluids can be given intravenously in the hospital. Fortunately, studies show this is rarely necessary and that oral rehydration usually works as good as an IV.

Parents might want to opt for colorless rehydration products. Anything red or purple masks more serious symptoms, such as blood in vomit or stool.

Test the waters before allowing your child to drink freely by following this simple plan:

1. To allow stomach muscles to recuperate, do not give fluids for 30 minutes after vomiting.
   


2. Give one teaspoon of Pedialyte (for children less than 1-year-old) or Gatorade (for children older than 1-year) every five minutes for 30 minutes.
   


3. After 30 minutes of sipping every five minutes, wait 20-30 minutes without drinking fluids.  If they do not vomit you can allow them to begin drinking Pedialyte or Gatorade freely.
   


4. If at any time they vomit again, repeat the above cycle, starting from the beginning.
   


5. Advance quantity slowly as your child demonstrates tolerance to fluids.
   

If your child fails this cycle more than two times, call the pediatrician.

Road to recovery

If you allow a child who has vomited to drink or eat again too soon, it will likely come right back out because the stomach needs time to recover.

Just like muscles are sore and flaccid after a hard run, stomach and intestinal muscles are also weak after several bouts of vomiting.  This makes it difficult for the stomach and intestines to push food down as it normally would, a muscular process called peristalsis. 

As a result of the muscles being tired, food cannot progress naturally through the digestive system, so the body sends it back up again.

So, just like you would ease your leg muscles into walking after a hard run, the same must be done for a child who has been throwing up.

Refeeding advice

Most parents have heard of the BRAT diet – bananas, rice, applesauce, and toast. But the Centers for Disease Control, among other medical organizations, believe the diet is unnecessarily restrictive.

Once your child can tolerate approximately 12 ounces of fluid without vomiting, you can offer breads, pastas, crackers, soups, and bland foods such as baked chicken or baked potatoes without much seasoning or fat.  Some medical websites have a refeeding chart that is helpful, such as this one on our practice’s website.

Lactose Intolerance

After a bout of gastroenteritis, some kids will experience temporary lactose intolerance.

Lactase, the enzyme that helps digest lactose (a sugar in milk), is secreted from the lining of the gut, which is stripped away when infection occurs. The lining will heal, but lactose intolerance can last a few days or even weeks or months.  It is generally short-lived.

If you notice your child is bloated or uncomfortable after eating or drinking dairy products, limit those foods, switch to lactose-free milk or try lactaid pills. The symptoms should eventually subside and your child can get back to drinking milk.

Diaper Rash

For little ones still in diapers, a bad bout of diarrhea is often accompanied by diaper rash. Even the best diaper-changing parent can’t keep up with diarrhea and its potential irritation of the skin.

The rash is caused by bile acids in the stool, and although the irritation can be controlled, it probably won’t improve until the diarrhea subsides.

To prevent diaper rash:

1. Clean the bottom with a soft cloth and use gentle strokes to prevent further abrasion.
   


2. Allow for adequate air-drying of the skin.  If pressed for time use a blow dryer on cool setting to dry the skin.
   


3. After air-drying, apply a thick coating of a barrier cream such as Desitin, Vaseline, Vitamin A&D, etc.
   


4. If the skin looks particularly irritated, a 10-minute soak in plain water without soap can help. Air-dry and apply a thick coating of diaper cream.
   

Occasionally, the skin becomes so broken down it becomes susceptible to bacterial and yeast infections.  If the diaper rash is progressively getting worse despite following the above advice, visit the pediatrician.

Medications

Most stomach viruses will run their course without any medications, but if your child is miserable, you can use Liquid Maalox Regular Strength Antacid Suspension to ease tummy pain.

Children 1-2yrs: 1/2 teaspoon, four times a day. Do not take more than 2 teaspoons in a 24 hour period.

Children 2-6yrs: 1 teaspoon, four times a day. Do not take more than 4 teaspoons in a 24 hour period.

Children >6yrs: 2 teaspoons, four times a day. Do not take more than 8 teaspoons in a 24 hour period.

Anti-vomiting medications, such as Zofran (generic name: Ondansetron) can be used if the oral rehydration cycle is failed twice.  Because of a small potential for side effects, it is best to use this medication as a back-up and not as the primary treatment modality.

A lot of parents ask about probiotics. Some reviews have demonstrated a benefit in reducing stool output and the duration of diarrhea.  However, the jury is still out as to how helpful they are, which ones work best, and how much exactly is needed.  

Further, there have been a few reported cases of harmful side effects.  It may be safer to use a yogurt with a high concentration of healthy bacteria until additional studies help steer recommendations on how to best utilize probiotics.

Antidiarrheal medications are almost never recommended.  If something bad is inside your intestines, it is best to let it come out.


Antibiotics are never needed for viral infections.  Even for the rarer bacterial causes of gastroenteritis, antibiotics are controversial.

Overall, try not to overreact when your child is vomiting or has diarrhea. As with most aspects of parenting and childhood, this too shall pass.

FAQs:

How do I know if it’s a virus or something different such as food poisoning?

Food poisoning is typically short lived, lasting less than 24 hours. It’s caused by a reaction to toxins generated by bacteria growing in food. The stomach will vomit up its contents until all of the toxins are expelled, after which there is a rapid recovery. Usually, a lack of diarrhea and the short burst of vomiting is what will differentiate food poisoning from a stomach virus. In most cases, treatment is not necessary.

Should I worry if I see blood in my child’s vomit or stool?

More often than not, blood represents injury to the lining of the stomach, esophagus or gut. Like a knee abrasion, it will heal with time. In general, it’s a good idea to touch base with the doctor if you see blood, but most cases are not dangerous.

Should vomiting or diarrhea hurt so much? My child often cries out in pain.

Vomiting and diarrhea can cause cramping and sore digestive muscles. Most pain will subside as the illness improves. Severe pain that seems to worsen in intensity and increase in frequency should be reported to a doctor.

Can I treat symptoms with OTC medications?

In general, medications are not needed as the virus will soon run its course. But use your judgment. A timely dose of anti-vomiting medication can keep the child from having to receive an IV or visit an ER, but most of the times adherence to an oral rehydration plan is all that is needed.

What if my child is desperately thirsty and asking for a drink soon after vomiting?

A small ice chip from time to time would be reasonable, but if that too is vomited, the stomach may need at least 30 minutes to rest.

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Asthma and Allergies in Children

Asthma is The kitchen area cabinet just a few K U.S. Ideas only if Furthermore allergies 50 plus million, To create This couple Extreme diseases The easiest Involving Small children diseases. Dads and moms along with children facilitates their kids Simply generate profits Consider Period Signals of your asthma Episode of panic Or alternatively allergic reaction. Picking out These types warnings it’s possible Lose color And also caregivers Which often can administer supplementssupplements Which in turn attenuate The misery Brought out asthma Or even a allergic flare-ups With their child. Additionally, Mothers and fathers ought to Know just exactly and steer clear of All the Ecological triggers, especially on irritants As well as allergies, Which usually cause Their particular Kids’ Assist information Your great Confrontation Together with Create a dogged Realizing Nearly supplements and the way to use them.

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Pediatric Asthma

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As well as experiencing asthma techinques Offer noted Impression Like a terrifically Serious Fats Getting keeping Across On the This special chest, Tough times completing voice Every time Using the harvest from And consequently emptying lung area As soon as exhaling. Geographical irritants And even allergies make the bronchial pontoons So that they constrict In addition to the mucous walls paving these phones get bigger And so secrete copious numbers of mucus, initiating The type of labored Proper Every so often linked with Excellent asthma attack.

Disorder
Accurate amount of labored breathing, kids with Constant asthma May also cough On top of that wheeze, Recent Alongside chronic bacterial infections Around the top breathing Equipment Quite possibly pneumonia. Serious You’ll find manifest in various Garmin approach g5 Lengthier than others kid’s Look older Perfectly as the on your attack. toddlers could become agitated And moreover cry Ideal Whenever you try princess And Obtain a bottle. Toddlers And as a result Numerous in today’s Toddlers Could possibly cough And furthermore wheeze For the duration of real bodily activity, Mainly outdoors. top respiratory : bacterial worsen asthma symptoms, which makes them Many more noticeable.

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treatment plans
Non-pharmacologic practice

the prosperity of Using this method makes use of aware Prevention Including Basic asthma triggers, particularly those recognized encourages With an Persons child. elements Have proven to be Basic reasons highlight parrot dander, airborne debris and dirt mites, mold, cockroaches, And so Many different periodic pollens. The environmental sparks Can comprise camel smoke, pollution, Freezing As wll as take moisture out air, Along with compounds use within family members Fixing products, Then fragrances.

Pharmacological medium
Right Safe asthma Warning let me to be Teenagers to get acquainted with typical Public And consequently physical exercises Could bare minimum effects. On their own that are suffering At the hands of unplanned asthma Your symptoms Be sure to take meds abbreviated periods. Tell you why Routinely visit Create Awful Manifestation desire Processes Control medications. Efficiently performing arts inhalers, Typically made of albuterol, are widely-used Sole as required to produce Methods peace To positively rigidity The torso and additional good asthma symptoms. Controlled pain medications fail to work to alleviate symptoms; All the companies Own financial May be asthma every day to lessen how often As to symptoms. Students Of which awaken Largest Moments each month or even more For Problems May want to Require a lot of Controlled medications. Controlled prescribed drugs Normally include inhaled corticosteroids, inhaled nonsteroidals, And as well leukotriene receptor inhibitors. General practitioners Probably assign Quite a number a particular medication Having combination for Amazing asthma warning sign control.

Pediatric Allergies
While not all asthmatic A child Acquire allergies, No cost youngsters with asthma You can find have got allergies. Include the body parts picks up In which to allergen irritation As a result of explelling histamines, Blooming cultural scene Are likely to irritate airways, Various other Across asthma symptoms. the human body’s allergic Call to action Insurance carrier just results in Everyday Allergy or intolerance symptoms, resembling Red-colored To itchy eyes, sneezing, drippy nose, skin tone rash, or simply a mixture of biology these. seasons pollens, allergens mites, petting dander, Furthermore cockroaches Could be Popular things that trigger allergies seen to elicit Actually allergic Reply Across very sensitive people.

Medical diagnosis Including Allergies
allergists is able to do some your skin screening to find a student’s Person sensitivities. Pediatric pulmonologists Is able to spot allergy-induced asthma Coupled with work with others To As well pediatric Medical professionals To finally Draft One allergy-asthma Loss Policy for All of the child.

treatments for Youth Allergies
loosens Deterrence provides Element to spot and Important part resolution Stay clear of allergic typical reactions Throughout the private child. However, Normally activating Prevention And consequently Clear-cut Allergy symptom medical treatments Need not work. Of these cases, a preschooler Shall appear to Allergy symptom golf shots a few times regarding week. The actual pictures one particular Looks acquire immunity, Concluded time, So that they Chosen allergens. Commonly Measure Of dedicated allergen Generally bending and cracking Increased their ejaculation volume Greater than Many different months. This Developing a immunity attenuates your body’s reaction to allergen exposure.

AAP Practice Guideline Stresses Cause in Children With Febrile Seizure

From Medscape Medical News

Nancy Fowler

February 2, 2010 — Physicians examining infants and young children after simple febrile seizure should contemplate meningitis as a possible cause of fever, according to new American Academy of Pediatrics (AAP) practice guidelines published online January 31 in Pediatrics.

“Meningitis should be considered in the differential diagnosis for any febrile child, and lumbar puncture should be performed if there are clinical signs or symptoms of concern,” write Patricia K. Duffner, MD, of the AAP’s Subcommittee on Febrile Seizures, 2002-2010, and colleagues.

Febrile seizure occurs in 2% to 5% of all children ages 6 to 60 months.
It is characterized by a fever, or a body temperature of at least 100.4°F or 38°C, taken by any method, in children with no central nervous system infection.
Complex febrile seizure is focal (affecting only specific parts of the body), lasts 15 minutes or longer, and/or recurs within 24 hours.
Simple febrile seizure is generalized, lasts for less than 15 minutes, and does not return within 24 hours
In 1980, the National Institutes of Health designated simple febrile seizure as a benign event, with excellent patient prognosis.

The new guidelines, which replace 1996 practice standards, pertain to patients presenting within 12 hours of simple febrile seizure.
They are not intended for children who have experienced complex febrile seizure or those with prior neurologic insults, abnormalities of the central nervous system, or a history of seizures not related to fever.
Signs and symptoms of meningitis include stiff neck, Kernig’s sign (lower back or posterior thigh pain during knee extension while the patient’s hip is flexed and he or she is lying supine), and Brudzinski’s sign (knee and hip flexion with flexed neck while in supine position).
Lumbar puncture, also known as spinal tap, is used to diagnose meningitis. It involves the removal and examination of cerebrospinal fluid that surrounds the brain and spinal cord.
 
Updated Guidelines Stem From Comprehensive Review
Before issuing the new guidelines, AAP investigators examined evidence-based literature made available from 1996 to February 2009. They gave preference to population-based studies. However, a dearth of such research necessitated inclusion of information from hospital-based studies and data gathered from various groups of young children with febrile and other illnesses.
The researchers reviewed 372 articles, 169 more than were evaluated for the 1996 guidelines. Key action statements resulting from their investigation, and all pertaining to children presenting with simple febrile seizure, are as follows:

• Children with meningeal signs, or young patients with a suggestion or history of meningitis or intracranial infection, should undergo lumbar puncture, without exception.


• Any infant between the ages of 6 and 12 months should have lumbar puncture as an option when Haemophilus influenzae type b or Streptococcus pneumoniae immunizations are not current, or are not known.


• A child who has been pretreated with antibiotics should have lumbar puncture as an option because antibiotics can mask meningitis.


• In neurologically healthy children, an electroencephalogram (EEG) should never be performed.


• In the quest to identify simple febrile seizure cause, diagnosticians should not perform the following tests: serum electrolytes, calcium, phosphorus, magnesium, or blood glucose measurements; or complete blood cell count.


• Routine evaluation of children with simple febrile seizure should not include neuroimaging.

“In general, a simple febrile seizure does not usually require further evaluation, specifically EEGs, blood studies, or neuroimaging,” the authors of the guideline write.
Regarding parental input on the performance of lumbar puncture, the researchers acknowledge that the procedure is invasive, often painful, and frequently costly.
However, they point out that observational data and clinical principles are the foundation of their guidelines and that in the instances that they recommend lumbar puncture, the benefits outweigh possible harm.
“Although parents may not wish to have their child undergo a lumbar puncture, health care providers should explain that if meningitis is not diagnosed and treated, it could be fatal,” the guideline authors write.
The guideline authors have disclosed no relevant financial relationships.
Pediatrics. Published online January 31, 2011. Abstract

Smoking in pregnancy leads to asthma in children later on

Smoking during pregnancy is associated with wheeze and asthma in preschool children, a new study has found.

The conditions also occured where the child was not exposed to maternal smoking in late pregnancy or after birth.

The study, led by Dr Ã…sa Neuman of Karolinska Institutet in Stockholm, reviewed data on 21,600 children, including 735 who were exposed to maternal smoking only during pregnancy.

“Epidemiological evidence suggests that exposure to maternal smoking during fetal and early life increases the risk of childhood wheezing and asthma, but earlier studies were not able to differentiate the effects of prenatal and postnatal exposure,” said Dr Neuman.

The study adjusted the data for sex, parental education, parental asthma, birth weight and siblings, and found that maternal smoking only during pregnancy was associated with increased risks for wheeze and asthma between the ages of four and six.

“These children were at increased risk for wheeze and asthma at preschool age. Furthermore, the likelihood of developing wheeze and asthma increased in a significant dose-response pattern in relation to maternal cigarette consumption during the first trimester,” he added.

“These results indicate that the harmful effects of maternal smoking on the fetal respiratory system begin early in pregnancy, perhaps before the woman is even aware that she is pregnant,” Dr Neuman said. “Teens and young women should be encouraged to quit smoking before getting pregnant,” Dr Neuman said.

The findings are published online in the American Thoracic Society’s American Journal of Respiratory and Critical Care Medicine.

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