Most individuals who contract the flu have mild disease and recover without problems; however, certain patients are more likely to have more severe disease or complications from the flu.

Children who are considered higher risk for influenza related complications and/or more severe disease should be evaluated in our office if they have influenza symptoms.

Influenza symptoms include:

• Fever >101, cough, sore throat, runny nose or congestion, body aches, headache, chills, fatigue, and sometimes vomiting and diarrhea
• Although it is possible to have the flu and not have a fever, this is very unusual

Higher risk patients include:

• Toddlers and infants under the age of 2
• Children 2-5 years who appear more ill (high fever >103, fast or labored breathing, dehydration, or listlessness)
• Anyone with chronic lung disease, including asthma
• Anyone with chronic disease, including weakened immune systems and diabetes

If your child is in a higher risk group and is determined to have influenza, we will prescribe Tamiflu. Tamiflu is an antiviral medication that can lessen the duration and severity of the flu. Tamiflu is most helpful if given within the first 48 hours of illness, although it may be of some benefit even if given later in the disease course.

If your child is NOT in a higher risk group, you should care for your child at home, observing for "warning signs" of more severe disease.

Home care for influenza:

• Give Motrin or Tylenol to lesson fever. Do not give aspirin or aspirin-containing products. Do not be surprised if Tylenol or Motrin does not completely relieve the fever, although it should bring it down several degrees.
• Encourage your child to drink lots of fluid and monitor for dehydration.
• Stay at home to avoid spreading the disease until 24 hours without fever.
• Cough and cold preparations are of no proven benefit, but can be administered to children over 5 years. Do not give cold medicine to children under 5 years.

When to call our office for lower risk patients - "warning signs" of more severe disease:

• Fast or labored breathing
• Bluish skin color
• Dehydration
• Being not easily awakened or aroused, interacting inappropriately
• Irritability and inconsolability (even with being held)
• New fever or worsening cough after symptoms seem to be improving
• Fever that lasts longer than 4 days or flu symptoms longer than 10 days and not improving

What to do if exposed to seasonal flu/H1N1 flu:

• Monitor for symptoms and follow the recommendations above if your child develops symptoms.

If you have a very high risk child (moderate-severe asthma, cancer or immune suppression, cerebral palsy or neuromuscular disease) and a household contact or very close contact is diagnosed with flu, please call our office. These select individuals should receive Tamiflu prophylaxis to prevent or lessen flu symptoms in these patients.

Normal Stooling Patterns in Newborns and Infants

In the first days of life, newborns pass meconium (black and tar-like) stools. By day of life 3-4, passage of yellow, green, or brown seedy stools is reassuring. All newborns should stool at least once in the first 48 hours of life. After the first 48 hours, some babies will not stool for up to more than 24 hours at a time. If your baby is comfortable, nursing or bottle feeding well, has a soft belly, isn't forcefully vomiting, and is having frequent wet diapers, then it is likely a matter of time before she poops! However, since decreased stool output can be a sign of poor feeding, please call our office during business hours if your infant is less than two weeks and hasn’t stooled in greater than 24 hours. If your baby is not feeding well, seems increasingly sleepy, and isn't urinating adequately, please call our office as he may be dehydrated. Adequate urination for a newborn involves having at least 1 wet diaper per day of life. This means that a 3 day old should have at least 3 wet diapers a day, a 4 day old should have at least 4 wet diapers a day, and any baby 5 days of age or older should have at least 5-6 wet diapers a day.

Stooling patterns vary greatly among infants. Newborns, especially breastfed newborns, often stool with every feed. Formula fed infants tend to stool less often (2-4 times per day) in the first months of life. Some infants don't stool everyday. This is especially true of exclusively breastfed infants over 2 months of age. Your baby might go from stooling multiple times per day to stooling every 3-5 days seemingly overnight. Keep in mind that exclusively breastfed infants are rarely constipated.

Formula changes and introduction of solid foods can also alter bowel habits. As long as your baby is comfortable, eating well, and eventually passing soft stool, don't worry. If your baby is becoming uncomfortable, straining without passing stool, or passing hard, pellet-like stools, then he is likely constipated.

Infant Dyschezia

Some infants scream, cry, and turn bright red in the face for 5-30 minutes before the passage of a normal soft stool. This is called ‘infant dyschezia’ and differs from constipation in that the stools are not hard when passed. This is thought to occur as an infant is attempting to poop, but not effectively relaxing his pelvic floor. So, he is trying to poop and ‘hold it in’ at the same time. His crying helps to increase his abdominal pressure, which eventually results in a soft stool and resolution of crying. There is no treatment for this. Suppositories and rectal stimulation might actually make things worse. Giving juices won’t help either. Although it is very difficult to observe this behavior in your infant, this is a normal occurrence in some infants and in time he will outgrow this tendency.

What to do for infant constipation

Giving your infant juice is generally all that is necessary. Prune juice is by far the most effective juice in treating constipation. Apple and pear juice have some efficacy in treating constipation. It is fine to give juice daily if necessary. Start with ½ ounce of juice per day, increasing up to 2 ounces of juice per day if needed. Do not give an infant less than 4 months old more than 2 ounces of fluid that isn’t breast milk or formula per day without discussing with our office. Too much additional water or juice can upset the salt balance in your baby's body, which can even cause seizures.

If juice fails, try an over the counter glycerin suppository. Babylax liquid glycerin suppositories are easy to use. Alternatively, you can cut an adult glycerin suppository to make it smaller for your infant. Insert the suppository into your infant's rectum and then hold his bottom together for 2-3 minutes to allow it to work (the longer the better). If, after an hour, she has still not had a bowel movement, you can repeat with another suppository. Solid glycerin suppositories do not have to melt to be effective. If your infant is over 4 months of age, consider introducing pureed baby food prunes. Other baby foods that help with constipation (to a lesser degree) are pears, cherries, peaches and apples.

Mineral oil, molasses, or karo syrup is not recommend for the treatment of infant constipation.

Call the office immediately if your infant begins vomiting with constipation, especially if the vomit is green (like bile) or bloody, or if your infant’s abdomen becomes hard, tender, distended, or discolored.

Toddlers and Children

Constipation often becomes a problem during potty training. Toddlers may withhold stools because they are too busy to stop playing, or they are afraid to poop in the potty. Sometimes it becomes a battle of wills - one that he will surely win! If your child has had painful stools in the past, she may become fearful of toileting and begin to withhold stools. This will lead to larger, more painful stools, and more withholding. If your toddler is constipated, don't attempt potty training until the constipation is under control. Often, it is necessary to use a stool softener until improved bowel habits are achieved.

Constipation is common in school-aged children, as well. Some kids, like toddlers, don't want to stop to go to the bathroom. Some are embarrassed to use the bathroom at school. If constipation remains unchecked, the rectum gets stretched out. The nerve endings stop working properly, and the child no longer perceives the need to pass a bowel movement. This can lead to fecal incontinence, which is the passage of often large amounts of stool with very little or no warning. Alternately, they may seem to have diarrhea, as they pass small amounts of liquid stool around the harder impacted stool. These children are often not aware when they have a bowel movement, and often don't even smell that they have stooled. Obviously, this can become a traumatic social problem and children should NEVER be punished for this.

What to do for toddler and childhood constipation

Diet is a good place to start. Try to increase the amount of fluid your child drinks. Offer lots of fruit, vegetables, and whole grains. You don't want to overdo juice, but 6-8 ounces of apple, prune, pear, or white grape juice may help. Try to avoid bananas and white rice, as these foods tend to be binding.

It is also important to establish a stooling routine. The body's natural tendency is to move it's bowels after a meal. Have your child sit on the toilet for 10 minutes after a meal 1-3 times per day whether he thinks he needs to or not. Try to help him relax - reading to him may help.

Stool Softeners

Often, we will recommend stool softeners for patients with constipation. Stool softeners are not stimulant laxatives, and are therefore not addictive. You will want to use the stool softener until your child is having soft stools independently and regularly. Often children need stool softeners for months to a year or longer. Once the bowel is retrained, many children can then stop using stool softeners while continuing to have more normal, regular, soft stools.

Our practice usually recommends Miralax (also known as Glycolax) for stool softening. This can be found over the counter and is a tasteless, odorless powder that is mixed with 6-8 ounces of fluid daily. Different children will need different amounts, ranging from 1/4 tsp to 3 TBS or more per day. The medicine needs to be titrated to the desired effect, which is 1-2 soft stools every 1-2 days.

Generally, start with 1/2 tsp for an infant, and 2 tsp for toddlers and children, daily. Mix this with 6-8 ounces of any fluid (milk, water, juice, etc). It's okay if it isn't finished in one sitting. Increase the amount of Miralax by 1/2 tsp every three days (maximum 3 tablespoons per day) until soft stools are achieved. It takes about 3 days to be effective, so don't increase the amount more than every three days. If your child starts to experience diarrhea, then skip a day and start again at half the dose you have been giving. You can't overdose on Miralax, and it is fine to stop abruptly, so don't be afraid to make adjustments.

As discussed above, have your child sit for 10 minutes on the toilet at least once a day after meals. Discuss with your physician when to stop therapy. If the constipation has been moderate to severe, expect that it may take months to even years for the stretched rectal vault to return to a normal size, and for the damaged nerve endings to work properly again. Stopping too soon may put you right back where you started, and delay the desired outcome of independent, functional stooling. Expect that with a commitment to this regimen, your child will eventually achieve this goal.

If your child is very uncomfortable and unable to pass stool, a stool softener will take too long to work. As with infants, try using an over the counter glycerin suppository. Repeat once in an hour if the first is unsuccessful. Glycerin suppositories can be cut for smaller children, apply lubricating jelly first for ease of administration. If still unsuccessful, try an over the counter pediatric Fleets enema, or half an adult enema. Continue Miralax if recommended when using suppositories and enemas.

When to worry

If your infant or child begins vomiting with constipation, especially if the vomit is green (like bile) or bloody. Call our office if her abdomen becomes hard and distended or discolored, or if she is experiencing severe abdominal pain.

How to take your child's temperature

Rectally: The most accurate way to take a temperature. This is most important in infants, especially those less than 2 months of age. Apply a small amount of lubricating jelly on the tip of a digital rectal thermometer and insert ~1/4-1/2 inch into your child's rectum. The thermometer will beep within one minute when the reading is done. Parents are often nervous to check their child's temperature rectally. Don’t worry, you won’t hurt your child with a rectal thermometer!

Axillary (under the armpit): An easy way to take a temperature, but may underestimate a temperature by one degree, and therefore we don’t recommend this method for infants less than 2 months. If your child’s axillary temperature is over 100.4 degrees, then he has a fever. If your child’s axillary temp is 99.5-100.4 axillary, he may have a low grade fever.

Ear thermometers: This is a reasonable way to check a temperature in children over 6 months. Pull the outer ear backward and point the thermometer directly into the ear canal.

Oral thermometers: This is a good way to take a temperature in older children. Have your child close his lips securely around the thermometer with the thermometer under his tongue.

Pacifier and forehead strip thermometers are inaccurate and we do not recommend their use.

Mercury thermometers should not be used as mercury is toxic if the thermometer breaks.

What to do about a fever

Fever reducers: As fevers are not dangerous and are likely beneficial in fighting infection, treat with fever reducers only to make your child more comfortable. Consider treating a fever only if it climbs >101.5 degrees. Don't feel the need to wake your sleeping child to give a fever reducer.

If <6 months old, you can give acetaminophen (Tylenol) every 4-6 hours. If >6 months, you can give Tylenol every 4-6 hours or ibuprofen (Motrin, Advil) every 6-8 hours.

Most fevers can be managed by giving only Motrin or only Tylenol. Both work equally well as fever reducers, but Motrin lasts a little longer. Acetaminophen (Tylenol or Feverall) also comes in suppository form if your child is vomiting or refusing to take oral medication. Dosing for suppositories is higher than for oral medications as less is absorbed. (See website section on medication dosing).

If a fever is particularly high or persistent, you can give both Tylenol and Motrin, but be very careful that Tylenol is not dosed more than every 4 hours, or Motrin more than every 6 hours. It is helpful to keep a medication log.

Of note, fever reducers generally reduce a fever by 2-3 degrees. Don't be surprised or alarmed if medication does not return your child's temperature to normal.

Fluids: It is helpful for your child to drink extra fluids when febrile. For infants, breast milk, formula, or Pedialyte is appropriate. Infants over 6 months can also have juice (such as apple, pear, or white grape). For children over one, milk, water, or other clear fluids are appropriate.

Sponge bath: A lukewarm bath may make your child more comfortable and help reduce the fever as the water evaporates and cools his skin. Never sponge your child with alcohol!

Watch for other symptoms to develop, and treat these symptomatically (see section on colds and vomiting and diarrhea).

ALWAYS REMEMBER:

HOW YOUR CHILD LOOKS AND BEHAVES IS MORE IMPORTANT THAN THE HEIGHT OF THE FEVER!

When to call the doctor:

IMMEDIATELY

• If your child is less than 2 months old and has a temperature greater than 100.4 degrees, taken rectally.
• If your child is breathing hard or fast. Children breathe more rapidly when their temperature is elevated. Reassess your child's breathing once the fever is down. Also keep in mind that children who are truly having breathing difficulties usually have cough and congestion as well.
• If your child is acting strangely or is difficult to arouse. When children have fevers they look "wiped out." You can give him Tylenol or Motrin. He may look better once the fever comes down. He will likely want to sleep more and play less; this is expected. He should, however, be easily aroused from sleep.
• If you think your child is dehydrated. It is okay if your child doesn't eat when she is sick. She does need to drink. If, while awake, a child <1 year hasn’t urinated in 6 hours, or a child >1 year in 8 hours, she may be getting dehydrated. Other clues are that she is no longer interested in drinking, her lips and the inside of her mouth are dry, or she is no longer crying tears.

DURING REGULAR OFFICE HOURS

If your child is over 2 months old and has had a temperature >/= 100.4 for more than 72 hours.

Febrile Seizures

One reason parents get nervous about fevers is that they fear their child may have a seizure with fever. Although febrile seizures are very scary for a parent, they are usually short and not harmful to the child. They are also fairly uncommon, but tend to run in families. Febrile seizures occur in children between the ages of 6 months and 6 years, and usually come at the beginning of a febrile illness, during the initial rapid temperature elevation. Therefore, often the seizure happens before you are even aware that the child is ill with a fever. For this reason, treating fevers more aggressively, or trying to prevent fever completely usually does not prevent a febrile seizure.

Children under six years average six to eight colds per year with symptoms lasting an average of 14 days. Young children in daycare appear to suffer from more colds than children cared for at home, and often are sick for most of the cough and cold season. However, when daycare children enter primary school, they catch fewer colds, presumably because they are already immune to a larger number.

Transmission

Colds are transmitted from person-to-person, either by direct contact or by contact with the virus in the environment. Colds are most contagious during the first two to four days. Some cold viruses can live on surfaces (such as countertops, door handles, or toys) for several days, and some can be spread when droplets containing viral particles are exhaled into the air by breathing, coughing, or sneezing, and then inhaled by another. Cold viruses are not usually spread through saliva.

COMMON COLD SYMPTOMS

The symptoms of a cold usually begin one to two days after exposure. In children, nasal congestion is the most prominent symptom. Children can also have clear, yellow, or green-colored nasal discharge. Fever (>100.4º F) is common during the first three days of the illness. Other symptoms may include sore throat, cough, irritability, difficulty sleeping, decreased appetite, and swollen lymph nodes. The symptoms of a cold are usually worst during the first 10 days. However, some children continue to have a runny nose, congestion, and a cough beyond 10 days. In addition, it is not unusual for a child to develop a second cold as the symptoms of the first cold are resolving; this can make it seem as if the child has a single cold that lasts for weeks or even months, especially during the fall and winter. This is not a cause for concern, unless the child has any of the more serious symptoms, discussed below.

COUGHS

Coughing is your body's way of clearing secretions and mucus, to keep it from 'settling' in your lungs. It serves a very useful purpose, so coughs should not be suppressed. Cough medicine is ineffective, anyway, so another reason to save your money and avoid buying cough medicine! Parents often notice that they feel 'congestion' rattling, or vibrating in their child's chest when he has a cold. The entire airway is connected from the nose to the lungs, and noise from congestion in the nose and sinuses travels all the way down into the chest, and thus seems as though it is originating in the chest. The only way to tell whether the congestion is truly in the lungs or simply being transmitted from the nose and sinuses is for a doctor to listen with a stethoscope. If your child is coughing mildly and/or infrequently with a cold virus, it is likely simply secondary to the cold. If your child's cough is persistent and bothersome, perhaps affecting his sleep, and/or if he seems to be breathing hard or fast when you observe his chest, the cough could signify a process in the lungs. If this is the case, please contact our office.

COMMON COLD COMPLICATIONS

Most children who have colds do not develop complications. However, parents should be aware of the signs and symptoms of potential complications.

Ear infection

If a child develops a fever (>100.4º F) after the first three days of cold symptoms, an ear infection may be to blame. Other symptoms of an ear infection include ear pain, irritability, difficulty sleeping or lying flat, and refusal to drink from a bottle.

Sinusitis

Children who have nasal congestion that does not improve over the course of 14 days may have a bacterial sinus infection. Doctors can't see a patients sinuses without an X-RAY, so they have to rely on symptoms to diagnose a sinus infection. If your child has had cold symptoms for over 2 weeks and other bothersome symptoms such as cough, decreased appetite, poor sleep, fatigue, and/ or fevers, it is reasonable to start antibiotics for a presumed sinus infection.

Pneumonia

Children who develop a fever after the first three days of cold symptoms may have bacterial pneumonia, especially if the child also has a persistent or deep cough, and/or is breathing rapidly.

Wheezing

Children who are prone to wheezing or asthma symptoms often are triggered by viral respiratory infections. A deep or persistent cough, chest tightness or difficulty breathing my signify that your child has developed wheezing.

COMMON COLD TREATMENT

Antihistamines, decongestants, cough medicines, and expectorants, alone and in combinations, are all marketed for the symptoms of a cold. However, there have been few clinical trials of these products in infants and children, and there are no studies that demonstrate any benefit in infants or children.

The United States Food and Drug Administration (FDA) advisory panel has recommended against the use of these medications in children younger than six. This includes prescription cough medicines. We agree with this recommendation because these medications are not proven to be effective and have the potential to cause dangerous side effects. For children older than 6 years, cold medications may have fewer risks; however, there is still no proven benefit.

Symptomatic Treatment

Fever reducers: Tylenol (acetaminophen) can be giving to a child over 2 months who is uncomfortable because of fever during the first few days of a cold. Ibuprofen (Motrin, Advil) can be given to children greater than six months of age. Aspirin should not be given to any child under age 18 years. There is no benefit of these medications if the child is comfortable and does not have a fever greater than 100.4º F (38º C), and it is not necessary for all children to be treated for fever. For instance, we don't recommend waking a peacefully sleeping child just to give a fever reducer.

Humidified air can improve symptoms of nasal congestion and runny nose. For infants, parents can try saline nose drops to loosen the mucus, followed by bulb suction. It is helpful to occlude the opposite nostril for adequate suction.

Fluids: Parents should encourage their child to drink an adequate amount of fluids. Children often have a reduced appetite during a cold, and may eat less than usual. Don’t worry as long as they are staying hydrated and urinating at least 4-6 times per day. Milk, water or other clear fluids are appropriate choices for children over one. Breast milk, formula or Pedialyte are appropriate for young infants, and infants older than 6 months can have juices as well.

Herbal and alternative treatments — A number of alternative products, including zinc, vitamin C, and herbal products such as echinacea, are advertised to treat or prevent the common cold. None of these treatments has been proven to be effective in clinical trials; their use is not recommended.

WHEN TO CALL THE OFFICE

Immediately

• Refusal to drink anything for a prolonged period, resulting in decreased urination (no urination for >6 hours in infants, >8 hours in children over one year, while awake).
• Behavior changes, including irritability or difficulty arousing. Many children sleep more when they are sick, but they should be easily aroused from sleep, without seeming confused or acting bizarrely.
• Fast, hard, or labored breathing

During Normal Office Hours

• Persistent coughing
• Fever greater than 100.4 for more than 72 hours (3 days)
• Nasal congestion does not improve or worsens over the course of 14 days
• The eyes become red or develop yellow discharge
• There are signs or symptoms of an ear infection (pain, ear pulling, fussiness, bottle refusal or difficulty lying flat)

As one would expect, the more serious the accident, the more likely the child is to sustain significant injury. For example, an infant who falls off a bed onto a carpeted surface is very unlikely to sustain significant injury. The majorities of falls in children occur from heights of 3-4 feet or less, and generally do not result in significant injury.

When to worry about a head injury in your child

1. Loss of consciousness
2. Vomiting
3. Seizures
4. Excessive sleepiness
5. Excessive irritability
6. Any abnormality in your child's neurological functioning: This includes any weakness, clumsiness, or changes in personality, or asymmetry of movement or facial expression.
7. Amnesia in older children: This includes amnesia for the event or short term memory loss occurring after the event.

If your child has any of the above symptoms after a head injury, you should take your child to the emergency room or call our office.

The doctor at the emergency room will evaluate your child and likely order a CT (cat scan) of the head. The CT is necessary to evaluate for any bleeding in the brain. If the CT is negative, then it is generally safe to discharge the child home under parental observation.

In children with mild head injuries with no loss of consciousness, normal alertness, no history of vomiting, seizures, or amnesia, the risk of serious pathology requiring medical or surgical intervention is much less than 1%.

If your child does not have any of the above warning signs, then you can safely observe your child at home. Some experts think that if there are no warning signs, you can safely let your child sleep through the night. Other experts recommend awakening your child several times throughout the night to reassure yourself that he is easily aroused and clearly recognizes you. Depending on how hard your child hit his head, you may want to wake your child every four hours throughout the first night after injury, especially if the injury happened close to bedtime and you were unable to observe your child awake for several hours.

Thrush is caused by yeast and presents with white patches that can coat the inside of the mouth and sometimes the tongue. Thrush can cause mild discomfort and is easily treated. Thrush is diagnosed by examination by a doctor.

Treatment

• A prescription antifungal medication called Nystatin is used to treat thrush. You will need to give 1 ml to each side of the mouth 4 times a day, after meals. You should rub the Nystatin directly on the affected areas using a cotton swab. Keep this up for at least 7 days or until all the thrush has been gone for 3 days.
• If you are breastfeeding and your nipples are red and sore, you may need to apply the Nystatin to any irritated areas on your nipples. (Thrush is no reason to stop nursing.)
• Limit pacifier use. Prolonged sucking can irritate the lining of the mouth.
• Soak all nipples and pacifiers in water at 130 degrees for 20 minutes after each use.

Call the doctor if:

• Your baby refuses to eat
• Thrush lasts longer than 10 days
• Fever develops
• Symptoms worsen

Symptoms

Fever is often the first symptom and may be high (103-105 degrees).

The hallmark of the disease is mouth and throat pain. Painful mouth and throat ulcers on a bright red base develop 2-4 days into the illness. The ulcers are most commonly seen at the back of the throat, but may also occur on the gums, tongue, or inside of the cheeks and lips. 95% of children with this virus will develop mouth ulcers.

Some children will develop a rash on their palms and soles, and/or between their fingers and toes. This rash looks like tiny blisters underneath the skin. Children may also develop a more generalized pink rash on the rest of their body.

This illness is most commonly seen in the late spring, summer, and early fall.

Hand, foot, and mouth disease is most common in children between the ages of 6 months and 4 years, but can occur at any age.

Expected Course

• The fever will typically last 2-5 days.
• The mouth ulcers usually appear by day 2-3 of the illness, and resolve in 7 days.
• The rash on the hands and feet is typically seen later in the illness, and can last up to 10 days. The hands and feet may peel as the rash is resolving.
• Dehydration is the main concern, as many children refuse liquids due to mouth and throat pain.

Home Care Instructions

• Pain Relief- give Tylenol or Motrin for fever greater than 101 degrees or mouth and throat pain.
• Encourage favorite fluids to prevent dehydration.
• Offer cold drinks, Popsicles or Sherbet.
• Avoid citrus, carbonated beverages, and salty or spicy foods.

For infants and toddlers offer a sippy cup if sucking on a bottle seems more painful.

Liquid Antacids: Older children may get some relief from mouth pain by swishing and spitting 1-2 tsp of an antacid solution (Maalox or Mylanta) up to 4 times a day.

Contagiousness and return to school

This virus is quite contagious and most children will get this virus during the first 4 years of life.

The incubation period is 3-6 days after exposure.

Children are contagious 2 days before to 2 days after the mouth sores develop.

Children can return to school or daycare once their fever has resolved. Children do not need to be excluded from school or daycare due to the mouth sores.

If a child develops the rash on the palms and soles or elsewhere on the body, it signifies an immune response, and the child is no longer contagious.

Call the office if:

• Your child has not urinated for more than 8 hours.
• Fever lasts more than 72 hours.
• Your child is refusing to drink.
• Mouth pain is severe. Some children will need prescription pain relief stonger than Motrin or Tylenol in order to drink fluids.

Gastro-esophageal reflux describes the process where stomach contents flow backward up into the esophagus. The majority of infants have some degree of reflux, or spitting up. For most, it doesn't bother them, and they eventually outgrow the spitting up. Gastro-esophageal reflux disease refers to symptoms or complications that occur when stomach contents reflux into the esophagus or mouth.

How do I know if my infant has GERD vs. benign reflux (spitting up)?

Babies with benign reflux are not bothered by their spitting up. They eat vigorously and comfortably, and gain weight appropriately. These babies sometimes spit up A LOT of milk, but they just don't seem bothered by it. It's a big mess and a nuisance, but of no harm to these "happy spitters." On the other hand, babies with GERD often seem uncomfortable with feeds. They often arch their backs during feeds, or pull away from the bottle or breast shortly after beginning a feed. A clue is if your infant is getting older, but taking less formula or breast milk. Some babies with GERD do not actually spit up; some have symptoms just from the food washing back into their esophagus. Some parents report gagging or swallowing sounds even when their infant isn't feeding, or can actually hear the formula or breast milk coming back into the esophagus. These infants often are not gaining weight well.

What symptoms should alert me that something more serious than GERD is occurring?

Symptoms that are not compatible with a diagnosis of GERD that warrant additional medical evaluation include vomiting that is green (bilious), bloody, or consistently forceful/projectile. Blood in the stool or a distended abdomen that does not go down in between feeds is also a cause for concern.

GERD vs. Colic

The million dollar question: why does my baby appear so uncomfortable, and why is he crying so much? If your baby has a certain time of the day when he is fussy, or if his fussiness is seemingly unrelated to feeds, colic is more likely. If the fussiness seems to occur during or shortly after feedings, reflux is more likely. Colic usually begins around two weeks, peaks around 6-8 weeks, and is significantly better by four months. Infant GERD can begin anytime after birth, and can persist throughout the first year. GERD can worsen between 4 and 6 months, a time when colic has generally subsided. Since both of these issues are so common, they often exist together.

What can I do if my infant has GERD?

• Positioning: Contrary to popular opinion, placing an infant on their back in a semi-reclined position (such as by placing in an infant carrier or elevating the head of the bed) actually worsens reflux symptoms. Alternatively, it is helpful to keep your infant upright or semi-reclined on his stomach after feeds. A good position is to have your infant on your chest in a semi-reclined or upright position after a feed. Babies should always be placed flat on their backs on a firm mattress when unobserved during sleep to decrease the chance of SIDS. If you are going to place an infant on his stomach for sleep, make sure he is on a firm mattress and you are observing him closely. This may be helpful for napping young infants with significant GERD.
• Over Feeding: Make sure you are not over feeding your infant. If she is gaining weight rapidly, but spitting up a lot, try decreasing the volume of feeds. Also, infants with reflux tend to do better with smaller, more frequent meals. Pace your baby during feedings, and burp her often.
• Thickening formula: Thickened formula often "stays down" better in infants with GERD. To thicken formula, add 1 teaspoon of rice cereal per ounce of formula or breast milk. We prefer Beechnut rice cereal because it is pure rice. You can add up to 1 tablespoon per ounce of cereal; experiment to see what works best. You may need to go up to a larger nipple size in order for the thickened formula to flow. Alternatively, you can "cross cut" a nipple by cutting a small "x" in the nipple if you are adding larger amounts of rice cereal. There are also pre-thickened formulas available, such as Enfamil AR (anti-reflux). This formula has rice starch already added, and thickens in the stomach in response to acid. Therefore, Enfamil AR doesn't work well if your baby is on acid suppressor therapy. The advantage of Enfamil AR over thickening with rice cereal is that the balance of nutrients is maintained, whereas when adding rice yourself you are adding extra carbohydrate calories. The disadvantage with Enfamil AR is that it can't be used with suppressor therapy and it is more expensive.
• Medications: If the above conservative measures are inadequate for your baby, call our office to discuss medications. The first medication we usually try for infants with GERD is an acid-blocker, such as Axid or Zantac. These medications are dosed two or three times per day. They should be given 15-20 minutes prior to feeds. This is important because we want the medication in his system BEFORE the food hits the stomach, turning on acid production.

Sometimes, we will recommend a trial of Maalox for your baby before prescribing the above medications. You can give your infant 1 tsp of Maalox 3 times per day for 2-3 days. If it seems to help, there is a good chance that your infant has GERD. Maalox is not a long term solution. Using Maalox chronically in infants can lead to electrolyte imbalances, so don't use it for more than 72 hours without discussing this issue with our office.

Some infants with reflux continue to have problems even after Axid or Zantac is started. If your infant continues to have problems, we may prescribe a stronger acid-suppressor, such as Prevacid, which is given 1-2 times per day, also 15-20 minutes prior to a feeding. You may also have heard of Reglan. Reglan is a medication which helps to move food through the GI tract. It is unclear if this medication actually helps infant GERD and it can have significant side effects. For these reasons, we seldom prescribe Reglan.

When should I stop medication for GERD?

The only way to know if your infant still needs his medication is to stop the medication and observe him. If you think your baby no longer needs the medication, try decreasing the frequency and see if symptoms increase or return. If symptoms don't increase or return, it is safe to stop the medication. Do you ever miss giving doses of medication? Does your baby seem bothered by missed doses? If he does, he probably still needs the medication. If he's not bothered, it's a good time to trial off the medication. Most infants are on these medications for 2-4 months, but some infants need medication throughout the first year, or even longer.

These medications are dosed based on weight, so if you're concerned that the medicine isn't working as effectively, it may be that the dosage needs to be increased. Alternately, her reflux may be worsening and need additional evaluation or medication. Contact our office to discuss these issues.

Should I switch to a different type of formula?

There may be certain infants whose GERD is attributable to a formula or breast milk intolerance. Suspect this if your infant's GERD is unresponsive to medical treatment. Often, these infants have other symptoms of allergy, such as skin rash, chronic nasal congestion, and/or recurrent wheezing. Discuss potential formula changes with our office.

What is the long term outlook for infants with GERD?

Infantile GERD is usually outgrown. Half of affected infants have stopped refluxing by 10 months, 80% by 18 months, and 98% by two years. However, some of these infants may go on to have trouble with GERD as children and even adults. Observe your child for symptoms as he grows and discuss concerns with our office. (See information on GERD in children and adolescents).

The passage of gastric contents into the esophagus (gastro-esophageal reflux) is a normal process that occurs in healthy infants, children, and adults. Most episodes are brief and do not cause symptoms, esophageal injury, or other complications. In contrast, gastro-esophageal reflux disease (GERD) is present when the reflux episodes are associated with symptoms or complications.

What are the symptoms of GERD?

The range of symptoms and complications of GERD in children and adolescents vary depending upon their age.

• Preschool: Preschool age children with GERD may present with intermittent vomiting or regurgitation. They may complain about upper abdominal pain, or that their "tummy feels funny." Less commonly, they may have respiratory symptoms such as chronic cough, wheeze, or hoarseness. Decreased food intake or poor weight gain without any other complaints may be symptoms of GERD in young children.
• Older children and adolescents: The pattern of symptoms and complications in older children and adolescents resembles that seen in adults. The cardinal symptom is chronic "heart-burn," or pain in the upper abdomen (under the breastbone). In younger children, the pain is often ill-defined. In older children, it may be described as squeezing or burning, and may radiate to the back or upward along the esophagus. Other symptoms include nausea, poor appetite, feeling full or bloated easily, belching, chest pressure, difficult or painful swallowing, and/or an acidic taste in the mouth. The pain or discomfort often occurs after meals, especially large meals, and typically resolves in minutes to hours spontaneously or after administration of antacids. Respiratory symptoms can also occur, including chronic cough, wheeze, hoarseness, and even pneumonia or sinusitis.

What symptoms make a diagnosis of GERD unlikely?

Diarrhea and constipation are not symptoms of GERD, and make GERD as a sole diagnosis unlikely. Warning signs that your child has something more serious include bloody, bilious (green), or forceful vomiting, weight loss, persistent fevers, or bloody stools. If any of the above warning signs are present, please contact our office to discuss.

How is GERD diagnosed?

GERD is usually diagnosed presumptively by the clinical constellation of symptoms. If GERD is suspected, then an acid blocker or acid suppressor is usually prescribed. If the patient gets better, then GERD is assumed to be the correct diagnosis. GERD can be diagnosed more definitively by inserting a probe into the distal esophagus and measuring the pH of the regurgitated fluid. Alternatively, it can be diagnosed by seeing inflammation or irritation of the esophageal lining during endoscopy (direct visualization of esophagus with a camera). Since these tests are fairly invasive, they are reserved for more complicated or severe cases.

Treatment of GERD

• Diet: People who suffer from GERD should eat small, frequent meals. It is also helpful to avoid eating in the two hours prior to bedtime. Certain foods tend to make reflux worse. Try to avoid acidic or overly fatty foods, and foods that contain caffeine or peppermint. Sodas and orange juice are very acidic and can exacerbate reflux.
• Positioning: Try not to lie flat for 2 hours following meals. It may help to elevate the head of your bed 6-8 inches.
• Weight control: If you or your child is overweight, losing weight often decreases reflux symptoms.
• Medications: Antacids are often helpful for occasional relief of reflux symptoms. Children 1-5 years old can have 1-2 tsp of Maalox or other liquid antacid every 6 hours as needed for one to two days. Children 6-12 years old can have 2-4 tsp per dose, and adolescents over age 12 can have the adult dosage. Antacids should not be used on a daily basis without discussing with our office.
• Acid blocking medications: These medications, such as Pepcid, Axid, and Zantac, block the effects of acid secretion. They can be taken on a daily basis to help prevent reflux symptoms. These medications are best taken 20-30 minutes before a meal, so that the medicine has taken effect prior to food consumption.
• Acid suppressing medications: These medications, such as Prevacid, Prilosec, and Nexium, are the most potent reflux medications. These medications turn off acid secretion in the stomach. We will often prescribe these medications if diet, lifestyle changes, and acid-blocking medications are not effective.

Complications of GERD

Longstanding untreated GERD can lead to serious complications, including esophageal ulcers or strictures, or lung disease. The most serious, and thankfully, rare complication is esophageal cancer.

Eczema is an inherited type of sensitive skin. It presents as a red, itchy rash that often starts on the cheeks at 2-6 months of age. Eczema is very common on the flexor surfaces (creases) of the elbow, wrist, and knee. Occasionally, the neck, ankles, and feet are involved.

What causes eczema?

A strong family history of asthma, hay fever, or eczema makes it more likely that your child may develop eczema. Flare-ups occur when there is contact with irritating substances (i.e. soaps or chlorine). In 30% of infants with eczema, certain foods can cause flare-ups. If you suspect a particular food, avoid it for 2 weeks, and then re-introduce it ("challenge") to see if it is the cause. If a flare-up does occur, avoid ever giving that food to your child until you talk to your doctor.

Home Treatment

Keeping skin moisturized is the best way to prevent flare-ups. Your child should bathe once a day for about 10 minutes. Eczema is very sensitive to soaps. We recommend a mild soap like Dove. Only use soap in areas that seem dirty. Washing with water should be sufficient. Never use bubble bath, baby soap, or perfumed shampoo on your child's skin. After bathing, gently pat your child dry with a towel, try not to rub his skin too vigorously. To help trap the moisture after the skin is hydrated, we recommend a lubricating cream such as Aquaphor. Other options are Vaseline, petroleum jelly, or Eucerin cream. This is to be applied on top of the steroid cream, if ordered.

Steroid cream is the main treatment of eczema. Over-the-counter hydrocortisone 1% ointment (Cortaid) is extremely mild and is safe for you to apply twice a day, every day, to any rough patches on your child's body. Do not apply hydrocortisone to the diaper area, or the area around the mouth or eyes without first speaking to our office. Apply the steroid cream to rough or itchy patches twice a day until the patch goes away. Continue with the bathing and moisturizing to try and prevent flare ups. Remember that eczema is a skin type, so dry patches will likely reappear. Immediately restart the steroid cream to the affected area. Also use on any itchy spots to prevent patches. Keep your child's fingernails short and wash their hands frequently to avoid infection.

Many children will need something stronger than over-the-counter hydrocortisone. If your child's rash is not improving within one week of using the ointment, call our office to discuss.

Once the dry patch has resolved, it is common for the skin underneath to look either lighter or darker than the surrounding skin. This is the skin's reaction to healing from inflammation. If the skin is smooth, but darker or lighter than the surrounding skin, don't use the steroid cream anymore. It will likely take many months, but the skin pigment will even out over time.

Avoid triggers that can cause flare-ups, such as excessive hot or cold air (use a humidifier) or harsh chemicals. Clothes made of cotton are more comfortable than wool fibers or other scratchy materials.

Call the doctor if:

• The rash looks infected (yellow pus or scabs, red streaks, or fever).
• The rash becomes open or raw.
• The rash flares up after contact with someone who has fever blisters (herpes virus can cause a serious skin infection in children with eczema).
• The rash has not improved after 7 days of treatment, or sooner if it worsens.