Coughs, Congestion, and Colds

"There's only one way to treat the common cold - with contempt"

    - the esteemed Sir William Osler, MD

Ah, the common cold. Common, indeed - the average preschooler has six to 10 colds per year, with each illness lasting 10 to 14 days. And the sad truth is, Dr. Osler's 1890s-era wisdom is still largely correct. He went on to say, "... toss the pills into the ocean. So much the better for mankind, so much the worse for the fish"!

For children less than 5, there just isn't any safe, effective treatment available to treat the common cold. None of the common cold medicines can convincingly outperform sugar water, and the FDA has warned of a number of serious adverse reactions when used in children under 2 (our advice: don't risk it). But that doesn't seem to keep cold remedies from being a billion-dollar-a-year industry.

We all know what a cold looks and feels like, although we sometimes seem to forget when it comes to our own kids. Signs of something more serious like pneumonia, bronchiolitis, or asthma could be:

• Prolonged or high fever (more than 2-3 days, or >102 degrees)
• Breathing fast (count breaths over one full minute while quiet or asleep; infants should breathe <50-60 times per minute, toddlers <40x/min, older children <30x/min)
• Working hard to breathe (heaving chest, visible rib movement, nasal flaring, grunting)
• Getting dehydrated (not drinking enough, no tears/drool, less than 3 urinations/day)
• Acting really ill or lethargic

If those are happening, please let us know - if you're travelling, we may want to start the zithromax, and possibly find someone to evaluate in person. We do have a lower threshold to start antibiotics when we can't see kids ourselves.
 

Other Complications:

If nasal congestion and wet cough last more than 2-3 weeks then it may be bacterial sinusitis, which can be helped by antibiotics as well; the color/consistency of the snot doesn't tell us if this is viral or bacterial, unfortunately. Ear infections can be a complication of colds, often marked by new fever and irritability when a cold seems to be running its course. Ear tugging and fiddling is not a reliable sign of ear infection in preverbal children, unfortunately.
 

Let's review the common medications and treatments for the common cold:

• Decongestants (pseudephedrine, etc) - Somewhat effective for daytime relief in adults and school-age kids, but they just don't work in young kids. Besides, does putting your ill, sleepless child on over-the-counter speed seem like a good idea?
• Decongestant Nasal Sprays (Afrin, Dristan, etc) - These work for short-term congestion emergencies (less than 2 days at a time) but can be nasally addictive, causing "rebound congestion" when you stop using them. Not routinely recommended, and not for infants/toddlers.
• Antihistamines (Benadryl, etc) - A good treatment for allergies, but colds are caused by a viruses; useful only for their sedative effect in desperate sleepless situations. Beware - 1 in 5 kids gets LOOPY on benadryl.
• Cough Suppressants (dextromethorphan, codeine, etc) - It sure is tricky suppressing that cough reflex without putting your child in a coma. Safe doses of codeine and it's synthetic cousin, dextromethorphan, don't seem to be that effective at suppressing this vital reflex. Codeine is also just not safe enough to use in kids anymore, especially in Ethiopian adoptees. That said, in older children with a lingering, nagging, non-productive cough, you might try some Delsym (long-acting dextromethorphan).
• Expectorants (guaifenesin) - These don't work in young children, who don't need any help making copious secretions. In older kids and adults, they may make phlegm thinner, but so does drinking lots of fluids. Mucinex is a single-ingredient, extended release form of this for older kids and adults.
• Tylenol or Ibuprofen - IF your child is uncomfortable from fever, or in pain, these can help. Otherwise you may be suppressing the body's immune response.
• Antibiotics - No. Nyet. Bu.
• Zinc - Yuck. Zinc lozenges and zinc up the nose have not shown to be effective in kids. But zinc deficiency is associated with poor immune function (and many adoptees are zinc deficient). There's lots of zinc in high-protein foods like meats, seafood, milk, and fortified breakfast cereals. A "complete" multivitamin with minerals can also help.
• Vitamin C - Controversial. Large doses may shorten symptoms in adults, but megadoses are not clearly safe in kids, and can cause diarrhea. Like zinc, let's just make sure you're getting enough, and some extra at the first signs of a cold may help.
• Echinacea - Recent study done here found no clear benefit at reducing symptoms in kids. Bummer.
• Probiotics - Lactobacillus milks, active culture yogurts, and probiotic supplements are emerging as a good thing, although definitive studies are still pending, and it's not at all clear that they treat colds. They may be effective at preventing colds, allergies, and diarrhea, with a host of other potential benefits.
• Andrographis (Kan Jang) - Herbal remedy that's all the rage in Scandinavia. Some smaller studies showing benefit in colds and flu. Promising, but larger studies may sink this ship as well.
• Umcka drops - Ancient Zulu Homeopathic Geranium-ness. Germans love this stuff, available here through Nature's Way. Some promise for sinus, throat, and bronchial infections, large high-quality studies are lacking, so who knows, really? If you enjoy taking the latest natural sounding probable placebos, give it a try.
• The Stuff That Teacher Invented Who Never Ever Got Another Cold (Airborne) - It was on Oprah, so it must work. This contains Lonicera, Forsythia, Schizonepeta, Ginger, Chinese Vitex, Isatis Root, Echinacea, along with vitamins, zinc and magnesium. Phew. Feels a bit faddish to me, with a few too many ingredients.
• Whiskey - Dr. Osler's preferred cold remedy: "hang your hat on the bedpost, get into bed, start drinking whisky. When you see two hats stop!" Not an option for the kids, but what you do with the colds they give us is entirely up to you.
• Humidification - Unclear benefit from humidifiers and vaporizers, but they feel good for many, and may keep nasal secretions easier to clear. If you use these, clean them obsessively, as they are effective at aerosolizing molds and bacteria.
• Menthol, Eucalyptus, VapoRub - Studies show that people think these are working even if they aren't. You can put them in the vaporizer, plug a gizmo into a wall outlet, or rub them onto your child. That may be the key ... with the massage, you get the healing power of relaxation and parental tender loving care.
• Chicken Soup - Yup, small studies and grandmothers actually agree on this one.
• Nasal Saline Drops/Sprays and Bulb Suction - This really can help infants and toddlers, who can't effectively blow their nose. Infants, in particular, have tiny nasal passages that they depend on for sleeping and eating. You can buy nasal saline or make it with 1/2 tsp salt in 1 cup warm water. Put 1-2 drops in each nostril before suctioning to help clear dry nasal secretions. A bulb syringe is most effective if you squeeze it, put the tip in one nostril, and pinch the nose to get a good seal on the side you're suctioning and close off the side you're not, and SLUUURP. Don't go too crazy with this, as you don't want to overly irritate the nasal mucous membranes.
• Plenty of Rest and Plenty of Fluids - Yes. Da. Shi.
• and finally ... Tincture of Time - The ONLY cure for the common cold. Support the immune system in its good work with rest, fluids, love, and attention, and otherwise stay out of the way.

Updated 8/07

Our Post-Placement Evaluations

Here's what we hope to accomplish during our hour-long initial appointments with new arrivals, ideally scheduled 1-2 weeks after you get home. We then like to see children roughly every 2 months until they've been home 6 months, to closely follow adjustment, growth, and developmental catchup. Our Welcome Home Guide is a printable summary of what we usually cover at our first visit, but here is a quick overview.

History and Physical Examination:

• Review any newly acquired medical, educational, or institutional records

• Interview older children, with interpreter

• Discuss family concerns and adjustment issues including sleep, feeding, and attachment

• Assess growth

• Thorough physical examination

• Developmental screening

• Screen hearing and vision - hard to accomplish accurately <4 years old, so ...

• Likely referral for audiology, opthalmology, and/or dental examinations

• If delays are greater than expected, Early Intervention referral

Immunizations:

• Immunizations from Korea (and sometimes Guatemala and Taiwan) are generally trusted

• From other institutional settings, we usually combine checking titers (blood tests of immunity, not reliable <1yo) and repeating immunizations based on the individual child's age and shot record

Lab Workup:

• Newborn screening panel (infants only)

• Complete blood count and ZPPH or ferritin (iron deficiency tests)

• HIV antibody; Hepatitis B panel; hepatitis C antibody (on arrival and 6 months postplacement)

• Hepatitis A titers (asymptomatic in young children, but can make their older contacts quite ill)

• Serologic test for syphilis

• Thyroid function tests

• Lead level

• Stool examination for ova and parasites (three preserved specimens - you'll get vials at the visit to collect and drop off)

• Stool examination for Giardia antigen, or a stool PCR panel that includes giardia (one fresh specimen)

• Urinalysis if growth deficient, symptomatic, or any history of issues

• Calcium, phosphorus, and alkaline phosphatase levels, if child has signs of rickets

• If height deficiency is profound, further lab evaluation for short stature

• Tuberculin skin or blood test (on arrival and 6 months postplacement - this is crucial)

Preparing Families for International Adoption

Dr. Bledsoe and her husband authored a lovely review article for pediatricians called Preparing Families for International Adoption, which

• describes the changes in the demographic, medical, and developmental characteristics of internationally adopted children
• discusses the role of the pediatrician in assessing information made available to families prior to adoption of a child abroad
• lists conditions commonly seen in children adopted internationally and characterizes their medical, developmental, and social consequences
• describes the current understanding of the long-term medical, developmental, and emotional outcomes of international adoption

Highly recommended as an overview of international adoption, even if it was written for health care providers ...

Craniofacial Resources, including Cleft Lip and Palate

The Craniofacial Clinic at Children's Hospital in Seattle just went online with a great resource for craniofacial conditions like ... (following links and text from their site)

• Cleft Lip and Palate
  The most common condition that we treat.
• Velopharanynegeal Insufficiency (VPI)
  Children with cleft palate are at risk for VPI, a disorder that affects speech.
• Pierre Robin Sequence
  A birth defect that involves an abnormally small lower jaw and breathing problems.
• Stickler Syndrome
  A genetic disorder of connective tissue that results in problems with vision, hearing, facial and skeletal development.
• Velocardiofacial Syndrome
  A complex craniofacial condition often linked with cleft palate.
• Van der Woude Syndrome
  An inherited form of cleft lip and/or palate.
• Craniosynostosis
  A birth defect caused by premature fusion of skull bones; the second most common condition we treat.
• Crouzon Syndrome
  A rare genetic form of craniosynostosis.
• Apert Syndrome
  A rare genetic form of craniosynostosis.
• Saethre-Chotzen Syndrome
  A rare genetic form of craniosynostosis.
• Positional Plagiocephaly
  A change in head shape caused by external pressure on the skull.
• Hemifacial (Craniofacial) Microsomia
  A condition with underdevelopment of the ears and jaws.
• Treacher Collins Syndrome
  A rare, inherited, congenital craniofacial condition that affects the bones, jaws, skin and muscles of the face.
• Other Rare Conditions
  We treat other conditions not listed here.

The Craniofacial Clinic site also offers a glossary of craniofacial terms.

Children's has another nice resource dedicated to cleft lip and palate:

• Birth Defects ToolKit - Cleft Lip and Palate

One especially detailed document is their "Critical Elements of Care", which goes into a lot of detail about what to expect over the years in terms of clinic visits, surgeries, and other interventions:

• Critical Elements of Care: Cleft Lip and Palate
  

Sleep Issues In Pediatrics Presentation

Dr. Bledsoe has given this presentation on sleep issues to local parent groups. This presentation is not specifically for adoptees, but some adoptees may eventually benefit from these approaches after being home a few months. Sleep is an emotional issue, with wild claims made on all sides of the attachment parenting to sleep training continuum. We've all got our biases, and you'll need to decide for yourself which approach feels right to you. Does it fit your parenting style in other areas? Can you (and other caregivers) be consistent in implementing it? Is what you're doing now what you hope to be doing months or years from now?

• Sleep Issues in Pediatrics Presentation (big download in pdf format)
  

Constipation

It's a sad day when poop just isn't funny anymore ... at least for someone like me who does enjoy poop humor and things scatological (it's an occupational hazard). That sad day is a lot more likely to happen when travelling to adopt a child. In fact, constipation is so common a concern for travelling adoptive parents that I've taken to inventing medical terminology with a reassuring cachet such as "transitional slowed bowels", just to take the edge off of the hour-and-minute countdown since last passed stool. It's also a problem for many other children in my practice ... our modern processed diet may be to blame, as a diet low in fiber, low in fluids, and high in sugars predisposes kids to constipation.

In general, constipation is defined more by what your child is passing rather than how often. Normal stool frequency in infants varies from several times a day to 1-2 times per week. But if your child is passing painful, hard "rocks", "golf balls", or "boulders" (egad), especially if there is intermittent leakage of more liquid stool (encopresis), then indeed we've got a problem. If your child is vomiting, or has a full, tight, and tender belly, then we've really got a problem needing urgent medical attention.

In the recently adopted child, constipation is often blamed on iron, when in fact it's more likely to be from the stress of travel and transition, dietary changes, and perhaps dehydration. The association between iron and constipation is overrated, and since most adoptees are iron-deficient, it's not wise to try and limit their iron intake.

Soy formula can cause harder stools, so you may not want to switch your child to this if constipation is an issue. Luckily, cow milk intolerance is another overrated issue - most infants and young toddlers tolerate cow milk products just fine (rarely, cow milk protein allergy can be associated with intractable constipation).

To assist you in your quest for smooth bowel movements, or Smoovements^TM, if you will ... I will now share with you ancient secrets of "FPBM - For Proper Bowel Movements". Let's start with F - FLUIDS, FRUITS, and FIBER are your Friends when it comes to constipation.

Infants:

• several ounces of 100% fruit juice 1-2x/day, especially prune, pear, or apple juice
• fewer white foods like bananas, rice, soy, cheese, white flour products, and ...
• more "P" fruits and veggies like pears, peaches, prunes, plums and peas
• substitute barley cereal for rice cereal
• in hot climates where dehydration is a concern, a few extra ounces of water can help, but since our kids usually need the calories, I'd stick with juice or watered-down juice
• if you've gone more than 3-4 days with no stool, and your child seems to be in pain or straining a lot, try a glycerin suppository and a warm bath; you can also gently lubricate around the anus with vaseline or diaper cream
• if your child is straining, you might try bicycling their legs or holding them upright in squatting position (their back against your chest, holding their knees up towards their chest)

Toddlers and Older Children:

• fruit juice, and fewer white foods/more "P" fruits and veggies as above can help ...
• ... but in this age group, we should focus more on fiber and fluids: goal is at least their age in years plus 5-10 grams of dietary fiber per day, with lots of fluids
• whole grain cereals (read the label - lots of fake "whole grain" stuff out there) - remember "Colon Blow Cereal" from Saturday Night Live? That's the ticket - bran cereals, whole grain cereals, muesli, mini-wheats, etc ...
• bran muffins, cookies, crackers, and pancakes with whole grains. Metamucil makes some psyllium fiber cookie-type wafers as well ...
• Benefiber is a nongritty, flavorless fiber supplement that dissolves more completely than Metamucil, for when you can't meet the fiber goal through diet alone
• You can also get your 100% juice plus 10g fiber premixed in one convenient but pricey juice box (they also carry fiber cookies)
• dried fruits (prunes, apricots, figs, raisins, etc)
• beans, peas, and lentils
• fresh fruits and veggies with fiber - carrots, cabbage, celery, rhubarb, prunes, pears, peaches, plums, apricots
• the constipation chapter below has nice recipes for "Right and Regular" jam and fruit/fiber smoothies
• you can try 1/2 tsp unprocessed bran or flax seed mixed with food 1-2x/day but only if your child is drinking adequate fluids
• for kids 4yo and up, popcorn is a great, tasty source of fiber, as are seeds and nuts

"B"-havior: 

• in older children with constipation, suggesting regular sitting sessions 2x/day can help - after meals is the best time
• reward successes, lay off the failures (it's bad enough as it is)
• regular exercise keeps you regular
• for kids who are fearful of pooping from passing painful large-caliber stools, sitting backwards on the toilet leaning onto the tank can help
• 3-5yo "magical thinkers" often feel that if they withhold stools after they've had a painful experience the poop will disappear. It won't. It'll just add to their "boulder collection". Reinforce that the poop needs to come out every day, and help it do so with diet, regular sitting, and Miralax.
• counseling may be necessary (and very helpful) for older children with encopresis

Medications that start with M:

• if diet isn't working, if symptoms are severe, if your child is withholding stool, or if there's leakage (encopresis) you need to talk to your doc
• my hands-down favorite laxative is Miralax, a tasteless powder mixed into your choice of fluids that is very safe, well-tolerated, and effective ... and now available over-the-counter
• if you've been dealing with long-standing constipation or encopresis, you need to continue interventions like Miralax for 2-3 months at least, to help the rectum and colon recover to a normal caliber
• Maltsupex or Milk of Magnesia are also frequently used
• Mineral oil is another old favorite but it's yucky (try it in ice cream) and can pose an aspiration risk in younger children
• bowel stimulant products like senna can be used occasionally but are not for chronic use
• DON'T enemize your child without consulting a physician, and avoid frequent rectal interventions in general (unnecessary and traumatizing)
• DON'T give honey or karo syrup to infants - there have been cases of botulism from this. UPDATE: Karo syrup manufacturing processes are now considered safer, but karo syrup no lomnger contains some of the helpful glycoproteins, so it may be less effective.

Remember, it's all about FPBM - "For Proper, Pleasing, Painless, and Punctual Bowel Movements"

• Fluids, Fruits, Fiber are your Friends
• Prunes, Pears, Peaches, Plums, Peas, Psyllium, Peanuts and Popcorn
• Bran, Beans, Benefiber, and Behavioral interventions
• Miralax (and/or Maltsupex, Milk of Magnesia, Mineral Oil)

Other Resources:

• Need more help? See this excellent book from a local colleague: The Ins and Outs of Poop
• Constipation Advice from DrGreene.com
• KidsHealth Soiling (Encopresis) Article
• Parent guide: Stool holding: When your child holds back bowel movements and is not toilet trained
• eMedicine Constipation Guide

Diaper Rashes

Want an advanced degree in diaper rash management? This excellent article from Pediatric Nursing takes you deep into the world of diaper pastes, for when Desitin just isn't cutting it anymore:

•  "Diaper Rash Care and Management"

Me, I'm a big fan of the descriptively named Boudreaux's Butt Paste for your basic diaper rashes and irritations. It works well, smells good, and, well, it's called Boudreaux's Butt Paste.

Another good option is Triple Paste. I use this on raw diaper rashes that need a really tenacious barrier paste.

Urgent Medical Care While Travelling

If you're a client of ours and dealing with an urgent medical concern abroad, please email or page us using the instructions in your travel packet. We'll do our best to diagnose your issue and recommend treatment.

However, for some conditions, there's no substitute for direct evaluation ... here are some good resources on this issue.

• Urgent Medical Care Abroad, by Jane Aronson, MD
• Medical Resources in China, by Todd Ochs, MD

Stuttering

Many children from age 18 months to 5 years old have occasional initial syllable or word repetitions, or use of filler pauses ("Umm ...") - this is called disfluency, and is usually a normal developmental stage where the mind is thinking of words faster than the mouth can utter them.

True stuttering is more common in boys, if there's a family history of stuttering, with later onset of symptoms, if there are speech/language delays, and if the stuttering is more often present than not, especially if present for 6-12 months or more.

Some characteristics of true stuttering include:

• frequent repetitions of sounds, syllables, or short words
• frequent hesitations and pauses in speech
• absence of smooth speech flow
• tense facial expressions or facial tics
• a fear of talking

A nice guide for parents trying to sort this out is "If You Think Your Child is Stuttering ...", from the Stuttering Foundation (they have a great website). I also really like their streaming video, with examples of disfluencies and true stuttering, and helpful advice.

Sensory-Perceptual World of Infants

Here's a handout on the Perceptual World of Infants that I usually give to parents of newborns. It's a slapdash summary of infant sensory development, shamelessly cribbed from What's Going on in There? : How the Brain and Mind Develop in the First Five Years of Life (highly recommended).