30 March 1997

1. Dealing With Colds and Asthma in Day Care
2. Wheezing, Bronchiolitis, Asthma, RSV
3. Child Won't Take Medicine
4. Questions: Crying in Crib, Pacifier, Poisonous Plants
5. Two Year Old Won't Eat
6. When Do You Worry About Spitting Up?
7. Call Your Doctor When You're Sick!
8. Ritalin May Aggravate Tic Disorders
9. Disclaimer

• Read Questions & Answers in Another Column

• Feature Article: Upper Respiratory Infections (URIs): The most common childhood illness. It is often over-treated and misunderstood. There is a confusing array of medicines that promise relief, but no cure in sight.

Dealing With Colds and Asthma in Day Care

Respectfully,
Provider in Boise, ID

Dear Provider in Boise: Bronchodilator medications may sometimes make children hyperactive, however, that does not mean the medication is too strong for the child. Anytime we treat a patient we risk side effects from the treatment. If the side effects are too extreme, alternative treatments must be considered. A decision always has to be made that balances the need for treatment against the risks. If a child has severe wheezing most parents will be more than happy to tolerate some hyperactivity as long as their child can breathe easily.

Children may develop asthma in early infancy. If the symptoms are frequent or severe, we usually recommend inhalation treatments using a home nebulizer. It is true that these are the same medications used in the hospital by trained respiratory therapists, but anyone can be trained to give the treatment. Such treatments should be given under the instruction of a physician who should closely monitor the patient's progress and condition.

Most daycare facilities simply don't allow children with colds, bronchitis, or other infectious diseases to attend. Children who come to daycare sick will only spread their infections to others which is not fair to the others. Asthma is not contagious, but if the affected child is having any difficulty breathing or if the child requires inhalation treatments you should not accept the child into your daycare unless you feel comfortable handling the required treatment and have available medical backup should the child get sicker.

Asthma can be treated by a pediatrician and does not require a specialist. Children with more serious problems with asthma may consult a pediatric pulmonologist. Many asthmatics have allergies and most allergists treat asthma.

"Children With Asthma: A Manual for Parents" by Thomas F. Plaut, published by Pedipress, is an excellent book for parents of asthmatics. You would also find it helpful if you decide to try to take care of these children while they are being treated for asthma. Colds are such a common problem, and yet, I don't know of any literature for parents about colds.

Sincerely,
Dr. Warren

-IAF

Both asthma and bronchiolitis cause wheezing. Many young infants with asthma wheeze in response to having a cold. RSV also causes a cold like illness. Therefore it can be difficult to tell asthma and bronchiolitis apart. A child who has bronchiolitis will generally have the illness at the same time a bunch of other babies have it, and the test for RSV should be positive. If a child has multiple episodes of wheezing it is more likely that it is asthma. A family history of asthma increases the likelihood of a wheezer being asthmatic. For the most part the treatment will be the same for acute bronchiolitis and asthma in a young infant except that most physicians would not use steroids to treat bronchiolitis, whereas any child requiring hospitalization for asthma should be treated with steroids.

Sincerely,
Dr. Warren

-ME

Dear ME: If the medicine tastes bad you may have no choice but to restrain your niece to get her to take it. You might try a giving it with a syringe. Put only a small amount in her mouth at a time and then hold her mouth closed under the chin until she has swallowed it.

For each medicine, check with your pharmacist to see if it can be mixed in any food or drink. Sometimes diluting it will make the taste less of a problem; however, you must be sure to put it in a small enough volume of food or drink so that it will be finished.

If the medicine tastes good your niece might be more willing to take it if it didn't come on a familiar spoon. Try putting it in a small cup or even a nipple. One of my patients got her child to take medicine by giving it to him on a lollipop.

Sincerely,
Dr. Warren

Also, when do you recommend weaning from a pacifier ?

Last question, is it safe to have plants in the house with an infant ? Is it true that a ficus plant is poisonous ? Where can i get a list of poisonous plants or should i just get rid of them all ?

Thanks for your help,
Best Regards.

-GS

Between 4 and 6 months it is a good idea to get the baby used to falling asleep in the crib. Even though you will want to establish a bedtime routine as described above, your goal is to relax your baby and put her into her crib awake but ready to go to sleep. That way she learns that your intention is for her to sleep in her crib rather than having the crib be a place she wakes up terrified with no idea how she got there. The reason I recommend starting this young is that between 6 and 8 months infants start to develop separation anxiety. After separation anxiety sets in it becomes even more difficult for a child to accept being left in his crib. Additionally, most 4 month olds should be sleeping through most of the night. Should they awaken, you would like them to be able to go back to sleep with minimal intervention, so it helps to have them used to going to sleep in their cribs.

It can never hurt to let a child cry in the crib. I even give this advice to mothers of younger infants when they cannot find a minute to get things done. That way they have more relaxed time to spend with their infants. It also can't hurt to hold, comfort, and cuddle your infant whenever you want to or feel the infant needs you. The answer is to use common sense and decide when you can let the baby cry and when it sounds like the baby needs your help. I must caution you not to set a time limit for yourself with regards to crying or you will teach your baby just how long to cry to get your attention. But if the baby's cry sounds like it needs attention, for the baby's safety and your peace of mind check on the baby and give the baby the necessary attention to help the baby learn that your intention is for her to sleep in her crib. Keep your intervention minimal and if you must take your baby out of the crib put her back awake.

Pacifiers are used initially to calm a baby because of their need to suck. As infants get older their need to suck decreases but they still find comfort in using the pacifier. By 4 months, the baby's ability to interact with you has increased to the extent that it is a good idea to try to calm the baby by playing with her and interesting her in the world around her rather than putting the pacifier in her mouth the moment she cries. That way, even though she may still use the pacifier quite a lot, she won't come to expect it and need it for every cry. There is no set age to get rid of the pacifier. Some babies are just calmer than others and may give them up on their own. If by the time your baby is a toddler he is still using the pacifier, then his dependence on it is purely emotional. The weaning process can be more difficult at that age, but it is best accomplished by putting increasing restrictions on the circumstances in which the pacifier is available, starting with eliminating walking around with it during play.

Plants do pose some risk to children. It shouldn't be necessary to avoid plants in the house, but until children have learned to respect plants, they should be out of reach. Plants pose the biggest risk as children go from the crawling stage to the walking stage because they have increased mobility, can reach higher objects, and still have a tendency to put things in their mouths.

The information I was able to find about Ficus plants indicated that they were irritating and could cause a rash. Your local poison control center might be able to point you toward some resources about poisonous plants. The following sites on the World Wide Web might also be helpful:

Common Poisonous Plants - List
http://health.ucsd.edu/poison/plants.htm

List of Poisonous Plants with Links to more information on some.
http://www.pharm.arizona.edu/centers/poison_center/plants/poison.html

Nonpoisonous plants
http://www.Pharmacy.arizona.edu/centers/poison_center/plants/non.html

Information about poisonous plants
http://hammock.ifas.ufl.edu/txt/fairs/wg/39633.html

Sincerely,
Dr. Warren

-HB

Nutrition doesn't have to happen at 3 meals a day or even every day. It has to happen over the long haul. One good meal a day can do the job of nourishing a child in his slow growth years. Remember that milk provides most of the nutrients he needs just like it did in his most rapid growth period during his first 6 months.

The biggest mistake a parent can make with a finicky eater is turn the whole day into a contest to get the child to eat. Children react negatively to the constant pressure to eat and the constant availability of food prevents them from learning a realistic understanding of meal time. It is reasonable to provide a small selection of nutritious foods, including your child's favorites, at each meal. Since children often don't eat large meals and may be hungry in between you can offer nutritious snacks as well. But these should be offered at regular intervals and if the child doesn't eat, or only eats a little, the meal or snack is over and the kitchen is closed.

Don't offer junk food out of the mistaken notion that any food is better than nothing. Junk food may be acceptable as a treat in a child who gets adequate nourishment from his diet, but when the finicky eater gets the idea that he can get junk food instead of meals his small appetite gives him the will to refuse food until he gets his treat. It is possible to be overweight and still be malnourished if too much of the diet is consumed as junk food.

If you child is consuming excess bottles or drinks, especially if they are mostly juice which can cause diarrhea, you must cut down on the liquid intake. While milk is nutritious, if your child fills up on liquids he will not have room in his stomach for solid food. It can be difficult to cut down on the drinks, especially when you are worried about your child's overall intake, since you won't see an immediate increase in his appetite. Don't let your anxiety about your child's diet prevent you from making the necessary changes. If your child is healthy and you control his intake of liquids and junk food, and you provide nutritious meals and snacks in a pleasant, pressure free environment, eventually your child will develop healthy eating habits. Healthy eating habits for a two year old generally include a lot less food and a lot less variety than most parents think it should.

My advice has all been predicated on the idea that your child is indeed healthy. If you are not certain that this is the case you should have your child checked by his pediatrician. To assure yourself that your child is being adequately nourished during this transition period you may need to have him weighed and measured several times over the next few months to determine if his growth and weight gain are adequate.

Sincerely,
Dr. Warren

His spit sometimes goes a little distance (a few inches) and is often what seems like a substantial amount of milk or food (a tablespoon or more).

I've vigilantly worked to keep him still after meals, but it takes a good 3 or 4 hours before he'll stop spitting and he eats every 4 to 5 hours. My strategy has been to keep him as still (flat on his back works best) as possible for thirty to sixty minutes after eating and then to let him play and clean up the messes for the next hour or two. When I feed him at bedtime, he sleeps through the night without spitting up.

He is still breastfeeding, and there have been times when I suspected the spitting was caused by foods I eat, but when I give him formula occasionally, he spits that too.

He's about to start crawling, and it has become very difficult to keep him still after eating. Any advice you can give will be much appreciated. Thanks.

-BA

If you notice certain foods increase the amount of spitting it is reasonable to avoid them as much as possible, but if your child is thriving (healthy, happy, growing normally), it is not essential. While keeping him still after a feeding may be helpful, it may thwart his motor development if you restrict his movement for excessive time periods. Since spitting will be aggravated by gas bubbles it is important to pay attention to burping after feeding. Since bubbles rise to the top the best position for the baby is to be kept upright as long as possible after feeding.

When a baby is gaining weight well it usually means that the amount of spitting is not excessive and therefore not a cause for worry, except for the mess it makes. Symptoms that might suggest a need for evaluation for more clinically significant gastroesophageal reflux are as follows:
Poor weight gain.
Irritability. This may indicate irritation of the esophagus by stomach acid.
Poor appetite. This may reflect discomfort on eating because of irritation of the esophagus.
Recurrent cough, wheeze, or pneumonia. This can result from stomach contents in the esophagus irritating the trachea or getting into the lungs.
Spitting up blood. This can result from irritation of the esophagus.

Sincerely,
Dr. Warren

Thanks,

-JL

My advice: Call your doctor!

Sincerely,
Dr. Warren

I appreciate your help!

-TS

Sincerely,
Dr. Warren

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