Fever Phobia Deconstructed

An excellent article detailing how parents and pediatricians should approach fever. I absolutely agree that the comfort of the child supersedes the fear-driven need to bring the number of the fever down.

My motto in the office is "treat the child, not the fever". In fact this motto can be extended to almost any other symptom, i.e. "treat the child, not the cough". As with all symptoms, it is far more important to elucidate the source of the fever rather than to focus on the fever itself.

The same goes with cough, runny nose, rashes, etc. If the source is benign then one need not worry about the symptom itself. Which does not mean you shouldn't treat the symptom - if there is discomfort it should be addressed.

On the other hand, if a pediatrician suspects that the source may be of concern, i.e. pneumonia, meningitis, kidney infections - a more extensive evaluation, closer monitoring and treatment will be called for.

Sweating Out a Fever
Focus on Symptoms, Not Just the Number on the Thermometer, Doctors Advise

When a child's temperature begins to rise, worried parents often spring into action, marshaling cool washcloths and pain relievers, making frantic calls to the doctor or even visiting an emergency room.

Now, the American Academy of Pediatrics is telling parents that the number the thermometer displays is just a number—and that making a feverish child comfortable is far more important than bringing his temperature to 98.6 on the dot.

Fevers are the main reason for one-third of calls and visits to pediatricians.

"The signs and symptoms provide much more information than just the fever itself," says Janice E. Sullivan, a professor of pediatric critical care at the University of Louisville School of Medicine in Kentucky and co-author of an AAP report on fevers, released Monday.

The report, aimed at calming what it calls "fever phobia," also says there is no evidence that lowering a fever will help a child get well faster, or that leaving a fever untreated could cause seizures, brain damage or death, as some caregivers fear.

Many pediatricians have given parents a similar message for decades, but it hasn't sunken in. There's widespread confusion over what fevers in both children and adults signify, when to treat them—even what constitutes an official "fever" (100 degrees Fahrenheit? 100.4?) Many parents also rely on the thermometer to tell them how sick a child is when he's too young to talk. To some, it's an objective measure, which can't be faked, of whether an older child should be packed off to school or sent back to bed.

Fevers are the main reason for one-third of calls and visits to pediatricians, the report notes. Yet many beliefs about them are based more on culture, tradition and playground chatter than scientific evidence. Ads showing parents fretting over thermometers confuse things further.

Drugstore Dangers
These days, navigating the world of children's pain relievers is almost as tricky as interpreting a child's temperature.

Johnson & Johnson's McNeil Consumer Healthcare unit recalled 136 million bottles of liquid Tylenol, Motrin, Zyrtec and Benadryl for infants and children last year after federal investigators found bacterial contamination and other problems at a plant in Pennsylvania. Subsequent recalls included Children's Tylenol Meltaway strips in bubblegum flavor, Junior Strength Motrin caplets and Children's Benadryl Allergy Fast Melt tablets in cherry and grape.

Problems ranged from moldy smells to floating metal particles to the possibility of excess concentrations of an ingredient. In a legal filing last week, Johnson & Johnson said alternative supplies are expected to be available in the second half of this year.

In their absence, many parents have turned to generics and drugstore brands, children's Advil or Triaminic, another liquid acetaminophen for children.

Experts are still concerned about combination cough-and-cold syrups. Manufacturers voluntarily withdrew those labeled for children under age 2 in 2007 after pediatricians complained that they didn't work well and posed a risk of accidental overdose. But this week's American Academy of Pediatrics report warns that parents should not give cough-and-cold


Fevers are the main reason for one-third of calls and visits to pediatricians.

"The signs and symptoms provide much more information than just the fever itself," says Janice E. Sullivan, a professor of pediatric critical care at the University of Louisville School of Medicine in Kentucky and co-author of an AAP report on fevers, released Monday.

The report, aimed at calming what it calls "fever phobia," also says there is no evidence that lowering a fever will help a child get well faster, or that leaving a fever untreated could cause seizures, brain damage or death, as some caregivers fear.

Many pediatricians have given parents a similar message for decades, but it hasn't sunken in. There's widespread confusion over what fevers in both children and adults signify, when to treat them—even what constitutes an official "fever" (100 degrees Fahrenheit? 100.4?) Many parents also rely on the thermometer to tell them how sick a child is when he's too young to talk. To some, it's an objective measure, which can't be faked, of whether an older child should be packed off to school or sent back to bed.

Fevers are the main reason for one-third of calls and visits to pediatricians, the report notes. Yet many beliefs about them are based more on culture, tradition and playground chatter than scientific evidence. Ads showing parents fretting over thermometers confuse things further.

Drugstore Dangers
These days, navigating the world of children's pain relievers is almost as tricky as interpreting a child's temperature.

Johnson & Johnson's McNeil Consumer Healthcare unit recalled 136 million bottles of liquid Tylenol, Motrin, Zyrtec and Benadryl for infants and children last year after federal investigators found bacterial contamination and other problems at a plant in Pennsylvania. Subsequent recalls included Children's Tylenol Meltaway strips in bubblegum flavor, Junior Strength Motrin caplets and Children's Benadryl Allergy Fast Melt tablets in cherry and grape.

Problems ranged from moldy smells to floating metal particles to the possibility of excess concentrations of an ingredient. In a legal filing last week, Johnson & Johnson said alternative supplies are expected to be available in the second half of this year.

In their absence, many parents have turned to generics and drugstore brands, children's Advil or Triaminic, another liquid acetaminophen for children.

Experts are still concerned about combination cough-and-cold syrups. Manufacturers voluntarily withdrew those labeled for children under age 2 in 2007 after pediatricians complained that they didn't work well and posed a risk of accidental overdose. But this week's American Academy of Pediatrics report warns that parents should not give cough-and-cold products containing acetaminophen even to older children, given the risk that they might unknowingly take other products with acetaminophen, which can cause fatal liver damage at high doses.

Many liquid medications for children still on the market have confusing dosing information, according to a study in the Journal of the American Medical Association in December. For example: a label calling for a one-teaspoon dose packaged with a cup marked in milliliters. Since the study was conducted, the Food and Drug Administration issued voluntary guidelines for making children's medication labels easier to understand. The researchers, from New York University, plan to repeat the study to see if the guidelines have made a difference.

In the meantime, experts say, parents should pay very careful attention to dosing information since even small errors can have big consequences in children.

"There's a huge desire to do the right thing, but when we think we're healing the child, we may be really treating ourselves" by taking action, says Glen Stream, president-elect of the American Association of Family Physicians.

Experts stress that a fever isn't an illness, it's a response, probably an evolutionary adaptation to help fight infection. Setting the body's thermostat (the hypothalamus gland in the brain) a few degrees higher slows the reproduction of bacteria and viruses and boosts white blood cells.

There's some evidence that illnesses may resolve faster when fevers are left untreated, the report notes. At the same time, elevated temperatures themselves can cause discomfort in children by interfering with sleep, appetite and activities.

"If your child looks uncomfortable, then treat the discomfort with acetaminophen or ibuprofen," says Dr. Sullivan. But she says a fever alone with no other symptoms doesn't need treating. "The fever itself doesn't tell us how ill the child is. There isn't a good correlation."

The report, which is aimed at pediatricians, not parents, doesn't specify other ways to make a sick child more comfortable. But Dr. Sullivan says parents should be on the lookout for rashes, irritability and altered mental status. 

"Anytime you have a significant change in behavior, you need to talk to your doctor," says Henry Farrar, who practices pediatric emergency medicine at Arkansas Children's Hospital and co-authored the report. It also stresses the need for rest and proper fluid intake. 

If a fever-reducing medicine is warranted to make a sick child more comfortable, the report says there is no substantial difference between acetaminophen and ibuprofen in safety or effectiveness. But it warns against combining them or alternating them—which some doctors recommend—because it compounds the risk of errors. 

COMMON AILMENTS ASSOCIATED WITH FEVERS

Some temperatures are cause for concern all by themselves. But going strictly by the numbers on a thermometer can be misleading, since people can react differently to the same infections.

The report also stresses the importance of checking package labels for the correct dosages, which are based on weight and age in children. As many as half of all U.S. parents give children incorrect doses, according to the report. 

And if a child is asleep, he shouldn't be awakened just for medication, the report notes. In one study, 85% of parents said they had done so. 

There are some cases where a fever alone can be worrisome. Parents should contact a doctor immediately if an infant under 3-months old has a fever of 100.4 or higher, which could signal a serious infection. Children with underlying conditions, such as weak heart muscles, may not be able to tolerate a fever and should get medical attention if one appears. 

Children and adults can spike fevers as high as 106 due to hyperthermia, or "heat stroke," a malfunction in the body's ability to cool itself, often after physical exertion in hot weather. Drinking fluids and being immersed in cool water can help; fever-reducing drugs don't.

Fevers can occur in children and adults for many other reasons, including auto-immune diseases like lupus, cancers like leukemia and lymphoma and just normal teething. Some people routinely run fevers even with minor illnesses, and some people seldom get them. (Rare fevers that last for weeks with no apparent reason are known as FUOs—fevers of undetermined origin.)

Even the classic 98.6 isn't so much "normal" as "average," experts note. A healthy person's temperature varies much as a full degree during the day, reaching highest in the evening and lowest between about 6 a.m. and 9 a.m. (just when tough school-or-bed decisions are being made.)

Given all that variability, does it make sense to check the thermometer at all? 

Yes, doctors say. Since most fevers accompany viral infections, experts agree that children with temperatures above 100.4 should stay home until they are fever free, without medication, for at least 24 hours, whether they have symptoms or not.

The same goes for adults—and they shouldn't be under the illusion that lowering a fever with medication also lowers their chance of infecting coworkers, experts say. "We really don't want people with fevers to be in the workplace," says Robert Hopkins, a University of Arkansas professor of internal medicine who serves on the American College of Physician's clinical guidelines committee. 

The illnesses with little or no fever pose more of a dilemma. Some viruses are most contagious in the early stages, before a fever has developed. Others, like last year's H1N1 virus, made many people miserable but seldom caused fevers.

That can make for tough calls for parents and school nurses when it comes to deciding whether a child who complains of illness, but doesn't have a fever, should be in school. 

"Sorting out the difference between a math-anxiety headache and an illness that could be contagious or prevent a child from learning is a judgment call," says Amy Garcia, executive director of the National Association of School Nurses. It helps to know the child very well, she says. "I had three boys myself, so I know the drill pretty well."

GAC FRUIT

Yes, it has a strange name. No, you most likely haven’t heard of it before. And yes, it is definitely a fruit you need to know. It’s Gac fruit (Momordica cochinchinensis), a strange and beautiful red fruit originating from Vietnam, where it is harvested in December and January. The fruit is cultivated throughout Southeast Asia and China, often as an ornamental plant due to its magnificent color. Also known as Chinese bitter cucumber, cundeamor and bhat karela, Gac fruit is rich in the antioxidants beta-carotene, lycopene (seventy times more than in tomatoes), and zeaxanthin. It contains the highest concentration of beta carotene of any known fruit or vegetable (ten times as much as carrots). Beta carotene is a reddish antioxidant that shows up in a host of fruits and vegetables, from apricots to pumpkins.

It converts to vitamin A in the body, and has a variety of protective properties.Gac fruit is traditionally cooked into glutinous rice to produce a brilliant orange rice dish known as xoi gac. The fruit and various preparations made from it are served as special dishes at New Year celebrations, and at weddings. As a traditional medicine, Gac fruit has been employed to treat conditions of the eyes, burns, skin problems and wounds. The juice of the fruit is consumed as a healthy beverage that is good for the eyes, immunity, reproduction, skin, heart health, and the prostate. Today Gac fruit extracts are making their way into supplement products in the US and abroad.

The zeaxanthin in Gac fruit protects the tissues of the eyes against exposure to ultraviolet rays, and helps to reduce oxidation of eye tissue, thereby enhancing overall eye health. Additionally, the betacarotene in Gac fruit helps to maintain good night vision, and reduces the risk of blindness.

For immune system enhancement, beta-carotene from Gac fruit converts in the body to vitamin A, and helps in the healthy development of white blood cells, including lymphocytes, which are important “foot soldiers” in the immune system, enabling the body to defend itself against disease.

Gac fruit’s beta-carotene supports healthy reproductive function by enhancing sperm production. Converted into vitamin A, this important nutrient also plays a key role in healthy embryonic development. The lycopene and beta-carotene in Gac fruit enhance skin health by mitigating oxidative damage in tissue. Think of oxidation as the“rusting” of our cells. These ingredients in Gac reduce that rusting process, and contribute to better-looking and healthier skin. The various antioxidants in Gac fruit enhance heart health by specifically combating atherosclerosis, or hardening of the arteries. Additionally, both lycopene and beta-carotene show protective activity against the risk of heart attack.

Additionally, lycopene, which is super-abundant in Gac fruit, helps to reduce BPH, also known as benign prostatic hyperplasia, a five dollar term for enlargement of the prostate. There is also good evidence that lycopene can help to reduce the risk of prostate cancer. Gac fruit grows on vines. As Gac fruit matures, it goes from a bright neon green to a lush, deep red. The fruit appears spikey and dangerous, and indeed the outer layer of the fruit (the pericarp) is toxic. But this is not the part that is eaten. Only the squiggley insides of Gac fruit (called the arils), which look strangely like red intestines, are consumed.

One Japanese study reported in the International Journal of Oncology suggested that Gac fruit may be a cancer-fighter. In this lab study, a water extract of the fruit inhibited the growth of certain tumor cells. This does not mean that Gac fruit is a cancer cure, but it almost surely will help to reduce the risk of some types of cancer. No doubt more science on the anti-cancer properties of Gac fruit will be conducted over time.
Because of its unusually high concentration of beta-carotene, Gac fruit is a valuable aid in preventing or treating vitamin A deficiency. One study of children conducted in Vietnam measured blood plasma levels of vitamin A before and after the consumption of a Gac fruit extract. The study showed that vitamin A levels increased with supplementation. In many developing countries, vitamin A deficiency is epidemic. Such deficiency can cause poor night vision, blindness, reduced ability to fight infections, higher rates of maternal mortality, poor embryonic growth, and reduced lactation. Supplementation with Gac fruit extract can alleviate chronic vitamin A deficiency, and help to reduce these health problems.

You are not likely to encounter a stack of cantaloupe-sized Gac fruits in your local supermarket any time soon. Likewise, you will not readily find Gac juice in the cold case at your corner store. But you will see this ingredient show up in more supplements, as health experts embrace the nutritious and healing virtues of this exotic fruit.

Answers about what I think about Richard Samuel's (Jodi Arias)

Since I am a pediatrician friends and family seem to think I have the answers to everything, yet I do not always. But, they know if they ask me about a topic I will research the topic and give them my honest opinion. Some then agree with me and some do not.

I was asked by several people what I thought of the defenses expert in the Jodi Arias trial. Yes, I have watch as much of the trial as I possible could, but I admit I have not followed it as intensely as I followed the Casey Anthony trial.  

But here is my take on Richard Samuel's. But, first let me explain his areas of expertise: 

First of all Richard Samuel's is a psychologist and not a psychiatrist (meaning he does not have a MD following his name). He can not prescribe medications for patients.

 A psychologist performs research and therapy on the mind. There are a number of specialists in this profession, ranging from clinical therapists to sports counselors, but almost all focus on practice, research, teaching, or a combination of all three. Though people often confuse the two, psychologists and psychiatrists are very different.

Specializations

  Psychologists have three main areas of focus: practice, research, and teaching. Most are trained in at least the first two, though they may emphasize one area more than the other in their work. Practice is the interaction with patients, and includes things like diagnosing conditions and creating treatment plans that often include counseling or cognitive behavioral therapy. Research consists of performing experiments and gathering information about why people or animals have certain behaviors and think the way they do, and generally includes things like interviews, experiments both in labs and in other settings, surveys, and studies on the physical aspects of how the brain works. In addition to these two focal areas, many people in this field also teach at the university level.

Training

The training to become a psychologist varies slightly based on specialization, but almost all have to have either a Doctor of Philosophy (PhD) in psychology or a related field or a Doctor of Psychology (PsyD). After getting the doctorate, a person usually has to complete a one to two year internship and get a few years of professional experience or residency before he or she can apply for licensure. Most people also get board certification in their area of specialization, though it's usually not required to practice. Those who work in schools or with children usually need special certification and licensure, and their training is more focused on education and childhood development.

As Compared to Psychiatrists

The main difference between psychiatrists and psychologists is their underlying focus. While psychiatrists are licensed doctors and have a medical focus, psychologists work with more non-medical means of treatment, like therapy and cognitive testing. Also, psychiatrists can prescribe medicine, while psychologists usually can't, though there are a few exceptions in certain regions. The type of training needed for each is slightly different as well: psychiatrists have to get a Doctor of Medicine (MD) degree, and then complete four or five years of residency training before they can become licensed to practice.

"Here is my take on Richard Samuel's assessment of Jodi Arias" 

(1  Was it really only an assessment of Arias and the findings and diagnosis there of? I think not.Thus being his job inside the jail is to assess inmates by interviewing them and rendering a bias diagnosis. I would say Samuel's should have only visited Arias no more than 3 or 4 times and then reported back his findings of said inmate (thus remaining bias).His ethics were already questionable from his bartering with the dentist as trade of services. I believe this is why Richard Samuel's moved to Arizona from I believe it was New Jersey. His ethics were already questionable and he paid a fine and had to take classes, although he lied and down played the incident as (having to read a book). 

( 2 Prosecutor Juan Martinez has been right to question Richard Samuel's evaluation of Jodi Arias and his ethics in how long he saw her (Why so many visits?) Then Richard Samuel's motives for purchasing a self help book for Arias. Should Samuel's had been the treating doctor then and only then could had referred Arias to the book, but not purchased the book for her.You can most certainly be helpful to someone, yet not show bias. If Samuel's referred this book to everyone (mother/brother) as Samuel's so stated that he did why did he not purchase (mother/ brothers) books also? But, I never heard him say that he purchased their books. Not only did Samuel's purchase a book, but also greeting cards for Arias. Bias? I think not. 

( 3. Then we come to Arias' DSM test for PTSD why are there 3 scores and only 1 test administered? Then the test was administered on the story (Lie) of the 2 Ninja's dressed all in black. I feel that Samuel's ethics came in question yet again with the 3 different scores. I have actually done my research and the DSM scoring is (simple) addition. How could someone make so many mistakes on simply adding numbers together?  Only my opinion, but I do not believe that Samuel's was at all bias and I also feel he had a underlying agenda. 

( 4. I think if it comes down to Samuel's (So Called) expert testimony to get Arias off that she will have a needle in her arm in a few years. I do not feel that Samuel's has conducted himself with professionalism.

This Bloggers Note: "Hurry Up And Get This Trial Over With" 

(Q&A) About Asthma

I have asthma. Does this mean my child will have it too?

There is definitely a genetic component to asthma, but how big a role genes play is unclear. While there isn't a specific asthma gene, it is more likely that your child will inherit the tendency to develop asthma.
Why does asthma seem to come and go? Asthma is inflammatory in nature, and there are certain things (triggers) that can cause a flare up.
I don't like the thought of my child being on daily medication. I also worry about the medication losing its effectiveness, and then not working when we really need it to.  Can't he just have meds when he's having symptoms? Regular use of preventative medications is the best way to calm and prevent flare-ups. If everybody with asthma used the proper medications, the number of hospitalizations and deaths would decrease. Remember, preventative asthma medications are only helpful when used before symptoms begin.  Remember, sun block only works if you put it on before the sunburn actually occurs.
Will my child outgrow asthma? Many children will eventually outgrow the propensity to have asthma flare-ups as their lungs mature and their bodies get bigger.  Even then, children who get better with age have a recurrence in adulthood. There is no cure for asthma, although it can be managed and controlled with medication.  The bottom line is that the factors which make a lung asthma-prone can still be present as an adult but the likelihood of flare-ups go down as the lung matures and grows physically larger.
Can food allergies cause asthma? While asthma is more common in children with food allergies, the presence of food allergies do not guarantee a child will have asthma.
Can the use of asthma medications prevent remodeling changes in the lungs? Unfortunately the answer is probably not.  More research is needed, but it appears that remodeling changes in the lungs cannot be stopped by diligent use of preventative medications such as corticosteroids - much of this is genetically predetermined.  However, responsible use of asthma medications can decrease the number of bad wheezing episodes and significantly improve the overall quality of life.  How much remodeling matters to overall asthma issues is unclear but we do know that in most children symptoms will improve as they get older.
What is the difference between Albuterol and Xopenex? Scientifically speaking, Xopenex is just the R-enantiomer of Albuterol, while Albuterol is both a R-enantiomer and S-enantiomer 50:50 mixture.  Practically speaking either medication works as a rescue medication and both are very safe.  Xopenex produces less tachycardia (fast heart rate), however the difference is likely modest.  In children with severe heart conditions it may be necessary to use Xopenex, but for most children either is fine and cost-effectiveness should guide which version of the medication to use.

Conundrum of cause

According to a 2010 National Health Interview Survey by the Centers for Disease Control, more than 10 million U.S. children aged 17 years and under have ever been diagnosed with asthma, and 7 million still have it.
The study shows that boys were more likely than girls to become diagnosed with asthma.
Furthermore, asthma cases in children under 4-years-old increased by 160 percent between 1980 and 1994. And there's been a steady increase in the nearly two decades since then.
An analysis by the U.S. Agency for Healthcare Research and Quality states that the percentage of children who use prescription medications for asthma has nearly doubled from 29 percent in 1997 to 58 percent in 2007.
While that could simply mean we're better at diagnosing asthma and have access to better medications, it's still easy to see why asthma is considered the leading chronic illness in kids.
But we don't really know why.
There is definitely a genetic component to asthma.  How big a role genes play isn't clear, nor is it obvious whether or not the environment is a factor – and if so, to what extent.
The "hygiene hypothesis," says that early exposure to the dirtiness of life helps prevent asthma.  If your child isn't exposed to dirt, other kids, and cold viruses early on, it leads to an imbalance in the immune system that in turn increases the risk of developing asthma.
One real-life example of this is the fact that country boys have less asthma and allergy issues than city boys.  They grow up around animals and are exposed early on to lots of thing, thus the immune system is more balanced and less prone to asthma and allergies later on.  However, keep in mind that even country boys get asthma, just less so than city boys.  It seems that early exposure to “life” reduces the risk of asthma - but doesn't entirely prevent it.
That's because the overall likelihood of developing asthma is multi-variable:  Environment, genetics, number of early colds, allergies, and other factors all play a part.  Sometimes the genetics are too strong to overcome.  But just because asthma runs in the family does not guarantee your child will develop it, although they do have a higher risk.
Should asthma actually manifest itself, it's important to avoid the triggers that exacerbate it. Therein is the "Catch 22."  Early on, when there is no asthma, let your kids be exposed to stuff and hopefully they will never develop asthma.  Yet should your child eventually get diagnosed with asthma, from that point on you may need to avoid the things that trigger it.
Triggers are things that make asthma worse or can cause an asthma attack – defined as any acute change in symptoms that interrupts your child's normal routine or requires medical intervention.

Triggers
Exercise:  The majority of children with asthma will present symptoms when they exercise such as coughing and wheezing.
Pollen:  This is a common allergen.  Most children with asthma have allergies, and allergies are a major trigger of asthma symptoms.
Animals with fur or hair:  Keep pets out of your child's bedroom, remove carpeting, and install a HEPA filter.
Mold:  Control indoor humidity.  Repair water leaks no matter how small.
Dust mites:  These critters live in mattresses, pillows, upholstered furniture, and carpets.  Get allergy-proof bedding and pillowcases.  Frequently wash bedding in hot water.  Avoid stuffed toys.  Vacuum and dust often.
Weather changes:  When air quality is poor, keep your children indoors and make sure they are compliant with asthma medications.
Airborne chemicals or dusts:  Try to avoid things like scented candles and air fresheners.
Menstrual cycles:  Monthly hormone fluctuations can trigger symptoms.  Make sure your daughter is compliant with asthma medications.
Viral infection:  Symptoms may flare with a cold.
Smoke:  Avoid tobacco and wood burning.

While parents do their best to make sure the home environment is asthma friendly, don't forget to check daycares, school and relatives' homes. Some triggers can't be avoided, which is why it's important to make sure your child is compliant with his or her medication regime.
That being said, there is no guarantee that an asthma outbreak or attack can be foiled by regular preventative medicine.
There are many different strengths of preventative medicine, and these are tailored-based on the severity of the asthma.  The hope is that as kids get older, they outgrow their propensity to have asthma flare-ups and can eventually be weaned off medications.
Nearly half of children will have a decrease in asthma symptoms by the time they hit adolescence, but about half of those will develop symptoms again when they're adults.
So even though asthma cannot be cured, both you and your child can breathe easier knowing that it can be controlled – and that even after a diagnosis of asthma, he can get back to the business of being a kid.


Tenets of treatment

Inhaled medications are the mainstay of therapy, and are delivered two different ways. The first is a nebulizer, which is a machine that emits humidified air combined with medication. The child inhales the air through a mask.
The other way to receive inhaled medication is through "Metered Dose Inhalers." MDIs are the puffers that most people are familiar with. Medication is sprayed directly into the mouth, but a contraption called a "spacer" helps make sure the medication goes directly into the lungs. Using an MDI without a spacer leads to half of the medication missing its mark – a waste of money that also comes with the risk of under medicating.  In general, MDIs (as opposed to nebulizers) are cheaper, more portable, and quicker and are therefore becoming the modality of choice in pediatrics.
So what's in the medication? The two most common groups of meds are preventative medications of which corticosteroids are the mainstay and rescue medications of which albuterol is the mainstay.
Inhaled corticosteroids are used on a daily basis, whether the child has symptoms or not, to prevent future episodes of wheezing. Think of it as sunblock for the lungs. The child puts it on every day to prevent future troubles.
Beta-agonists are the Aloe vera that soothes the sunburn once it happens. Albuterol is the most commonly used beta-agonist. It works by relaxing the muscles of the airways in the lungs, helping them open to let more air through. The effects of Albuterol are short lived. It needs to be given again and again, usually every four hours, until symptoms subside. The Albuterol, or aloe Vera, makes one feel better after the burn, but does not prevent future episodes. Only sunblock, or inhaled corticosteroids, can do that.

Some parents get freaked out by the word "steroids," picturing pumped-up athletes risking illegal consumption just to make their muscles bigger. Rest assured that corticosteroids are not the same thing. Corticosteroids are similar to steroids that already occur naturally in the body.
That being said, corticosteroids can affect your child's height by causing temporary growth delay. But if that’s the case, it's very minimal, and should resolve through catch-up growth once the medication is stopped. It will not prevent your child from reaching his or her genetic potential in height. And, keep in mind that the side effects of corticosteroids are considerably less serious than the side effects of poorly-controlled asthma – which includes stunted growth overall, even death.


Diagnosis is in the details

Asthma is a disease that is diagnosed by history.  In other words, one cannot make a diagnosis of asthma the very first time a child wheezes.  It's like your friend who show up late to your home for dinner; it would be premature to label them "tardy" after one episode, but if they come late multiple dinners in a row, they are likely "tardy" friends.  With every subsequent wheezing episode, the more likely these are not one time events but a sign that there is underlying asthma.
If asthma is suspected, your child may be referred to a lung specialist for a series of pulmonary function tests - this is typically needed in the more severe cases while the milder cases can be handled by an experienced pediatrician.   Not only will this confirm the diagnosis, it will help define the severity of the disease.
These tests are designed to measure lung volume and respiratory muscle function, but must be performed correctly in order to be accurate. It's not very easy to measure lung function in small children, which is why pediatricians rely heavily on history. The more episodes of wheezing and shortness of breath a child experiences, the more likely the child is asthmatic.
Another way to diagnose asthma is to start children on asthma medications and see if they respond. If they respond positively, meaning they experience an easing of symptoms, they probably have asthma. If the medication does not help, the wheezing and coughing is probably secondary to a cold virus.
The diagnosis of asthma can be tricky, and while there are tools to help, it requires the combination of history, tests, and serial exams to be as precise as possible.


Asthma: A Pedi Perspective

It's difficult to diagnose, can attack without warning, and unfortunately we don't know exactly what causes it.

It's said to be the most common chronic medical problem in children, fortunately it's manageable with medication.
Asthma is a lung disease that causes inflammation and narrowing of the airways, making it hard to breathe.
While it affects people of all ages, it most often starts in childhood. According to the American Academy of Pediatrics, between 80 to 90 percent of people with asthma develop symptoms by the age of 4 or 5.
Parents tend to worry at the first sign of a cough or wheeze, but in reality, a one-time episode is not indicative of asthma. That would be like labeling a friend of yours "tardy" just because she showed up late one time.
Further coloring the diagnosis of asthma in shades of gray is that children with asthma can present with different symptoms at different times.


When to wonder?

The most common symptoms of asthma are coughing, wheezing, chest tightness, shortness of breath and difficulty breathing.
Coughing is a protective mechanism designed to move mucus through the respiratory track. In a child with or without asthma, coughing can be worse at night because during the day gravity and activity helps mucus drain and clear from the airways; however at night, laying horizontal and the lack of movement allows mucus to pool in the airways thus increasing the coughing bouts.
Coughs caused by a virus can last anywhere from two to six weeks or sometimes even longer, but chronic coughing - coughing for more than eight weeks - should be brought to the attention of a doctor.  Although asthma can present with just coughing, an experienced doctor can help distinguish between a cough caused by a cold virus (or other germs) versus a cough secondary to asthma.  It should be noted however that in a child with asthma, cough is often initiated by a cold virus and exacerbated by the underlying asthma producing a mixed picture, hence it may take a few visits to delineate whether asthma is a true player or not.
Often the easiest way to differentiate the two is a trial run of asthma medications to see if there is a response to the medications or not. If there is a response, the good news is there is something you can do for the cough. The bad news is your child may have asthma. If there is no response to the medicine, the good news is your child is unlikely to have asthma. The bad news is there's not much you can do about the cough.  Keep in mind that in children with asthma, there is usually a mixed picture of a cold virus triggering asthma symptoms; in other words the asthma medications will help control the asthma but not the symptoms brought on by the cold virus itself, so a positive response may not be a complete response.
Although asthma can present with just coughing, a child with true asthma will typically have a chronic cough combined with wheezing.  However, note that what most moms call wheezing and what most doctors call wheezing often differ.  There are many sound-a-likes to wheezing that can be best distinguished by an experienced clinician.
Wheezing occurs when the muscles in the airway tense up or clamp down due to inflammation. The result is decreased diameter in the airways, making it more difficult to move air. Just like you make a whistling sound when you purse your lips and breathe, the airways also make a wheezing sound when the diameter is narrowed.
Just as a chronic cough on its own does not mean your child has asthma, a wheezing episode alone is not necessarily indicative of it either, since both of these things can happen in response to a bad cold. A cold virus may cause just enough inflammation in the lungs to cause a one-time wheezing episode.
That being said, kids with asthma will not only wheeze chronically but their lungs will actually show changes that can be seen under a microscope. This is called "remodeling."
Airway remodeling is a response to long-term airway inflammation that can lead to permanent structural changes.
Asthma is more likely to manifest itself in long-term changes if it shows up before age 3, with the child displaying obvious symptoms of these changes by age 6.  Asthma that starts after age 6 is less likely to become a long-term problem.
Flu Vaccine Update 2013

How is the flu vaccine formulated?
Flu viruses are always changing. Each year, experts study thousands of flu virus samples from around the world to figure out which viruses are making people sick and how these viruses are changing. With this information, they forecast which three viruses are most likely to make the most people sick during the next flu season. These strains are then used to make the flu vaccine for the next flu season.

On February 23, 2012 the WHO recommended that the Northern Hemisphere’s 2012-2013 seasonal influenza vaccine be made from the following three vaccine viruses:

*an A/California/7/2009 (H1N1)pdm09-like virus
*an A/Victoria/361/2011 (H3N2)-like virus
*a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses)

While the H1N1 virus used to make the 2012-2013 flu vaccine is the same virus that was included in the 2011-2012 vaccine, the recommended influenza H3N2 and B vaccine viruses are different from those in the 2011-2012 influenza vaccine for the Northern Hemisphere.


When to get vaccinated?
Yearly flu vaccination should begin in September or as soon as the vaccine is available and continue throughout the influenza season, as late as March or beyond. The timing and duration of influenza seasons vary.

While influenza outbreaks can happen as early as October, most of the time influenza activity peaks in February or later. About 2 weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body.


How many shots will my child need?
This year's seasonal flu vaccine will again include the Novel 2009 H1N1 vaccine which was used during the global pandemic and which was also included in the 2010-2011 and 2011-2012 seasonal flu vaccines. This means your child will only need to get vaccinated with ONE TYPE of flu immunization this year.

If your child is 9 years or older, regardless of what flu immunizations have been given in the past, they will only need ONE immunization this flu season.

However, if your child is under 9 years of age, they may need TWO immunizations this year. See the chart below to assist you in knowing how many shots your child will need this flu season.


Please note that the decision tree sponsored by the CDC (Centers for Disease Control) and ACIP (Advisory Committee on Immunization Practices) are slightly different this year. Our office has decided to use the ACIP decision tree as it is more conservative.

If your child needs 2 flu vaccines this year, they should be spaced apart by a minimum of 4 weeks (28 days). There is no deadline by which the 2nd flu vaccine needs to be completed, but once the minimum 4 weeks has passed, the sooner the better as your child will have optimal protection only after the 2nd immunization.

0 flu shots since July 2011 1 flu shot since July 2011 2 flu shots since July 2011
Under 9 years of age 2 flu shots needed 2 flu shots needed 1 flu shot needed
9 years of age or older 1 flu shot needed 1 flu shot needed 1 flu shot needed


If your child is under 6 months of age, they are too young to receive the flu vaccine.  It is imperative then for all surrounding family members (and caretakers) to receive the flu vaccine as soon as possible to create herd immunity.  Essentially, if everyone surrounding the infant is protected, it decreases the risk that the baby will be exposed to the live flu virus.


Will a quadrivalent vaccine be available for the 2012-2013 season?
Traditionally, the flu vaccine covers 3 different strands of the flu virus and is labeled a trivalent vaccine.  Starting next year some pharmaceutical companies will produce a flu vaccine that will be expanded to include 4 different strands of the flu virus thus adding 33% more protection.

Flu vaccine for the US market is produced and distributed by the private sector. While some manufacturers are planning to produce a quadrivalent (four component) vaccine in the future, quadrivalent vaccine is not expected to be available for the 2012-2013 season.

What Does Your Smile Say About You?

Want to succeed in business, fill up your social calendar, and get more romance into your life? One secret may be in your smile.

Your smile -- simple, straightforward, and most important, sincere -- can attract more than admiring looks. A smiling face tells people that you’re an outgoing and intelligent person worth getting to know.

When someone has a big smile, it shows they’re willing to open up and expose a part of themselves," says Pamela McClain, DDS, president of the American Academy of Periodontology. Over the long term, smiling can benefit your health, perception at work, social life, and romantic status.  With that much at stake, it's worthwhile to discover what your smile is saying about you -- and how to interpret the smiles flashed your way.

Smiling Eyes Aren't Just for the Irish

Many Americans look at the mouth to judge a person’s mood, but people smile for all sorts of reasons: anger, fear, embarrassment, confusion, to deceive. It’s really your eyes that give you away.

The muscles around the eyes can’t be forced to look happy. When people smile for real, their cheeks rise and the skin around their eyes bunches up. In fact, in certain countries where suppressing emotion is a cultural norm, people look more at each other’s eyes to gauge emotion.

A Smile Makes You Look Successful

"A smile conveys confidence and professionalism," says Lily T. Garcia, DDS, DDS, MS, FACP, president of the American College of Prosthodontists. People who project a positive outlook are generally more open and flexible. They tend to cope better with challenges than people who are withdrawn and unsmiling.
A study that followed a group of women for 30 years shows the lifetime benefits of smiling. The women who displayed genuinely happy smiles in their college yearbook photos went on to have happier marriages and greater well being.

In the same study, a group of strangers looked at the college photos and reported their assumptions about the women’s personalities. The women who smiled were judged to be more positive and competent than those who didn't.

Turn that Frown Upside Down

Want to be happy? Just smile.

Believe it or not, forcing yourself to smile can actually make you happier.
Paul Ekman, PhD, a psychologist who is an expert in facial expressions, taught himself to arrange the muscles in his face to make certain expressions. To his surprise, he found himself feeling the emotions that he was mimicking. When he raised his cheeks, parted his lips, and turned the corners of his mouth up, he felt happier.

Ekman and his research partner went on to do a study of college students to see if they, too, would feel happier by making themselves smile. The researchers measured the students’ brain activity while the students followed instructions to smile using the muscles in their cheeks and around their mouths.
Whether the students smiled spontaneously or on purpose, the activity in their brains was virtually the same. They felt happy.

Smile Anxiety

Chipped or missing teeth, fillings, or discolored teeth are unveiled when your lips part to smile – so some people simply avoid it.

If you find yourself wanting to cover up your smile, you could be holding yourself back in more ways than you realize. "Life is much more challenging for people who are so self-conscious about their teeth they don’t want to smile," McClain says. Make a date with your dentist to talk about your concerns and potential corrections. Many dental problems can be fixed.


One of McClain’s patients with excess gum tissue was ashamed of her short-looking teeth. "We did a procedure called crown lengthening, and it was amazing what a difference it made,” McClain says. “She was so much more self-confident."

100 things to do before you die.

1)  ride: in a hot air balloon

2)  see: Grand Canyon, Arizona
3)  Make a difference in someone's life
4)  see: Great Barrier Reef
5)  go: on a helicopter ride
6)  go: whale-watching
7)  go: on safari
8)  Travel to the seven continents
9)  do: scuba diving
10) Swim with dolphins
11) Sleep under the stars
12) see: Northern Lights (Aurora Borealis)
13) do: sky diving
14) Raise a happy and healthy child
15) see: Broadway play (New York)
16) do: white water rafting
17) see: Seven New Wonders of the World
18) do: canoeing or kayaking
19) Shower in a waterfall.
20) see: Mona Lisa at the Louvre
21) see: Mardi Gras, New Orleans
22) Create a loving and happy home
23) see: Great Wall of China
24) learn: a foreign language (or 2 or more!)
25) Travel: Italy
26) visit: all 50 of the United States
27) ride: on an elephant
28) see: Stonehenge
29) see: New Years Eve at Times Square (New York)
30) visit: Machu Picchu, Peru.
31) Get married
32) see: Olympic Games (summer)
33) Travel: Australia
34) see: Yellowstone National Park
35) Maintain my ideal weight
36) do: a bungee jump
37) ride: a camel
38) see: Sistine Chapel
39) Find the love of my life
40) see: Amazon Rainforest
41) Travel: France
42) see: Great Sphinx of Giza
43) donate: blood
44) go: camping
45) see: Iceberg
46) Experience weightlessness
47) Sleep in a castle
48) Travel: Greece
49) see: Louvre Museum (Grand Louvre)
50) visit: Rio de Janeiro, Brazil.
51) go: paragliding
52) get: a university degree
53) do: Adopt a pet from an animal shelter
54) see: Victoria Falls
55) ride: London Eye (Millennium Wheel)
56) do: paint balling
57) get: a tattoo
58) see: Smithsonian Institution, Washington, D.C.
59) climb: a mountain
60) ride: a jet-ski
61) cruise: Antarctica
62) Travel: Around the World Trip
63) see: Mount Everest
64) go: on a 2nd honeymoon (or 1st, 3rd...)
65) Travel: Germany
66) Write and publish a book
67) visit: Jerusalem Old City, Israel.
68) see: Times Square at Night, New York
69) ride: a mechanical bull
70) see: Rock Concert
71) see: Egyptian Museum
72) see: Super Bowl.
73) see: Westminster Abbey
74) Have a child
75) see: Oktoberfest in Munich
76) do: Volunteer at a Homeless Shelter
77) see: gorillas in the wild
78) Travel: United States
79) become: a millionaire
80) drive: a race car
81) ride: in a Cable Car
82) see: Van Gogh Museum (Amsterdam)
83) see: Turtles hatch and run for the ocean
84) see: Volcanoes National Park, Hawaii
85) cruise: Amazon River
86) ride: a Roller Coaster
87) cruise: Caribbean
88) Travel: Egypt
89) Build a snowman
90) see: Carnival in Rio de Janeiro
91) Practice meditation
92) do: rock climbing
93) Kiss the Blarney Stone
94) ride: a Motorcycle
95) climb: the Statue of Liberty
96) Travel: United Kingdom
97) see: Saint Paul's Cathedral
98) Start my Own Business
99) my home: has a pool
100) see: Solar eclipse

My Birthday Was Great Thanks Everyone

My Birthday Cookie my Aunt Cathy Always sends I Love Them

I want to thank all my wonderful friends that have either been sending comments to my facebook pages or bringing me gifts to work, though UPS and the postal service. I have so many gifts and cards that I either need to lay them out on the table or bed and take a pic of all them at once. 

Let me start by saying that I love and appreciate everyone for such kindness. All I ever need is your friendship and love, but I am thankful for all you do. You amaze me with your kindness and friendship. There is no way I could ever repay such kindness for all I receive. Here are a few pictures to show off your kindness. 

Another Watch everyone ask about my big pink watch it measures heart rate even how long I worked out and so much more. From My daddy

Yellow Roses and a beautiful beautiful birthday weekend from Blake so beautiful I love them .

Beautiful Flowers and Card from Dylan & Dawson & I appreciate the lady at the florist helping them make a pic/card for them to send me.Love them 

This gift was sent to me by Haley and Maddie I can sure use these I love them

A beautiful Cards and earrings I received at work from Stacy I love them Stacy

Secret Garden products From Jean at work thank you so much

Night light and candles from the office staff thanks everyone .

Different gifts from the hospital staff thanks everyone 

Purses from my secret admirer ;) Thank you 

Stationary and place mats from Aunt Cathy I Love 

You!

Chocolate from Andrea Lawson Thank you. 

Jewelry from Sue Thomas Thank you so much 

Odds and ends from Carol Kennedy I love them ->

From the hospital nursing staff two purses a wallet  purse, ballet jewelry holder, stationary and pen and a quilt. Thanks I love everything. 

Gown from Tina Holloway Thank you so much I love it

Many other presents by Blake I love them baby 

 From Uncle Doug & Family I love it 

From Michelle Paris Aww I love it g/f 

  

Different presents from colleagues thanks everyone 

From Granny I love you so much thank you granny

I am so blessed you have friends and family like you thanks for making my day special. I love and appreciate everything so very much. God bless you all. 

Thanks for all my cards