Allergies and Other Topics
The most common allergens are foods (nuts, milk, soy, egg, shellfish), seasonal environmental factors (pollen, trees, grasses), dust, pet dander and saliva, and medicines. Allergens cause histamine release resulting in flushing of the skin, eyes and nose. In the skin, this results in hives: raised areas surrounded by reddened skin that frequently itches. Hives can be treated with over-the-counter products: diphenhydramine (Benadryl) and oral antihistamines including cetirizine (Zyrtec) and loratadine (Claritin). Bathing with colloidal oatmeal soap and applying topical calamine, Benadryl and/or hydrocortisone can also help. In the nose and eyes, histamine causes swelling, redness, clear runny discharge and itch. Nasal sprays and eye drops can be used in addition to oral antihistamines if needed to control symptoms.
Food allergies require avoidance of the food. Testing and consultation with an allergist is often helpful to properly identify the food so that it can be avoided. It is important is the identity related foods that should be avoided or ingested with caution and those that are safe to consume. Environmental allergies do not have to be treated if they are mild and do not cause distress. Therefore, identification of the specific cause is not always relevant. Treatment for seasonal allergies is generally limited to the allergy season. Pollen, grass and tree allergies are worse in the Spring and Fall. Dust allergy can be controlled by reducing dust-trapping surfaces like carpets and drapes. Hard flooring surfaces are best. Floor coverings should be frequently vacuumed using a HEPA filtering vacuum. Pillows and blankets should be covered with allergen covers (generally plastic or tightly woven fibers) and bedding should be washed frequently. If pets are the culprit, they should initially be kept out of the allergy sufferer’s room.
A serious allergic reaction involving multiple organ systems is called anaphylaxis. The skin and respiratory, gastrointestinal, and nervous systems may all be involved. Symptoms include at least two of the following: hives, wheezing, shortness of breath, significant sudden vomiting and diarrhea, confusion, and reduced alertness levels. Anaphylaxis generally occurs within fifteen minutes of exposure and rarely occurs later than two hours after an exposure. Even if symptoms seem mild, anaphylaxis should be taken seriously, as it can become life-threatening.
The general rule is that reactions that only cause hives will only result in hives with future exposure and allergens that cause anaphylaxis the first time will always cause anaphylaxis. The important exception to this rule is peanut. Peanut ingestion may initially cause hives but with subsequent exposure result in anaphylaxis. For this reason, anyone with a peanut allergy should carry epinephrine, even if their reaction has never caused anaphylaxis.
Epinephrine is unstable in very hot and cold temperatures, so this medicine should never be left in car glove compartments and other areas subject to marked temperature shifts. If anaphylaxis occurs, administer epinephrine if it is available and call emergency services (9-1-1). If epinephrine is not available, immediately call 9-1-1. Repeat doses of epinephrine may be needed in anaphylaxis, so anyone needing epinephrine should be observed in an emergency setting for at least four hours.
For most people, eczema is dry, scaly skin. It is generally worse in winter months since both cold air and home heating methods can cause dry air. Patients with eczema triggered by environmental allergies may have flares in their allergy seasons. Treatment of eczema entails increased hydration and moisturization and humidifying the air when needed. Frequent baths with gentle soaps help hydrate while not irritating.
There are two thoughts regarding whether more or less frequent bathing helps. Generally daily bathing, with the addition of a Baby or mineral oil to the water, greatly helps most people. Make sure to add the oil toward the end of the bath, after the child has gotten hydrated. The oil will lay on the water surface and coat the skin as the child exits the bath. Don’t add the oil before the child gets in. Doing so will coat the skin on entry and prevent hydration. Dry wet skin by blotting, not by rubbing, to reduce inflammation. Apply fragrance-free moisturizer after the bath and frequently throughout the day as needed. Moisturizers may need to be applied as often as four times a day. Since rubbing anything on dry skin, even a moisturizer, can sting, one trick is to wet affected skin mildly before applying moisturizer.
Eczema can also become inflamed or infected. Inflamed eczema will look like red, thickened skin that is more intensely itchy and is occasionally painful. Inflamed eczema should be treated as above but may also require topical steroids. When it comes to topical steroids, weaker is better, since too potent a steroid applied too often or for too long can cause thinning of that skin and change its color. The weakest steroid is hydrocortisone 1%, available over the counter. Steroids should be used only for inflamed eczema, and for the shortest duration necessary to reduce the inflammation, generally twice a day for less than two weeks.
Eczema of the hands is very common in the winter. Dry air coupled with washing hands in water and not drying well is the cause. To prevent hand eczema, thoroughly dry wet hands, or avoid water by using sanitizer (with aloe or a moisturizer added is best). To speed healing, add a thick moisturizer (petroleum jelly or lanolin) at night and cover the hands in cotton gloves when sleeping (in addition to frequent daytime moisturizer use).
Diaper rashes are very common. Urine and stool acids can break down the skin and cause erosion that may bleed and cause pain. Irritant diaper rashes generally affect only the skin covered by the diaper. Treatment with a zinc-containing product will treat the rash. If babies are prone to diaper rashes, once the skin is healed, barriers (petroleum jelly, lanolin and Aquaphor) can be applied to insulate the skin from acid exposure.
Yeast or fungal infections are also common in infants. These rashes are identified by their intense red color and the presence of “satellite” spots, red bumps that spread away from the irritated skin. These rashes are treated with over-the-counter creams (clotrimazole and mycostatin), which are applied twice a day until the rash resolves and then for three additional days. At all other diaper changes, apply a zinc containing product.
Diaper rashes can also be due to bacterial infections, though this is less common than the other types. A bacterial diaper rash with cause multiple erosive areas that bleed, usually with the skin between them appearing to be normal. Apply topical antibiotic cream or ointment four times a day.
Babies as young as four months of age can be spoon-fed foods, although food is not necessary for growth until six months. There are two feeding rules to follow.
The first rule is to ensure the food is the right texture. First foods should be very thin purees, which can be thickened as tolerated. Teeth most commonly break through the gums between six and nine months of age. Teeth enable infants to mash firmer foods. Around nine months of age, infants can finger feed. Great finger foods include small pieces of fruit and softened vegetables, cheerios and puffs. Toddlers begin to (messily) use utensils at around fifteen months and can handle some bigger and firmer foods, such as chunky peanut butter and pieces of grapes. Large, round and hard foods, such as whole nuts and grapes, continue to pose choking risks until age two and should not be given until then.
The second rule is to limit the frequency at which new foods are offered. Breast milk or formula can also be offered at mealtime, but should be offered after the food. A baby may consume a few ounces at a time. Only one new food should be introduced per week at this age. Eating solids will result in your baby drinking less. Babies who are offered food at four months of age should be offered one to two feedings a day. Only one new food should be offered per week. At six months of age, two to three feedings per day can be offered and new foods can be introduced every three days. At nine months, babies may eat three large meals a day. New foods no longer need to be separated at this age.
What to feed a baby is a common question. It is easier to answer what not to feed a baby. Babies under one year should not drink milk or consume raw honey. Introducing milk before one year can cause the baby to develop food allergies. This is not the case with other dairy products, such as cheese and yogurt, which can be given in the first year. Raw honey can contain botulism spores which can paralyze an infant. Baked or cooked honey that is in other food is safe to give your baby after six months. New data supports the introduction of peanut to infants by six months of age in order to prevent peanut allergy. Peanut powder or creamy peanut butter can be mixed with breast milk, formula or water to get the proper texture. Other common allergenic foods can be introduced at any time, but can be delayed if there is a strong family history of allergy to those foods. Although many people follow the traditional path of starting with cereals and then move on to vegetables before fruits, any order is acceptable provided these two rules are followed.
Asthma refers to the reversible narrowing of the lower airway, from to muscle constriction and inflammation caused by triggers, most commonly viral infections, weather changes, allergies and exercise.
Symptoms of asthma include wheezing, shortness of breath, chest tightness and nighttime cough. Acute symptoms and signs are reversible with bronchodilator (rescue) medication. Frequent symptoms indicate poorly controlled asthma and require daily preventative medications (controllers).
Bug Spray and Sunscreens:
Bug sprays are approved for use on those aged six months and older. The most common options are lemon/eucalyptus oils, picaridin and DEET. The American Academy of Pediatrics recommends only using products with a maximum of 10% picaridin or 30% DEET. Products can be applied directly to skin or clothing. Treated skin should be washed once indoors and treated clothing removed and washed before re-wearing.
Sunscreen can be used for infants six months old and older. Use products with SPF ratings of 30 or more that protect against UVA and UVB rays.
There are two categories of sunscreen - barriers and chemicals. Barriers (zinc oxide and titanium dioxide) coat the skin and limit penetration of the sun's rays. Barriers are not absorbed by the skin and are considered the safer choice. Chemical sunscreens, on the other hand, are absorbed by the skin. Many companies sell products that are barrier-only, chemical-only and combination products. We recommend barrier products.
Sunscreen should be applied fifteen minutes before sun going into the sun and reapplied every two hours, or sooner on wet skin. Be cautious when using spray sunscreens around the face, as they can irritate the eyes, nose, mouth and airway. Spray sunscreens can also provide uneven protection, so they should be rubbed into the skin after applying.
Fever is a normal response to inflammation and infection. It is a sign of an underlying process and generally not itself a problem. In general (other than as noted below for infants), notify us if fever is higher than 103, or is lasts more than four days, is associated with pain, respiratory distress or dehydration. In many cases, the non-fever symptoms are the ones that determine the timing and type of evaluation that is needed.
Determining the cause of a fever is often more important that treating the fever. Although viral and bacterial infections can both cause fever of any magnitude, significant bacterial infections are more likely to cause higher fever than viral infections. Notify us if your child has fever above 102F/39C. An evaluation for the source of the fever can be done and, when indicated, antibiotics prescribed to treat bacterial infections. Viral illness can also cause fever, which can persist more than five days before subsiding. Low grade fever (less than 100.4F/38C) does not need to be treated.
Fever in an Infant Under Three Months Old:
Fever is an infant younger than three months of age is approached differently. Since these infants have limited social-developmental skills, it is difficult to differentiate ill from well infants without additional tests. Therefore, we have a lower fever threshold in this age range (100.4F/38C). For infants with a fever over 100.4F/38C, a comprehensive evaluation, possible empiric antibiotic treatment and admission to the hospital may be indicated. Do not treat infants in this age range without first notifying our office.
Acetaminophen (Tylenol) is approved for treatment of fever and pain in infants two months of age and older. It can be given every four hours as needed. Ibuprofen (Motrin, Advil) is approved for infants six months of age and older for pain, fever and swelling, and can be given every six hours as needed. Ibuprofen is preferred over acetaminophen for higher fever (102F, 39C), injury with swelling and for nighttime use, when a longer duration of fever control is helpful. The two products are metabolized by different organ systems and have different adverse effects. Therefore, they can be given together, though that is rarely helpful. However, if one product does not adequately control symptoms until it can be given again, acetaminophen and ibuprofen can be alternated. Specifically, acetaminophen can be given, and ibuprofen given three hours later. After another three hours, acetaminophen could be given again, continuing to alternate as needed. Given this way, each acetaminophen dose is given at least four hours apart and each ibuprofen dose is given at least six hours apart. See our medicine dosing sheet for weight-based dosing suggestions.
Around three percent of children from six months to five years of age may develop a seizure due to a very high (around 104F/40C) or rapidly increasing fever. Only half of infants who have a fever related seizure (febrile seizure) will have a second febrile seizure, and only one-quarter will have a third. In a simple febrile seizure, a child's eyes will roll back, the body will stiffen and then rhythmically contract. After it is over, a child will be drowsy. Although scary, febrile seizures are rarely dangerous. If a febrile seizure occurs, place the child on his/her side, ensure the airway is protected and call emergency services (9-1-1).
It is normal for babies to be hungry at night. They will waken and need to feed. In fact, two-thirds of babies won't sleep six hours at a time until they are one year old. Sleep training is not about expecting babies to sleep through the night. It is about helping babies who too frequently waken out of habit to develop new sleep associations (to replace being fed or rocked by a caregiver) so that they can get more sleep and get themselves back to sleep without parental intervention.
The trick with sleep training is to know when it is appropriate. In other words, to know when the infant is waking because of hunger and when it is a habit (due to caregiver-dependent sleep associations). A hungry infant will have a good feeding (similar duration and/or volume as a day feeding) and return to sleep. A hungry child may waken three or four times at night. If those frequent feedings are good feedings, and the infant returns to sleep easily after the feeding, then sleep training is not indicated. A baby that is waking out of habit will generally have frequent smaller feedings ("snacks") and may not settle back to sleep easily. If these infants are growing well, they do not need these snacks. Sleep training for these infants is appropriate and can be started in infants as young as four months old.
To sleep train, put babies down to sleep when tired but not asleep. If they fall asleep during a feeding, rouse them gently when putting them down, so they are sleepy but not asleep. This way the baby will learn to fall to sleep on its own. If they waken, and you know they are safe, overtired and not hungry, you can let them cry for up to one hour. Many parents are unable to let their infants cry for very long because the parental instinct is to tend to them or because a crying infant may disrupt a sibling's sleep. Letting an over-tired infant cry for a while is not neglect. Letting them cry gives them the chance to successfully return to sleep and create new associations that don't involve the parent. Generally, within a week many of these infants can sleep longer at night, waken for fewer snacks and return to sleep more easily. Infrequently, some infants become more agitated and don't easily settle down. Sleep training may not work as well for these infants.
A normal stooling regimen is one that results in the painless passage of soft stool. A child who passes such stools but only every few days is not constipated. A child who passes wide, distended stools that cause pain and withholding behaviors is constipated, independent of the frequency. Dietary treatment for constipation involves increasing the amount of fiber (fruits and vegetables - especially prunes) in the diet. Juice, which is mostly sugar, can also help, as both fiber and sugar pull water into the colon to soften the forming stool. Increasing water intake will not treat constipation, since water is absorbed out of the intestine and excess water is excreted through the urinary tract. Medications may be needed to treat constipation when diet alone is insufficient.
Many toddlers will be ready to toilet train around age two years. Awareness that they have urinated or stooled is the first step. The second step is awareness of the need to urinate or stool. Toddlers may go to a certain part of the house to do this in private. At this stage, toddlers who have been introduced to the potty and are receptive to it can be successfully toilet trained.
Training involves a lot of positive reinforcement, initially just for sitting on the potty and eventually for successes. Be aware that there are very few things in life that your toddler can control, but toileting is one of them. Just because your toddler can toilet doesn't mean he or she will choose to. Battles over toileting are discouraged. Children may be anxious about toileting, and conflict will only make the anxiety worse. If there is too much anxiety over toileting, it is sometimes best to hold off training for a while.
The schedule for immunizations in childhood is formulated to protect your child from diseases when you child is...