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Friday, June 3, 2016

Post #44 Transitioning Babies to Solid Foods

This is an unedited excerpt from my 2nd book, "What to Know Before Having Your Baby" - coming out in February of 2017.

Because infants begin their life on breast milk, parents often think that milk is essential for their child’s diet even beyond the first year of life.  While milk is absolutely important for the first few months of life, once babies can start eating solids, the value of milk (breast, formula, or cow’s) quickly diminishes.  Milk’s main purpose is for humans (and animals) to provide an easy source of nutrition to their babies until they are ready for solid foods – which offer a far greater diversity of nutrition.

By one year of age, the bulk of a child’s nutrition should be from solid foods – ideally they should be eating a well-balanced diet pulling from all of the food groups.  At a maximum, a one year old should be taking no more than 24 oz of milk or formula, and as long as they are eating a balanced diet, there really is no minimum amount of milk that a one year old needs.  And though milk does offer vitamin D and calcium – you can get plenty of vitamin D from the sun and all the calcium you need from meat, certain vegetables, soy, nuts, beans and other solid foods.

Solid food introduction can begin anywhere between 4 to 6 months of age.   Traditionally, parents in the U.S. start with cereal, move to fruits & vegetables, and add meats as the last food group.  However, many experts now recommend reversing that order as meats are the most nutritious in vitamins and minerals and cereals are mostly filler foods with the least amount of nutrition.  Regardless of the order, by 8 to 9 months of life at the latest, babies should be eating from every food group, and ideally the sooner the better. 

Past concerns about causing food allergies led to a very conservative approach to introducing solid foods. Recommendations were to give only one new food every 3 days and certain foods such as peanuts and eggs were to be avoided until several years of age.  New data has clearly shown that this thinking was incorrect and it is now known that early introduction of foods (particularly highly allergenic foods) is helpful and reduces the risk of food allergies in the future.  Outside of honey, which can cause botulism, all other foods are safe to eat for babies as long as parents are careful of choking hazards. 

As for the “one new food every 3 day rule” – although this rule might help figure out what food caused an allergy by making the process of elimination easier, most kids with true allergies will have to undergo a series of tests if a true food allergy is suspected, thus making this rule unnecessary and a bit overly restrictive.   It is perfectly reasonable and definitely easier to be aggressive and introduce several new foods at a time.

While there is a whole line of baby foods available at the supermarket, feel free to offer bite size portions of soft foods that parents eat for their own meals.  Foods such as pastas, baked potatoes, soft meats, and steamed vegetables are all safe, nutritious, and tasty for babies to consume as soon as they can chew well.  The more flavors children encounter early on, the less picky they will be later!

So go ahead and give them a bite of your dinner – they’re probably eyeing you as you eat it and wondering where their portion is!  As long as you can mash a food between your pointer finger and thumb, even with no teeth, baby’s gums are powerful and can handle it.  The sooner they are eating real foods, the sooner you can cook one meal and make your life easier.  And ultimately if it is nutritious for you, it is nutritious for them.

So how should you incorporate the solid foods into your current feeding schedule?  The truth is there is no singular best way, but here is one method of doing it.  Pick one meal to begin with such as the feeding closest to breakfast time.  Before giving formula or breast milk, start by allowing your baby to eat as much solid food as they will take.  When they will no longer take any more solids, top them off with their normal bottle or breastfeeding until they are full.  Once they seem to have the hang of one meal, add a second around lunchtime, and soon thereafter a third around dinnertime.  It is that simple!

Some simple rules of thumb with feeding:

1.     You are in charge of the quality of food, the child is in charge of the quantity of the food.  They will never shortchange themselves!

2.     Aim for a balanced diet over a week at a time.  Not every day and certainly not ever meal needs to be perfectly balanced.  It all goes to same place!

3.     A child’s growth controls their appetite, not the other way around.  Your kids will grow in spurts controlled by their hormones and appetite will follow accordingly.  Again, they will never shortchange themselves!


Ideally, your child should be eating 3 solid food meals a day covering all of the different food groups by 8 to 9 months of life.  And by one year of age, children should essentially be eating what their parents are eating.  The bottom line is there is a lot of freedom in how to start solids.  Try lots of different foods and have some fun with it!

Thursday, December 10, 2015

Post #43 My Father the Pediatrician


I recently wrote a new book geared to help parents have more meaningful conversations with their pediatrician and which will hopefully save them a copay or two as well!  As I reflect back on the five year journey in writing this book, I wanted to highlight the contributions of my biggest influence – my dad.

In the summer of 1973, my father, thirty years at the time, boarded a plane with his best friend to fly overseas for the very first time in his life.  Having recently finished medical school and his mandatory army training in South Korea, he was headed to the United States to begin his residency in Passaic, New Jersey.  He would leave his recently betrothed and pregnant wife behind to pave the way for a better life in the land of opportunity.

On a layover in Tokyo, a fancy new camera caught my dad’s eye.  Japan at the time was light years ahead of Korea in terms of technology and my father reckoned that electronics were cheaper in Tokyo than they would be in New Jersey.  He and his friend saw an easy opportunity to arbitrage a quick profit and spent what little money they had in hopes of selling the camera as soon as they immigrated into the States.  As fate would have it, the camera was cheaper in America – is a good deal ever to be found at the airport other than possibly duty-free goods?

With even less money now but a fancy state-of-the-art camera to chronicle his adventures, my father began working long hours and preparing for the arrival of my mother who was ready to give birth to moi soon.  The camera was an inauspicious start that would belie the incredible blessing that the United States would be to our family.

My parents both took huge risks (most have paid off better than the camera) and made many sacrifices to give my brother and I a better life.   As a father of three now, although I am much more cognizant and thankful for what they must have encountered to establish life here in America – learning the trade of medicine in a foreign tongue, racism, no nearby family support, and the lack of any good Korean restaurants in Passaic (the travesty!) – I will likely never fully comprehend their early difficulties.

My father actually completed two separate residencies in America.  When he first arrived in the United States, he trained as a family practice doctor and for a while after moving to Virginia, my family enjoyed a comfortable life.  But as a foreign medical school graduate, my father was not allowed to sit for the board certification exam for family practice and so he decided to pursue a second residency in pediatrics (who did allow foreign graduates to sit for board certification).  I will forever be grateful for his career change!

We returned to New Jersey, replete with a new little brother having been born in Virginia, and for three years the four of us lived on the meager salary of a pediatric resident.  We lived in the bottom floor of a tiny two-bedroom duplex that had a scrumptious bakery at the foot of the hill we lived on.  Although we were poor, my brother and I were always happy, catching fireflies in the summertime and throwing snowballs and eating warm pumpkin pies from the bakery during the cold winters.  After finishing his training, my parents were eager to start their future elsewhere, so we headed south to Houston, Texas.

My father’s first practice was on Bingle road next to a diner that served the best chocolate ice cream shakes.  I still remember the antiseptic smell that would overpower you as Donna the nurse would walk you to the back, tempting you to lose the recently consumed shake.  There are many memories of me wailing as I received various vaccinations and penicillin shots – a tradition that my daughter has taken to new depths of sobbing. 

My father opened his first solo pediatric practice in 1983 at Memorial City hospital on Frostwood road in Professional Building One.  My mother served as the office manager and ran the business operations and the never-aging Masako, who still works for me today, was one of their first new hires.  Many of my friends from church worked for my father at one time or another, a tradition that I still carry on today.

I finished my own residency training in 2002, and after a short mission trip to Vladivostok, Russia joined my father’s practice – a true mom and pop organization with their newly minted pediatrician son in tow!  In late 2004 my father retired to go to the mission field in Yanbian, China, after which Dr. William Pielop and I started Blue Fish Pediatrics which just opened its third office in Katy and hired its thirteenth doctor this year. 

Looking back at my career and life, it is easy to appreciate the outsize influence my dad has had on me.  I love the Lord.  I married a beautiful Korean woman.  I am mildly OCD.  And I love my work as a pediatrician.  Lucky for me and because of the sweat equity that both my mom and dad put into his practice, I never had to flip a camera to get my start in medicine. 

Dad, thank you for your hard work, sacrifice, and your love for the Lord.  For everything you have done for me, I would like to dedicate my new pediatric book to you.  Without you, I would never be where I am today.  

Sunday, August 9, 2015

Post #42 A book review - Being Mortal: Medicine and What Matters in the End by Atul Gawande

In his breathtaking book, Being Mortal: Medicine and What Matters in the End, Atul Gawande (one of my favorite authors) elegantly describes three different modalities of patient counseling that doctors employ. 

The first is the oldest and most traditional approach, a paternalistic relationship.  The doctor not only has the knowledge to guide the patient, but also possesses the experience and wisdom to make decisions on their behalf. 

The second type of relationship is termed "informative."  Here the doctor informs you about the facts and figures related to your medical problem, along the lines of a talking Wikipedia page donning a white coat, but allows you to make your own decisions in regards to your health. 

And finally, the third type of relationship is called "interpretive."  Here the doctor asks a series of probing questions to discover your priorities and assists you in navigating the medical maze to achieve your goal. 

Methodically, Gawande utilizes a small gamut of actual patients he has encountered in real life, including his own father, and through their life stories he takes the reader step by step in his maturation process as he evolves from a mixture of initially employing the first two approaches - leaning heavily towards the informative style - to an actualization of becoming an "interpretive" doctor.
 
At times, along the way, Gawande has to remind himself of what he has learned from palliative experts and even Daniel Kahneman's research on kidney stones and colonoscopies (another favorite of mine! - the author not the procedure), to stay true to his new "interpretive" approach, which over time he recognizes as being a clear cut above the other two modalities. 

His most moving example is his own father, who is diagnosed with a  spinal tumor and begins losing first his grip in tennis and later his grip over day to day activities.  His father, also a physician (as is his mother - slacker family the Gawandes), seeks the counsel of two neurosurgeons, both of whom have excellent pedigrees and reputations. 

The first doctor goes into information overdrive overwhelming both Atul and his father, and despite being doctors themselves, they struggle with the tsunami of facts and statistics which leaves them feeling rudderless with no sense of direction; the neurosurgeon himself advocates operating right away.
 
The second doctor, takes the time to listen to the father's desires and goals in life, especially his optimal endgame, and helps the family to formulate a plan which will maximize his ability to achieve what is most important to him at the given moment in time.  The interpretive doctor exemplified. 

Rather than jumping at surgery which could lead to further complications - together, the neurosurgeon and the Gawandes arrive at the decision to wait on surgery, which although promises some relief of pain and restoration of function, also carries with it the risk of leaving the elder Gawande a quadriplegic. 

Although one of his hands is slowly becoming numb, in his time following the initial consultation where he decides to forgo surgery, Gawande's father throws himself into his role as newly elected Rotary district governor and precedes to follow through on a goal to speak at the meeting of each of his district's fifty-nine clubs, not just once but twice to each group.  (If the Gawandes make you feel insufficient, join the club.)

Over time, the tumor takes its toll and several years after the initial diagnosis, and several important life goals later, Gawande's father finally decides to submit to surgery.  The surgery goes well, but in 20/20 reflective hindsight, it becomes clear that had they followed the advice of the first surgeon, the scalpel would have been utilized several years prematurely and the hand of unnecessary risk would have been forced sooner than required. 

Even in pediatrics, although on a much less dire scale, I personally see how the interpretive doctor modality is superior to simply being informative or paternalistic. 

Although, I understand the natural history of an ear infection, and how 80% of ear infections in children over two years of age will improve without antibiotics, albeit with a slightly longer course of pain; I don't know the family's schedule (unless I ask).

Perhaps there is an important wedding they need to fly to over the weekend or maybe the family has a vacation coming up that has been in the works for several months.  While these are not life or death situations, I can fully appreciate the importance of preserving the quality time of a much needed break for the family, especially if it is a once-in-a-lifetime trip to Disney World which has received an immense amount of planning and a considerable portion of the family budget.

This would certainly push me to recommend antibiotics over watchful waiting.  Certainly, we should be judicious about antibiotic use when at all possible, but how can one weigh the risk of a 10 day course of amoxicillin and its small contribution to the scourge of antibiotic resistant bacteria vs. the preservation of a once-in-a-lifetime trip to Disney World. 

It is impossible to weigh in terms of any sort of risk assessment or even epidemiological probabilities.  Even my nerdy Pi-loving math professor brother would struggle with this.

And that is precisely the point.  I can't quantify the decision by myself, but by understanding the family's immediate goal and knowing the studies and treatment options for an ear infection, I can help a mom and dad to decide what is best for their family in the given situation.

These are ideas that have been floating around in my head for a while and as he so often does, Gawande's timely prose has helped sharpen thoughts that needed some coaching and fine-tuning.

Being Mortal is well worth reading for anyone who has grappled not just with medical decision making but is interested in a strategy for approaching the end of one's life and maximizing their personal goals with the assistance of the modern medical community who has hopefully read this insightful book.

Friday, December 5, 2014

Post #41 Update on the 2014-15 Flu Vaccine

The main circulating flu this year is a recently mutated H3N2 strain (91% in one sample).  Because of this new mutation, the vaccine currently used is not a great match for this particular strain. 

In my medical opinion, this paradoxically makes it even MORE IMPORTANT to get the flu vaccine. Mainly, because the worse protection the flu vaccine offers, the more widespread the flu will be this year, and this increases the likelihood that a large percentage of people, both immunized and unimmunized, will contract the flu. However, those who are unimmunized will be at an even greater risk of catching the flu. 

Essentially, there is less herd protection this year and everyone is going to get exposed. And while the flu vaccine is not a great match it still offers some protection against the new H3N2 strain, and since it is highly likely that almost everyone is going to get exposed to the flu, some protection is better than no protection. Also, the flu vaccine protects against the 9% of other strains circulating. 

Sadly, 5 kids have already died this year from flu-related illnesses and the flu season is just beginning.

Deadlier Flu Season Is Possible, C.D.C. Says

Saturday, August 17, 2013

Post #40 Flu Vaccine Update 2013-2014 (Quadrivalent vs Trivalent)

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 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.
The 2013-14 U.S. trivalent influenza vaccines will contain:

*an A/California/7/2009 (H1N1)pdm09-like virus
*an A/Victoria/361/2011 (H3N2)-like virus
*a B/Massachusetts/2/2012-like virus


The newer quadrivalent vaccines will include an additional vaccine virus:

*a B/Brisbane/60/2008-like virus

While the H1N1 virus and the H3N2 virus used to make the 2013-2014 flu vaccine are the same viruses that were included in the 2012-2013 vaccine, the recommended influenza B vaccine virus(es) are different from those in the 2012-2013 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.

In our area, a local pediatrician friend has already reported 2 cases of flu "A" seen in siblings this past week at their office.  A rapid flu test was used, however at this time no further confirmation is available.  If confirmed, this may point towards an early and long flu season.

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 recent global pandemic and which was also included in the past three 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.

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 2010
1 flu shot since July 2010
2 flu shots since July 2010
Under 9 years of age
2 flu shots needed
2 flu shots needed
1 flu shot needed
9 years of age of 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 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.


Quadrivalent vs. Trivalent flu vaccine

Traditionally, the flu vaccine covers 3 different strands of the flu virus (2 "A" strands and 1 "B" strand) and is labeled a trivalent vaccine.  Starting  this year, some of the the flu vaccine products will be expanded to include 4 different strands of the flu virus (2 "A" strands and 2 "B" strands) thus adding 33% more protection.

This means that both the trivalent flu vaccine and the quadrivalent flu vaccine will be available this year.  Within approved indications and recommendations, no preferential recommendation is made for any type or brand of licensed influenza vaccine over another by the CDC (Center for Disease Control).

The manufacturing process for the quadrivalent vaccine is the same as the trivalent vaccine and as such there should be no increased adverse effects in using the newer quadrivalent vaccines.

At our office, the trivalent injection vaccines are shipping out sooner than the quadrivalent injection vaccines (with no shipping date for the quadrivalent injection vaccines given as of 8/17/13).  The quadrivalent nasal vaccines are shipping now.  Unfortunately, children under 2 years of age and those with asthma (and a few other scenarios - please see CDC website) cannot receive the nasal vaccine and must receive the injection vaccine.

It is this author's opinion that when possible, a quadrivalent vaccine is preferable as it protects against an additional "B" strand that the trivalent flu vaccine does not.  However, from a timing standpoint, if the quadrivalent is unavailable, it is probably more important to get the trivalent vaccine as soon as possible, rather than to wait on an unknown availability date.

In the event that a child will need two flu vaccines this year, it is ideal to get as many quadrivalent doses as possible.  The most ideal would be to receive both flu immunizations with the quadrivalent vaccine. 

However, if this is not possible or ideal because of vaccine availability, the next best scenario is to receive at least one quadrivalent and one trivalent, although this is only marginally better than receiving two trivalent shots.  Because of timing and availability, if both shots given are the trivalent vaccine, this is still preferable to waiting on the quadrivalent vaccine, if availability is uncertain.

Children receiving the nasal flu vaccine and requiring two doses do not have to worry about this issue, as all nasal flu vaccines are expected to be quadrivalent this year.

Parents should know that in a child who requires two flu immunizations this year (see chart above), the reason it is recommended to get the second immunization is that in a naive immune system, a single injection of a flu strand does not afford very good protection.  (This is pertinent mostly with the injection as the nasal flu vaccine affords good protection with one dose - however two may still be recommended per the CDC algorithm.)  For ideal protection, a booster of the same strand should be given as soon as possible.

This is why a single injection of the trivalent vaccine (which has 3 flu strands) followed by a booster injection of the quadrivalent vaccine (which has 4 flu strands) or vice versa is only marginally better than receiving two trivalent flu shots. 

In the preceding scenario, the 2nd "B" Brisbane strand (which is only included in the quadrivalent vaccine) would only be received once.  Thus, there would be good protection against 3 strands of flu and only marginal protection against the quadrivalent-only strand of Brisbane "B"  flu.

In the end, practically speaking, timing is probably more important than worrying about quadrivalent vs. trivalent flu vaccine.  When possible the quadrivalent should be received, but when the quadrivalent is unavailable it is probably best to move forward with the trivalent vaccine.   The faster the flu season infects children, the more important timing becomes.

If the quadrivalent vaccine is unavailable, some parents may initially opt to get the readily available trivalent flu shots (once or twice) and then desire to follow-up with two additional boosters of the quadrivalent flu shots as they become available. 

This could possibly lead to a scenario where a child receives 3 or 4 flu shots during this season (1-2 initial trivalent shots followed by two quadrivalent shots).  This would ensure early protection against the 3 strands of flu in the trivalent vaccine followed by addtional protection against the Brisbane "B" strand which is only covered by the quadrivalent vaccine.

As the author of this blog, I am unsure about the safety of receiving 3 or 4 flu shots in a single season.  The flu shot has been historically shown to be very safe with few side effects, but I am unsure of the data regarding this many shots.  

The pediatrician and parents will have to weigh the risk and prevalence of the Brisbane "B" strand vs. the unknown potential side effects of receiving 3 or 4 flu shots.  This author's educated guess is that there is little risk to a 3rd or 4th flu vaccine in a single season, but at this time I have no specific data to support this claim.

At our office, the quadrivalent vaccine will be preferentially given, when in stock, unless otherwise requested by the parent.


Flu Vaccine Egg Allergy Protocol (per CDC)

1. Can the child eat lightly cooked egg (e.g., scrambled egg) without reaction?
If so, the vaccine should be administered per usual protocol

2. After eating eggs or egg-containing foods, does the child experience ONLY hives?
If so, the vaccine should be administered and the child will be observed for reaction for at least 30 minutes following vaccination

3. After eating eggs or egg-containing foods, does the child experience other symptoms such as: cardiovascular changes (e.g., hypotension), respiratory distress (e.g., wheezing), gastrointestinal symptoms (e.g., nausea/vomiting), reaction requiring epi-nephrine, or reaction requiring emergency medical attention?
If so, the child shoud be referred to an allergist with expertise in the management of allergic conditions for further evaluation.


When will the vaccines be available at Blue Fish Pediatrics Memorial?

At Blue Fish Pediatrics Memorial, during regular office hours (starting August 19, 2013), the flu vaccine will only be available at well visits for all patients of Blue Fish Pediatrics Memorial and family members living in the same household with patients under 6 months of age.  Flu vaccine will also be administered during sick visits at their doctor's recommendation.

The flu vaccine will be administered at all well child visits until supplies are exhausted (no additional appointment or phone call is required).

To help accommodate our busy families, we have designated four Saturdays for flu shots (the clinic will still be open on these Saturdays for sick patients).

Because of the high volume, these flu clinics are for BLUE FISH MEMORIAL PATIENTS ONLY. Weekday vaccine appointments will be made for Cypress patients who arrive at these flu clinics. For more information, please see the CYPRESS flu newsletter.

The dates of the Saturday Blue Fish Pediatrics Memorial flu clinics:

Saturday    Sept 14, 2013          8:00 AM—1:00 PM
Saturday    Sept 28, 2013          8:00 AM—1:00 PM
Saturday    Oct 12, 2013           8:00 AM—1:00 PM
Saturday    Oct 26, 2013           8:00 AM—1:00 PM

Any Blue Fish Memorial patient or parent is eligible to receive the flu vaccine on these four specially designated Saturdays.  Also eligible are any family member(s) living in the same household with patients under 6 months of age.  On these specially designated Saturdays you will not need an appointment and can walk-in at your convenience for the flu vaccine.

·        The availability of certain flu products may be limited towards the end of the flu season.
·        The intradermal flu vaccine will NOT be available at Blue Fish.
·        The recombinant flu vaccine will NOT be available at Blue Fish.

Saturday, July 13, 2013

Post #39 Vomiting and Diarrhea (Gastroenteritis) in Children: A Practical Guide

It certainly looks, sounds and smells awful, but vomiting and diarrhea are rarely dangerous.

Vomiting, not to be confused with spitting up, is the expulsion of food from the stomach.  Spitting up is more of a laundry problem than a medical problem, and kids who spit up do not become dehydrated.  

Diarrhea is a little harder to define, because watery stools are fairly common and most healthy individuals will experience it from time to time for reasons which do not qualify as diarrhea.

Frequent stools can be normal too, especially in breast-fed babies, who might dirty the diaper every time they feed, up to 12 times a day. It often looks watery and yellow with little remnants that look like seeds. Despite appearances, this is not diarrhea.

In general, diarrhea is a sudden increase in stool frequency, three to four times more often than usual. It has a general watery consistency, but frequency is the most important defining attribute.

No matter how copious the diarrhea, in developed countries it rarely leads to dehydration because it's easy to replenish lost fluids.

By far, the most common cause of vomiting is viral "gastroenteritis," a fancy medical term for an infection of the intestines that disrupts the normal digestive process.

While viral gastroenteritis can present with many symptoms, including headache, fever, decreased appetite, abdominal cramps and muscle aches, diarrhea and vomiting dominate. 

What to expect
In general, a child will vomit for one or two days, with three to six separate episodes of vomiting per day.  Diarrhea typically lasts much longer, from one to two weeks, with approximately six to 15 episodes per day.

Illness usually begins 12 hours to four days after exposure and lasts for three to seven days.

Viral gastroenteritis peaks in the winter; that's when 70 to 90 percent of cases are seen in the hospital.

Rotavirus Vaccine
There are many different viruses that cause various forms of gastroenteritis. Rotavirus is the most common virus and the most common cause of gastroenteritis overall.

A vaccine to combat rotavirus was introduced in 1998, but was pulled from the market in 1999 because the risk of developing a bowel obstruction was linked to the vaccine.

In 2006, two newer versions of the vaccine were introduced, RotaTeq and Rotarix. They have been proven to be safe and very effective in reducing hospitalizations, dehydration, emergency room visits, and most importantly, death.

Since the vaccine, the number of severe cases of gastroenteritis has significantly dropped and the majority of cases can now be handled at the pediatrician's office instead of the hospital.

Non-viral causes of gastroenteritis
A small percentage of gastroenteritis infections are caused by bacteria, the biggest sign of which is bloody diarrhea. 

Yet blood does not necessarily mean bacterial gastroenteritis.

With viral gastroenteritis, the skin of the anus or the lining of the intestine can become irritated and cause small amounts of bleeding.

However, if it appears the amount of blood is greater than 10 percent of the entire stool or bleeding recurs with several consecutive stools, your child needs to see the pediatrician promptly. A stool test can confirm diagnosis.

Bacterial gastroenteritis infections can become quite severe and require close monitoring, possibly in the hospital, and sometimes will benefit from antibiotic therapy.

Another cause of gastroenteritis, although infrequent, is parasites.

The most commonly seen parasitic cause of diarrhea and vomiting in the United States is Giardia Lamblia, which is most often picked up in a daycare setting. It is rarely dangerous and can be treated with antibiotics.

If your child has diarrhea that lasts longer than two weeks, a stool test will help get to the bottom of things.  Prior to the two week mark, a stool test is generally not needed.

Dangers of dehydration
Although vomiting and diarrhea can be exhausting for a parent, vomiting and diarrhea in and of themselves are not dangerous to a child.

The potential of dehydration is the greatest danger.  A simple way to understand dehydration is to think of your child's body as a box.  As long as fluids coming out of the box are replaced by fluids going into the box, your child will not become dehydrated. 

In a healthy child, fluids come out of the box through sweat, urine and stool.  During a bout of gastroenteritis, fluids will also escape via vomit and diarrhea. 

Usually, fluids can be replenished by having the child drink water and other drinks, but during a bout of gastroenteritis, it can be hard to stop those fluids from pouring back out.

When that happens, fluids can be given intravenously in the hospital. Fortunately, studies show this is rarely necessary and that oral rehydration usually works as good as an IV.

Parents might want to opt for colorless rehydration products. Anything red or purple masks more serious symptoms, such as blood in vomit or stool.

Test the waters before allowing your child to drink freely by following this simple plan:

  1. To allow stomach muscles to recuperate, do not give fluids for 30 minutes after vomiting.
  2. Give one teaspoon of Pedialyte (for children less than 1-year-old) or Gatorade (for children older than 1-year) every five minutes for 30 minutes.
  3. After 30 minutes of sipping every five minutes, wait 20-30 minutes without drinking fluids.  If they do not vomit you can allow them to begin drinking Pedialyte or Gatorade freely.
  4. If at any time they vomit again, repeat the above cycle, starting from the beginning.
  5. Advance quantity slowly as your child demonstrates tolerance to fluids.

If your child fails this cycle more than two times, call the pediatrician.

Road to recovery
If you allow a child who has vomited to drink or eat again too soon, it will likely come right back out because the stomach needs time to recover.

Just like muscles are sore and flaccid after a hard run, stomach and intestinal muscles are also weak after several bouts of vomiting.  This makes it difficult for the stomach and intestines to push food down as it normally would, a muscular process called peristalsis. 

As a result of the muscles being tired, food cannot progress naturally through the digestive system, so the body sends it back up again.

So, just like you would ease your leg muscles into walking after a hard run, the same must be done for a child who has been throwing up.

Refeeding advice
Most parents have heard of the BRAT diet – bananas, rice, applesauce, and toast. But the Centers for Disease Control, among other medical organizations, believe the diet is unnecessarily restrictive.

Once your child can tolerate approximately 12 ounces of fluid without vomiting, you can offer breads, pastas, crackers, soups, and bland foods such as baked chicken or baked potatoes without much seasoning or fat.  Some medical websites have a refeeding chart that is helpful, such as this one on our practice's website.

Lactose Intolerance
After a bout of gastroenteritis, some kids will experience temporary lactose intolerance.

Lactase, the enzyme that helps digest lactose (a sugar in milk), is secreted from the lining of the gut, which is stripped away when infection occurs. The lining will heal, but lactose intolerance can last a few days or even weeks or months.  It is generally short-lived.

If you notice your child is bloated or uncomfortable after eating or drinking dairy products, limit those foods, switch to lactose-free milk or try lactaid pills. The symptoms should eventually subside and your child can get back to drinking milk.

Diaper Rash
For little ones still in diapers, a bad bout of diarrhea is often accompanied by diaper rash. Even the best diaper-changing parent can't keep up with diarrhea and its potential irritation of the skin.

The rash is caused by bile acids in the stool, and although the irritation can be controlled, it probably won't improve until the diarrhea subsides.

To prevent diaper rash:

  1. Clean the bottom with a soft cloth and use gentle strokes to prevent further abrasion.
  2. Allow for adequate air-drying of the skin.  If pressed for time use a blow dryer on cool setting to dry the skin.
  3. After air-drying, apply a thick coating of a barrier cream such as Desitin, Vaseline, Vitamin A&D, etc.
  4. If the skin looks particularly irritated, a 10-minute soak in plain water without soap can help. Air-dry and apply a thick coating of diaper cream.

Occasionally, the skin becomes so broken down it becomes susceptible to bacterial and yeast infections.  If the diaper rash is progressively getting worse despite following the above advice, visit the pediatrician.

Medications
Most stomach viruses will run their course without any medications, but if your child is miserable, you can use Liquid Maalox Regular Strength Antacid Suspension to ease tummy pain.

Children 1-2yrs: 1/2 teaspoon, four times a day. Do not take more than 2 teaspoons in a 24 hour period.

Children 2-6yrs: 1 teaspoon, four times a day. Do not take more than 4 teaspoons in a 24 hour period.
Children >6yrs: 2 teaspoons, four times a day. Do not take more than 8 teaspoons in a 24 hour period.
Anti-vomiting medications, such as Zofran (generic name: Ondansetron) can be used if the oral rehydration cycle is failed twice.  Because of a small potential for side effects, it is best to use this medication as a back-up and not as the primary treatment modality.

A lot of parents ask about probiotics. Some reviews have demonstrated a benefit in reducing stool output and the duration of diarrhea.  However, the jury is still out as to how helpful they are, which ones work best, and how much exactly is needed.  

Further, there have been a few reported cases of harmful side effects.  It may be safer to use a yogurt with a high concentration of healthy bacteria until additional studies help steer recommendations on how to best utilize probiotics.

Antidiarrheal medications are almost never recommended.  If something bad is inside your intestines, it is best to let it come out.

Antibiotics are never needed for viral infections.  Even for the rarer bacterial causes of gastroenteritis, antibiotics are controversial.

Overall, try not to overreact when your child is vomiting or has diarrhea. As with most aspects of parenting and childhood, this too shall pass.

FAQs:

How do I know if it's a virus or something different such as food poisoning?
Food poisoning is typically short lived, lasting less than 24 hours. It's caused by a reaction to toxins generated by bacteria growing in food. The stomach will vomit up its contents until all of the toxins are expelled, after which there is a rapid recovery. Usually, a lack of diarrhea and the short burst of vomiting is what will differentiate food poisoning from a stomach virus. In most cases, treatment is not necessary.

Should I worry if I see blood in my child's vomit or stool?
More often than not, blood represents injury to the lining of the stomach, esophagus or gut. Like a knee abrasion, it will heal with time. In general, it's a good idea to touch base with the doctor if you see blood, but most cases are not dangerous.

Should vomiting or diarrhea hurt so much? My child often cries out in pain.
Vomiting and diarrhea can cause cramping and sore digestive muscles. Most pain will subside as the illness improves. Severe pain that seems to worsen in intensity and increase in frequency should be reported to a doctor.

Can I treat symptoms with OTC medications?
In general, medications are not needed as the virus will soon run its course. But use your judgment. A timely dose of anti-vomiting medication can keep the child from having to receive an IV or visit an ER, but most of the times adherence to an oral rehydration plan is all that is needed.

What if my child is desperately thirsty and asking for a drink soon after vomiting?
A small ice chip from time to time would be reasonable, but if that too is vomited, the stomach may need at least 30 minutes to rest.