Noisy Breathing

A common complaint I hear from parents is their child has noisy breathing. One frequent concern is that it may be wheezing, or asthma. Here is a short guide to noisy breathing.

Infants often have noisy breathing. It’s usually heard on the inhale. Most often it is not associated with any coughing or problems with feeding or sleep. In fact it usually bothers the parents much more than it bothers the child. Babies often have some nasal congestion. They have very small nasal passages and any irritation or even temperature variation can cause some swelling in the mucosa, or lining of the nose, that makes them sound “congested”. Another common issue with small babies is called laryngomalacia. That is a fancy term for a soft or slightly weak larynx. When the baby breathes in, it collapses a bit causing a raspy noise. This usually improves markedly when the child is laid on its stomach (for tummy time, not for sleep, of course) and gets worse when the child is on its back. However, it is not dangerous and doesn’t cause the baby any distress. If baby looks like his breathing is labored that could be a more serious problem. One would see the head bobbing up and down and the stomach going sharply in and out when breathing. Also if cough is present it should be brought to a medical provider’s attention. Furthermore if the baby is having difficulty with feeds, she should see a doctor right away. A more rare problem is called choanal atresia which is a blockage or partial blockage of the nasal passages. These babies would have to pause in their feeding just to breathe through their mouths.

Older children usually get some sort of noisy breathing when they are ill. This may come in various forms. Nasal congestion is the most common and can cause a rattly sound that seems like it must be coming from the chest but often is not. Usually children with nasal congestion alone do have cough due to post nasal drip (the mucous going down the throat at night is irritating), but they don’t have labored breathing, they can usually drink fluids without difficulty, and sleep pretty well. If you are not sure what is happening, it is always best to call the advice nurse or the doctor’s office for help.

Stridor is another sound that babies and young children may make when sick. Again, it is heard when the child inhales. It is usually louder when the child is crying and often disappears when the baby stops crying. Try sucking in your breath as if you were surprised but keep your mouth closed. That’s what stridor sounds like. These babies often have a barky low pitched cough that sounds like a seal. This is most commonly due to a viral illness called croup but also can be heard if the baby has swallowed or inhaled an object and it’s stuck in the laryngeal area. Another illness that can cause stridor that has become quite uncommon in the vaccine age is Epiglottitis. These children are extremely ill with high fever, and need to be seen immediately.  Signs that a child should be seen right away are any distress, drooling, high fever, or stridor at rest. If you can hear the funky sound in the breathing when the baby is not crying, call the doctor. Sometimes the advice nurse will be able to listen over the phone and tell you if it’s stridor or not. If someone has croup, standing in front of the open freezer is helpful.

And finally, wheezing. Many people come in saying they think their child is wheezing. Wheezing is often quite difficult to hear without a stethoscope. If it is “audible wheeze”, you generally hear it on the exhale (although it is possible to have it on the inhale). It’s a high pitched musical type of sound.  Wheezing can  result from different causes. Infants can get wheezing with a bad viral cold, and that is called bronchiolitis.  Any child can also get wheezing from asthma, which can start at any age. If there is a strong family history of asthma and/or the baby already has eczema, there is an increased chance of developing asthma. Other causes of wheezing include a foreign object aspirated into the lungs, anatomic abnormalities, other rare infections like TB, and a condition called vocal cord dysfunction (usually seen in older girls).  Again the bottom line is to look for signs of distress, such as any dusky or bluish color change, retractions (which means pulling between the ribs, under the clavicles, in the belly, or in the soft area at the base of the neck), coughing so badly that the child can’t sleep or eat properly, for example. Fast breathing can also be a sign of distress but a child can breathe fast with a fever as well so check that the temperature is normal before assuming the fast breathing is due to a respiratory problem.

Parents of children with asthma frequently express frustration when I see them, that they didn’t start the asthma treatments because they didn’t hear any wheezing. Again, wheezing is hard to hear and can be a late sign of an asthma exacerbation so look at cough as the main sign and use the medicine when the cough starts.

If your child is having any of the signs of distress discussed above, or if you think your child has inhaled an object/piece of food,  it is important to seek medical attention or advice immediately.

Sleep Glorious Sleep!

Sleep is one of my favorite topics. There are so many simple things that can be done to help babies sleep better and safer. Most new parents know that they won’t get a lot of sleep at first, but they don’t always know that they can teach their child to sleep and improve the situation. Most children need to learn to sleep. “Sleep training” has become such a controversial phrase that implies letting a baby cry himself to sleep. There can be a more gentle approach to teaching a child to sleep through the night but it takes patience, consistency and dedication!

One valuable resource for learning about sleep in infants is called Healthy Sleep Habits, Happy Child, by Mark Weissbluth. Dr. Weissbluth is a sleep specialist and he advocates the controversial crying method once problems develop. However you feel about that, the information on preventing sleep problems is where I feel his book has the most value. He discusses the sleep needs of babies at different stages, the need to make sleep a priority (“Respect your child’s need to sleep” is his mantra) and what signs tell you that a baby is sleepy. Most importantly he discusses the difficulty that can arise once a child becomes overtired. Many people don’t recognize that their baby is tired until she is cranky and rubbing her eyes. What is key to remember is that at this point it is much more difficult to get a baby to sleep since the child is already overtired. I’m sure we’ve all had the experience of being so tired that the adrenaline kicks in, our heart starts pumping hard and we get into bed and stare at the ceiling. This happens to babies too and can cause a vicious cycle in which a child is tired, the parents are tired but no one can get to sleep.

Another invaluable resource that I highly recommend is the Happiest Baby on the Block DVD, by Dr.Harvey Karp. He demonstrates a technique for calming a baby that involves the 5 S’s: swaddling, shushing (loudly), sucking (on a paci), stomach hold (not for sleeping of course) and a gentle shimmy type shake (never a strong shaking!) This is only one technique but it works for many babies and can be lifesaving.

The final tool that I think is crucial is White Noise and it should be loud. There are apps, there are CD’s, there are white noise machines and even fans (which help prevent SIDS). The general thought is that the baby heard fluid swishing loudly around its ears for many months and this type of sound makes it feel like it’s still in the womb and it also helps drown out sounds that could wake someone up!

So what is the magic secret? Of course there is no “one size fits all” formula. Here are some tips from the above sources and being a pediatrician for 14 years as well as a parent for 3, that I have found helpful to families.

1. Newborns should not be awake for more than two hours. Generally by about 1.5 hrs, one needs to start the process of putting the baby to bed, whatever that involves. Initially it probably involves nursing or drinking a bottle, rocking and swaddling. The point is to watch the clock and get used to making the sleep habits a priority. I admit this is much more difficult for second or third babies of course, but try to keep the schedule of the infant in mind when planning the day.

2. When a newborn cries at night, you have to attend to it. When an older infant (6-8 weeks) cries, it may not be necessary to go in right away. A mild “complaining” cry may be something that just helps the baby go back to sleep. A sight pause of a few mintues before helping baby out, may be the best help of all in teaching him to get himself back to sleep. Once the crying intensifies, then there may be a need for comfort, food, diaper change that should be met. This technique of pausing before going to the baby is quite popular in France according the book Bringing Up Bebe by Pamela Druckerman and, according to her experience, their kids sleep through the night much earlier than ours do.

3. Along similar lines at about the same point (2 months), it is helpful to start putting the baby down when sleepy but still awake. This is a skill that may take time to develop, and require some tolerance of small amounts of crying, but it is worth the effort.  All people have sleep cycles with periods of wakefulness during the night. If a baby only knows how to fall asleep with the caretaker present, then every time he wakes during the night, he will need that person there to fall back to sleep. If a baby learns to fall asleep on his own he will be able to repeat that as long as there are no other pressing issues, when he wakes normally during the night.

4. Safety is the most important thing. Babies should always sleep on their backs to prevent Sudden Infant Death Syndrome (SIDS). There should be no fluffy bedding like comforters, bumpers, or pillows around them anywhere. The AAP does not recommend anything in the baby’s sleeping space, including the products that are marketed for infants such as reflux inclines wedges. The AAP does not recommend bed sharing, but does recommend room sharing for newborns. Co-sleeping is also a risk for SIDS, increasing the risk by almost three times according to a recent meta-analysis (study that analyzes multiple smaller studies in one database) in Journal of Pediatrics from January, 2012 by Venneman et al. A fan in the room also helps prevent SIDS. It is very tempting to put baby on the tummy or do something else that helps her sleep better, but “safety first” is another good mantra to keep in mind.

5. Another book that many people know is The Baby Book by Dr. James Sears. Again, each book has its value whether you agree with all of its tenets or not. For me the most valuable piece of advice in that book was the concept of “nighttime parenting”. Just because we want a child to sleep doesn’t mean there is an on-off switch. Thinking of the middle of the night routine as parenting rather than as an interruption to my sleep helped me through the rough patches.

6. Recognizing the tired signs will help immensely in getting your child to bed (both for naps and for bedtime) before the adrenaline rush kicks in . When baby slows down kicking her arms and legs around and vocalizing, when the yawning starts and the eyes droop, it’s time for bed!

7. One thing I have found very helpful is developing a routine. Of course the general routine is important but really it’s conditioning the child to fall asleep to a particular song, with back rubbing or patting, or hair stroking, that will help immensely in the middle of the night. Pick one that the child seems to like and stick with it.

8. Babies don’t know the difference between day and night but there are some things we can do to help them figure it out as their brains develop a circadian cycle. Exposing them to light in the morning, at a reasonable wake up time (7 or 8 am) helps them to register “morning” and stimulate melatonin production. In complement to that, keep the lights low at night even with feedings and diaper changes, and try to keep the voices quiet and the mood calm. In other words, 2 am is not playtime!

Every child has their individual temperament and every family has their individual needs. I don’t think there can be a cookie cutter approach to sleep.  Sleep is important, make it a priority, read the books, take what works for you from each and then make your own plan.

Infant skin care

I can’t count how many times a week I have to tell the parents of a newborn baby that the scented brand name babywashes and oils are not good for their baby’s skin. The baby products that are marketed to new parents are scented, which is irritating to an infant’s skin (everyone’s, actually). In addition the way the acid-base balance is set to prevent eye irritation  is also irritating to the skin. One should not use anything on an infant’s skin that “smells like a baby”.

I should mention that I have no financial interest in any company at this time. I am not being paid to support any products. Have you heard the joke where two elephants are sitting in the bath and one says to the other “pass the soap” and the other says “no soap radio”. Everyone who knows the joke laughs and the person who has not heard it before feels dumb because he doesn’t get it. Truth is, there is nothing to get, but I think of it all the time because “no soap” is what’s best for a baby. They really don’t get that dirty, and water does the job well. If you feel that’s not good enough, the least costly option that is less irritating is Dove for sensitive skin. If you really want a “baby” cleanser, Aveeno, is also not as bad. Cetaphil is a non soap cleanser that is very gentle as well. Getting into the more expensive options, it’s mostly a matter of personal preference and what works for each individual child.

Next, baby lotion is not necessary. They all peel, it’s normal. If a child has eczema and really needs an emollient, plain old fashioned Vaseline is generally the best thing. There is actually a “baby” Vaseline now with a scent, so that is to be avoided. Again there are many pricier options (Aquaphor, Eucerin, calendula) but dermatologists recommend Vaseline since it is the least irritating/allergenic.

If a baby has cradle cap, the easiest remedy is just mineral oil; rubbed into the scalp prior to the bath. Then comb out the flakes with a fine tooth comb afterwards. Don’t be afraid to come over the soft spot, you won’t do any damage. It’s tougher than you think.

I also feel that the scented diapers can be irritating.  Huggies seems to be the least irritating of the common brands on the drugstore shelves. Wipes can be irritating as well. If possible, avoid them for the first few months. A wet napkin or paper towel (Viva towels are good for this) is less abrasive and can help avoid rashes. If you are using regular wipes, it is best to rinse them off before use.

If a rash develops, see your baby’s doctor.  There are many benign rashes but some are more serious and it’s best to have it checked out. And lastly, never use your own medication on a baby’s skin, it could be too strong for them. Infant skin is thin and steroids penetrate more easily. It’s very important to ask a doctor before using any medicated creams or ointment on an infant.

Intro to pedimedi

I have been a board certified general pediatrician for 14 years, at academic medical centers. I give a lot of advice to friends and family members about their children and medical issues that pertain to children and I thought it may be helpful to start a blog for others to read about those issues as well. I am starting this blog to help people with general pediatric medical issues. Of course this information will not substitute for medical care for your child in times of illness and I cannot give specific advice to anyone. There are many medical websites out there these days but I feel that they give some very general information and for most people that I know, it is usually not enough. If anyone has any thoughts about what topics would be interesting to read about, please post in the comment section. I am by no means familiar with all the ins and outs of blogging so forgive me if my site is not fancy!