In most cases, the children begin crying at the conclusion of the slide and refuse to bear weight on the leg.  A trip to the physician or  emergency facility leads to an X-ray, and, there it is:  a very painful spiral fracture of a pretty big bone.  Treatment is usually with casting for  about four to six weeks, and in some instances surgery might even be necessary.  Besides Dr. Gaffney, many other orthopedists around the country are trying to get the word out about avoiding this entirely preventable injury:  kids are better off sliding alone, on an appropriate height slide,  or  from mid-height, perhaps  with an adult standing at the side to assure safety.  But this is one of those instances in which “common sense” just doesn’t seem to be good enough, and what seems safest isn’t.   Pediatric  orthopedist  Dr. Edward Holt of Annapolis has come up with this  informative video on the subject: http://www.ivillage.com/parents-put-toddlers-risk-playground-slide/6-a-448057.

But no one is suggesting getting rid of sliding boards.  Just avoid sliding down the board with your child in your lap!

And side effects?  Quite unusual and very mild: a little irritation or stinging, which is sometimes due to an incorrect salt concentration.  But very safe.

And now comes the report from the Louisiana Department of Health in mid-December of two adults who experienced some very, very  serious complications from Neti-Pot nasal irrigation:  fatal cases of meningitis and destructive brain effects  from the rare but serious ameoba,  Naegleria fowleri, an organism which causes necrosis in the brain, and is found in warm fresh bodies of water mostly in the southern states.   Almost all cases of niglaeria come from swimming in water harboring the parasite, which offers the opportunity for it to enter the nose and anatomically navigate to the brain.  And in these two particular Louisiana cases, contaminated tap water used for nasal irrigation, took same route of this devestating infection entering the fluid behind the brain.  Over the last decade there have been about thirty cases of fatal Naegleria, all but these two from swimming.  It does not result from simply drinking water which contains the ameoba.

An epidemiogist with the Louisiana state health department made a simple recommendation:  water used for  nasal irrigation should not be simple tap water, but either boiled or distilled.  And the general consensus even outside Louisiana seems to concur with this.  While this is rare infection, it is very simple to avoid that risk altogether by using one of these alternatives to right-from-the-tap.  

And where does leave us regarding the safety of the Neti-Pot and other means of  nasal saline irrigation?    Countless individuals have used the technique for many, many years, with an excellent safety record.  These two cases were tragic but quirky,  and geographically related.  They   present no  reason to avoid this form of treatment But the recommendation to use appropriate water as recommended–a very simple measue– just makes sense.  Now gettting kids to cooperate with the rest of the procedure  remains much more difficult.

In theory this should eliminate the confusion and inappropriate dosing.  But, as is so often the case, we deal with practicality and not theory.  And the reality is that there is still some of that far more concentrated product on store shelves, and certainly lots in family homes.  And the latter is likely to remain the case for some time. 

Because of the this the F.D.A. issued a reminder warning in December, that parents and other caretakers should exercise care in giving babies, especially young infants, acetominophen.  Specifically the Agency is making these recommendations (verbatim from its bulletin):

• Read the Drug Facts label on the package very carefully to identify the concentration of the liquid acetaminophen, the correct dosage, and the directions for use.
• Do not depend on a banner proclaiming that the product is “new.” Some medicines with the old concentration also have this headline on their packaging.
• Use only the dosing device provided with the purchased product in order to correctly measure the right amount of liquid acetaminophen.
• Consult your pediatrician before giving this medication and make sure you’re both talking about the same concentration.

Through this consultation,  when medical staff is calculating a dosage based on weight, the volume you will be administering  neither more nor les smedication  than efficacy and safety  require.   The F.D.A.’s Carol Holquist listed these addition precautions about more quantitatively detailed dosing accuracy:

• Look for the “Active ingredient” section of the Drug Facts label usually printed on the back of an over-the-counter (OTC) medication package. 
• If the package says “160 mg per 5 mL” or “160 mg (in each 5 mL)”, then this is the less concentrated liquid acetaminophen.  This medication should come with an oral syringe to help you measure the dose.
• If the package says “80 mg per 0.8 mL” or “80 mg per 1 mL,” then this is the more concentrated liquid acetaminophen. This product may come with a dropper.

The bulletin concluded by listing the many  brand names under which acetiminopen for infants is marketed, but they should  uniformly list acetominophen as the active indredient.

This piece by the Journal’s health columnist Melinda Beck was not a pediatric article.  There was no mention of children at all.   But  the whole subject of gingival health and appreciation of its importance is enormously important in child heath care.  It is represents  an excellent example of early preventive care and the establishment of early and hopefully lifelong oral health habits.  The most visible arena of preventive health in children is, of course, is  prevention of obesity, with pediatricians counselling patients and their parents about diet, exercise,etc. from a very early age, in an effort to prevent the many serious effects of overweight later in life.  But the emphasis on healthful lifestyle practices and the establishment of good habits has become ever-wider in scope in recent years, with “anticipatory guidance” being a regular part of pediatric checkups.

And, it is in this sense that, although an adult article, this WSJ piece carries a highly valuable application in children as well.  It was serious enough when poor oral hygiene and lack of flossing caused “only” gingivitis, local gum disease.  But as the far wider and more serious ramifications become recognized and well documented–a risk factor for heart attacks, strokes, diabetes, and even more–the importance  of  good dental habits (the reasons for this are beyond the scope of this posting.)   This include the obvious, limiting concentrated sugar foods,  regular brushing, regular dental visits, but in addition we  really start stressing early–and making it a real habit.    Flossing  is an unusually clear example of a very simple, essentially cost-free, practice can yield huge  health dividends later in life.  A few inches of string and a few seconds a day.  So relatively simple, and so, so  important.

Postscript:  the full article from the WSJ  can probably be accessed via the link http://online.wsj.com/article/SB10001424052970203686204577112893077146940.html  In addition, the February 2012  issue of Consumer Reports has an excellent article, “Dental Do’s and Don’ts.”

Although the 1999  statement had already proposed that there was more negative than positive effect of media exposure on the very young and had discouraged TV viewing for those under two years.  A plethora of data in the dozen interving years has more than  borne that out and the recommendation to keep children of this age as “screen-free”  has been reaffirmed.  Most pediatricians and many parents have realized this without an organizational policy statement, but  the AAPs stand  does add the support of solid advances in the understanding of early brain development in presenting a “more comprehensive piece of guidance.”

The key findings, taken directly from the AAP’s advance press release:

 Many video programs for infants and toddlers are marketed as “educational,” yet evidence does not

support this. Quality programs are educational for children only if they understand the content and

context of the video. Studies consistently find that children over 2 typically have this understanding.

 Unstructured play time is more valuable for the developing brain than electronic media. Children learn

to think creatively, problem solve, and develop reasoning and motor skills at early ages through

unstructured, unplugged play. Free play also teaches them how to entertain themselves.

 Young children learn best from—and need—interaction with humans, not screens.

 Parents who watch TV or videos with their child may add to the child’s understanding, but children

learn more from live presentations than from televised ones.

 When parents are watching their own programs, this is “background media” for their children. It

distracts the parent and decreases parent-child interaction. Its presence may also interfere with a young

child’s learning from play and activities.

 Television viewing around bedtime can cause poor sleep habits and irregular sleep schedules, which can

adversely affect mood, behavior and learning.

 Young children with heavy media use are at risk for delays in language development once they start

school, but more research is needed as to the reasons.

The report recommends that parents and caregivers:

 Set media limits for their children before age 2, bearing in mind that the AAP discourages media use for

this age group. Have a strategy for managing electronic media if they choose to engage their children

with it;

 Instead of screens, opt for supervised independent play for infants and young children during times that

a parent cannot sit down and actively engage in play with the child. For example, have the child play

with nesting cups on the floor nearby while a parent prepares dinner;

 Avoid placing a television set in the child’s bedroom; and

 Recognize that their own media use can have a negative effect on children.

And keep this in mind:  these present only a  skeletal summary of guidelines, address only the youngest children.  There is obviously much, much more to say about media effects on all ages.  But this will do for the scope of this article.  Key bottom line:  electronic  devices of all kinds simply cannot do what loving, attentive, and mindful human caretakers can provide.   A final thought:  the full AAP statement appeared on pages 1040-1045 of the November issue of the journal Pediatrics.  Separated by only 33 pages  is another revised Academy Practice Guideline article–on  ADHD.   Parents who invest enough in the recommendations of the  first article  may well have to deal less over the years with the problems covered in the second.  No guarantees, of course, but it certainly might make a big difference.

However, there is an important bonus to having young adults protected against pertussis when they become the parents of a newborn infants.  Although (hopefully) these babies will receive their own whooping cough immunity as they get their own vaccines, there is a period of vulnerability.  Until first immunization at  six to eight weeks  (and even a few additional weeks until antibodies are produced) they are fully susceptible to pertussis should they be exposed.  And really dependable  protection is assured only after the second dose a couple of months later.  Since many studies have demonstrated that most cases of infant pertussis are acquired from unrecognized infection of family members caring for babies, it is highly adviseable that parents and other close relatives assisting in this care be vaccinated with Tdap anytime before or just after the birth of the new family member.

And how do grandparents figure into all this?  Not surprisingly, pretty prominently.  In one study of over a thousand children under three years of age, 35% of them were cared for by grandparents for at least three months.   Even without specific studies, it is obvious that grandparents or other older family members  very frequently assist in the care of  newborns and young infants, usually with very close contact.  And here is where Tdap immunization has been a bit more problematic:  to date, both brands are  licensed for use only up to 64 years.  However,  there is now enough published evidence that these vaccines are considered safe and effective in individuals 65 years and older, and in a policy statement in the October 2011 issue of Pediatrics , the A.A.P. is now recommending vaccination for all older individuals in the setting of care for young infants–grandparents, other family, and all health care personnel.

The term that has been adopted for providing this pertussis-safe haven for young infants is “cocooning,” and with this newest recommendation the cocoon should be an even more secure one.  But the last word is that all infants should still receive their own vaccines according to the recommended schedule.  Whooping cough remains a potentially devastating infection and is highly preventable.

The practice of swadding young babies has been around for a more years and used by more cultures than one could accurately assess, and in recent years has become increasingly popular in our country.  Perhaps with this increasing inclination in mind,  three organizations dealing with pediatric orthopedics, have mutually developed some guidelines as to how to safely swaddle babies.   The September issue of AAP News features an article by prominent pediatric orthopedists and AAP authorities Dr. Charles Price and Richard W. Schwend, describing risks to babies’ hip development  from improper swaddling, specifically hip dislocation or  dysplasia.  Reviewing studies in which included experience with swaddling methods  native American Indians and Japanese and Turkish parents, as well a benchmark 2007  study and another study by the same “5 S’s” Dr. Harvey Karp, both in the journal Pediatrics,  the authors summarize the safer method of swaddling recommended in the guidelines presented by the three authoritative groups mentioned above.  In brief,  safe swaddling, the infant’s hips should be flexed (not tightly maintined straight), somewhat abducted (separated), and maintained to allow some movement rather than maintaining  rigid tightness.  All of this is to prevent or minimize the risk of the condition of developmental dysplasia of the hip, a potentially serious condition with possible permanent consequences for gait throughout life.  As usual, this is necessarily an inadequately brief discussion given the goal of this article, but hopefully the main points are clear.

And to clarify correct positioning, the Academy presented it’s own parent guide to safe swaddling, written by AAP author,  Trisha Korioth.  Risking a little repetition from what’s already been said,  here is the statement  as presented in AAP News:

Updated flu vaccine recommendations from the American Academy of Pediatrics (AAP) stress the importance of getting a new flu shot this season – even for children who received one last year.

The 2011-2012 flu vaccine protects against the same three influenza strains as last year’s vaccine. But because a person’s immunity drops by as much as 50 percent 6-12 months after vaccination, it’s important to receive another dose this year to maintain optimal protection. This is only the fourth time in the past 25 years that the composition of the trivalent seasonal influenza vaccine has remained the same for a second year.

The AAP guidelines are included in the policy statement, “Recommendations for Prevention and Control of Influenza in Children, 2011-2012,” published in the October 2011 print issue of Pediatrics (published online September 1).

The AAP recommends everyone 6 months or older receive influenza vaccine. Special efforts should be made to immunize all family members, household contacts, and out-of-home care providers of children who are younger than 5 years; children with high-risk conditions (e.g., asthma, diabetes, or neurologic disorders); health care personnel; and all women who are pregnant, considering pregnancy, or breastfeeding during the flu season. These groups are most vulnerable to influenza-related complications.

Most children with a history of mild egg allergy (i.e., hives) can safely receive the influenza vaccine without needing an allergy consultation, but parents should consult an allergist before administering flu vaccine to children with a history of severe egg allergy (i.e., cardiovascular changes, respiratory or gastrointestinal tract symptoms or the required use of epinephrine).

This year’s policy contains a simplified dosing algorithm for administering the influenza vaccine to children depending on the child’s vaccine history and age at the time of the first administered dose:

• Infants younger than 6 months are too young to be immunized.
• Children 9 years of age and older need only 1 dose of influenza vaccine.
• Children 6 months through 8 years of age need only 1 dose of the 2011-2012 influenza vaccine if they received at least 1 dose last season.
• Children 6 months through 8 years of age should receive 2 doses if they did not receive any vaccine last season. The second dose should be administered at least 4 weeks after the first.
• An intradermal vaccine has been recommended for people 18 through 64 years of age.

Editor’s Note: Information for parents and caregivers on the new flu recommendations will be posted on www.healthychildren.org/flu  on Thursday, September 1. Reporters who would like a direct link to this flu guidance to include in their story should contact the AAP Department of Communications.