Medical Advice - Hirsch Pediatrics

Dr. Hirsch Medical Advice

Treating a Fever and Medication Dosing Instructions

Note: These guidelines are only for children who are 2 months of age or older and are fully vaccinated with no chronic medical illnesses. Please call Dr. Hirsch or go to the ER if your child is under 2 months old and has a fever (rectal temperature of 100.4 Fahrenheit or 38 Celsius). Also this handout is meant to provide general guidance and should not be used as a substitute for more detailed advice that can be given over the phone or at an appointment. If you have any significant or ongoing concerns, please call the office.

My infant/toddler has a fever. What should I do?

DO NOT PANIC!
Even for infants, fever is not harmful. Fever is a normal reaction of a healthy immune system that is responding to an infection. The vast majority of infections in children are due to viral illnesses and do not need antibiotics to treat.
Fevers typically range from 100.4 – 105 degrees and may last for 3 – 5 days.
To help your child feel better, please treat the fever!

If you say the fever is not harmful, why do you recommend TREATING THE FEVER?

Most children are very uncomfortable with a fever and because of this they may appear very sick with decreased energy, decreased appetite, fussiness, and faster breathing.
By treating the fever, you can avoid unnecessary sick visits as well as emergency room and urgent care visits.
Typically within 1 hour of giving a fever reducing medication, your child should “RECOVER” and look significantly better. Once your child is more comfortable you will have a better idea if the underlying illness requires an office visit or more immediate attention.

What should I expect after I treat the fever, and when do I need to worry?

After you treat the fever, within 1 hour your child should recover (see above). If your child recovers well then it is usually okay to continue close observation at home for the next few days.
If after you treat the fever, your child does not recover well and continues to be extremely irritable, lethargic, or have difficult/rapid breathing, then please call to schedule an appointment ASAP. If it is after regular office hours, then I would typically recommend that you proceed directly to the emergency room or urgent care. Please see our website for information on our recommended urgent care and emergency rooms. If you need to go to an emergency room or urgent, we will contact you the next business morning to ensure your child is doing well and the appropriate management is in place.
In addition, please schedule an appointment if your child has a low grade fever that after a few days suddenly becomes much higher.

How do I treat the fever?

All children age 6 months and old should be given IBUPROFEN (Motrin, Advil, other generic brands) every 6 – 8 hours as needed for fever and fussiness.
Important Note for children over age 6 months: Ibuprofen works significantly better and lasts longer for children and should ALWAYS be given instead of acetaminophen.

All children age 2 – 6 months should be given acetaminophen (Tylenol, other brands) every 4 – 6 hours as needed for fever or fussiness.

Please see our separate handout for a dosage chart. Note: For older children, you can also use chewables or pills according to the milligram dosage.

What else do I need to know about treating fevers?

These are guidelines based on my experiences of treating many children. If you still have concerns or feel that your situation is different, please contact the office (regular hours) or urgent care/ER (after-hours). If you proceed to urgent care/ER, we will contact you the next business morning to ensure your child is doing well and the appropriate management is in place.
If your child develops fussiness or fever and it is too soon for your next ibuprofen dose, you can give a dose of acetaminophen in addition to ibuprofen at any time. Just remember to space ibuprofen doses by 6-8 hours and acetaminophen doses by 4-6 hours.
It is safe to give ibuprofen and acetaminophen (in the correct dosage and timing intervals) for as many days as is necessary. Please note that it is normal for fevers from viral illnesses to spike every 4 – 6 hours for 3 – 5 days in a row. However, please contact us if you have to give these medications for more than 5 days in a row.
It is safe to give ibuprofen and acetaminophen with other medications including antibiotics, steroids, and Benadryl.
If your child has a fever and symptoms that may suggest an ear infection, strep throat, or urinary tract infection, please call to make an appointment. If it is after-hours or weekends, it is okay to wait until Monday as long as your child is well-appearing and recovers well with acetaminophen/ibuprofen.
Vaccines can typically cause fevers for 2 – 3 days.
You can also give acetaminophen and ibuprofen for children who are fussy or uncomfortable for any reason even if there is no fever.

Ibuprofen (Motrin , Advil, other generic brands) may be given every 6 – 8 hours Important note for children over age 6 months: Ibuprofen works significantly better and lasts longer for children and should always be given instead of acetaminophen.
Weight	Ibuprofen Milligram Dosage	Ibuprofen Infant Drops 50mg/1.25ml	Ibuprofen Children’s Liquid 100mg/5ml (Note: 1 tsp = 5 ml)
12 – 17 lbs	50 mg	1 dropper (1.25 ml)	½ tsp (2.5 ml)
18 – 23 lbs	75 mg	1 ½ dropper (1.875 ml)	¾ tsp (3.75 ml)
24 – 35 lbs	100 mg	N/A	1 tsp (5 ml)
36 – 47 lbs	150 mg	N/A	1 ½ tsp (7.5 ml)
48 – 59 lbs	200 mg	N/A	2 tsp (10 ml)
60 – 71 lbs	250 mg	N/A	2 ½ tsp (12.5 ml)
72 – 95 lbs	300 mg	N/A	3 tsp (15 ml)

Acetaminophen (Tylenol, other generic brands) may be given every 4 – 6 hours
Weight	Acetaminophen Milligram Dosage	Acetaminophen Infant and Children’s Liquid 160mg/5ml (Note: 1 tsp = 5 ml)
9 – 11 lbs	60 mg	1/3 tsp (1.875 ml)
12 – 17 lbs	80 mg	½ tsp (2.5 ml)
18 – 23 lbs	120 mg	¾ tsp (3.75 ml)
24 – 35 lbs	160 mg	1 tsp (5 ml)
36 – 47 lbs	240 mg	1 ½ tsp (7.5 ml)
48 – 59 lbs	320 mg	2 tsp (10 ml)
60 – 71 lbs	400 mg	2 ½ tsp (12.5 ml)
72 – 95 lbs	500 mg	3 tsp (15 ml)

PDF HANDOUT: Everything You Need Know About Treating Fever and Dosage Instructions

Treating a Cold, Cough and Congestion

Note: These guidelines are only for children who are fully vaccinated with no chronic medical illnesses. Please call Dr. Hirsch or go to the ER if your child is under 2 months old and has a fever (rectal temperature of 100.4 Fahrenheit or 38 Celsius). Also this handout is meant to provide general guidance and should not be used as a substitute for more detailed advice that can be given over the phone or at an appointment. If you have any significant or ongoing concerns, please call the office.

How do I know if my child has a cold, and what exactly is a cold?

A cold, also known as an upper respiratory infection, is caused by one of over 200 viruses that infect the nose, sinuses, throat, and ears. Typical symptoms of a cold include cough, congestion, runny nose, sore throat, red and draining eyes, ear pain, swollen lymph nodes, and decreased appetite. Because of these symptoms, your child (and thus you) can have many sleepless nights as well as mild difficulty breathing.

How long will the cold last?

Most cold symptoms such as runny nose, cough, and congestion can TYPICALLY LAST UP TO 10-14 DAYS OR LONGER. Typically the fever will only last 3-5 days.

Will my child need antibiotics to treat the cold?

Because the symptoms are due to a virus, ANTIBIOTICS WILL NOT HELP your child feel better and thus should be avoided for the vast majority of typical uncomplicated colds. The inappropriate use of antibiotics for a viral illness like a cold can lead to uncomfortable or harmful side effects in your child as well as concerning future antibiotic resistance.
One exception to this rule is when your child’s symptoms are consistent with an acute bacterial rhinosinusitis (ABR) which I will often treat with a 10 day course of antibiotics. ABR can be diagnosed when the cold symptoms are not getting better after 10-14 days or seem to get much worse after 5-7 days. Please note that your child must have an office visit before I will prescribe antibiotics and antibiotics will not be called in by phone unless your child has already been seen during the current illness.

Can I give my child cold medications?

Hirsch STRONGLY DISCOURAGES using the vast majority of cold medications for all infants and young children, particularly under age 6. Not only are these medications found in studies to be no better than placebo; they can cause harmful side effects. One exception is the Vick’s Vapor Rub which can be used in children age 2 and up and has been shown in studies to improve some cold symptoms, particularly at night.

Okay, so I understand that my child will not benefit from antibiotics or cold medications, but he is really having a tough time with sleeping and feeding! Is there anything I can do to make him feel better?

YES!
In addition to the most effective treatments of TIME AND PATIENCE, I would recommend treating particular symptoms with the following interventions:

Stuffy nose/nasal congestion – Please use the Nosefrida suction device with saline drops as often as needed day and night. To use the Nosefrida on older infants or toddlers, you will often need a helper or a blanket wrap around the torso to hold the child still while you remove the mucous. To use the saline drops, lay your child down on a carpeted surface and tilt his chin up a little. Put 1-2 drops of saline in a nostril and then after a few seconds you can suction the mucous out. Note that you can purchase or make normal saline nosedrops by mixing 1/2 teaspoon of table salt in 8 ounces of water. The salt water can be dripped with an eye dropper or wet cotton ball. Hirsch Pediatrics can also give you several vials of saline at no cost if needed.

Cough – Children over 1 year old can be given 1 teaspoon of honey at bedtime and as needed. Also keeping the air in your child’s bedroom moist with a humidifier is helpful. For middle of the night coughing fits, you can try bringing your child into a humid room like a bathroom that is steamy from hot water running. It is common for small children to vomit after coughing fits.

Fever/fussiness/ear pain/sore throat – Children 6 months and older should be given ibuprofen. Children from 2-5 months can be given acetaminophen as needed. Please visit the Hirsch Pediatrics website for a handout on dosage instructions. Using these medications can be particularly helpful at bedtime.

Difficulty sleeping – Fortunately the sleepless nights will improve, though it may take several nights. It is helpful to sleep on an incline whether this means holding your infant in your arms for a few nights or using pillows for your toddler.

When should I make an appointment to see Dr. Hirsch?

While I am always happy to see you and your child(ren), for most common colds you can safely avoid an office visit. HOWEVER, I always want to see your child for an appointment if he has any PERSISTENT DIFFICULTY BREATHING (that is not just due to nasal congestion), has symptoms that are not getting better after 10-14 days, or seems to get much worse after 5-7 days.
For ear pain that is significant and persists despite using the appropriate dosage of acetaminophen or ibuprofen please schedule an appointment. Note: Most ear infections are mild and do not need to be treated with antibiotics as long as the pain is manageable during the day and improves after several days. Thus, I strongly recommend avoiding antibiotics for mild ear infections especially when it is prescribed from an urgent care center.
Sore throats with cold symptoms like cough and congestion do not need an appointment for a strep test because a strep throat infection does not cause cold symptoms.
If for any reason you are still concerned and would like an appointment, please do not hesitate to call for an appointment at any time.

When do I need to really worry and go to the ER immediately?

It is very rare that you would need immediate attention that can not wait until the next morning. However, I would recommend going to the ER if your child is having persistent and significant difficulty breathing or skin looks blue around the mouth.
Signs of difficulty breathing can include a respiratory rate of over 60 times per minute, retractions (skin along the rib cage being pulled in with each breath), and abdominal breathing (belly going in and out rapidly with breathing).

When can my child go back to school or daycare, and when is my child still contagious?

Though the cold symptoms may linger for a week or two, most children are able to return to school or daycare when they have been fever free for 24 hours; the daytime cold symptoms are mild; they do not require active management such as steaming, acetaminophen, ibuprofen; and children feel comfortable enough to participate in regular daycare or school activities.
The peak contagiousness period is immediately before and at the start of the symptoms as well as during the fever. Once your child’s symptoms are improving she is much less contagious.

How can I prevent my child from catching a cold?

Most infections are spread by transmitting a germ from a contaminated surface to a mucous membrane. Contaminated surfaces are those surfaces where a living germ has landed or been placed (usually by a contaminated hand), such as doorknobs, toys, and other people’s hands. Mucous membranes are parts of your body that can internalize a germ and thus lead to infection. These include your eyes, nose, and mouth. Therefore, the vast majority of infections are transmitted when a child or their caregiver touches a contaminated surface and thereby contaminates their hands, and then touches their (or someone else’s) eyes, nose, or mouth.
Therefore, when you have a cold in your house, it is helpful to frequently wash your hands, disinfect surfaces, and limit direct contact with a child’s mucous membrane.
Limiting exposure to groups of children in daycare or other public places will decrease transmission of colds. However, since that can be hard to do, regular hand washing and trying to keep hands away from eyes, nose and mouth are the best ways to minimize cold transmission.

PDF HANDOUT Everything You Need To Know About Treating Cold and Cough and Congestion

Pink eye (conjunctivitis)

What is “pink eye” (also known as conjunctivitis)?

Conjunctivitis is simply the medical term for “pink eye.” The conjunctiva is the outermost surface of the white part of the eye and the inner surface of the eyelid. When the conjunctiva is infected or irritated it will appear pinkish or reddish and is called conjunctivitis or pink eye.

Does my child have pink eye?

If your child’s eye appears pinkish or reddish then “yes” your child probably has conjunctivitis.

So now I think my child has pink eye. What should I do?

DO NOT PANIC!
Fortunately the vast majority of pink eye cases are due to mild viral infections and usually improve on their own in 3-4 days without the need for an appointment or prescription eye drops.

Is “pink eye” contagious and when can my child go back to daycare/school?

As noted above most cases of pink eye are due to mild viral infections and thus are contagious (similar to any other viral infection such as a cold).
However unlike colds which can linger for 10-14 days, most pink eye infections tend to improve on their own in 3-4 days.
Most daycares/schools should allow a child back if the eye drainage is minimal (not recurring throughout the day) and the child overall looks well without fever or fussiness.

When are prescription eye drops for pink eye helpful?

Prescription anti-bacterial eye drops are helpful for eye injections that are more serious and thus may come from bacteria. Eye infections from bacteria tend to persist for more than 3-4 days or have thick greenish pus that accumulates frequently during the day.
Also some child care centers require that any child with pink eye (even if it is very mild) take prescription eye drops for 24 hours before returning to daycare.
Note: This daycare policy has very little medical justification since the vast majority of conjunctivitis cases are due to viral injections and thus do not improve any sooner with anti-bacterial eye drops.

How do I get a prescription for eye drops?

If you feel your child may benefit from eye drops, please contact Dr. Hirsch during regular business hours and Dr. Hirsch will send a prescription to your pharmacy without an appointment.
You can also send a message through your patient portal 24/7 and Dr. Hirsch will respond the next morning.

What if I need a prescription for eye drops after-hours?

Fortunately as noted above there is no medical need for an after-hours or immediate eye drop prescription.
However if you still feel that your child needs an immediate after-hours prescription for eye drops, then your child should first be seen at an after-hours clinic.

When does my child need an appointment for pink eye?

Please make an appointment if the eye drainage or redness is not significantly improved (with or without eye drops) after 7 days.
Also your child should be seen immediately if there is significant swelling and redness around the eye or if your child has any blisters around the eye or cold sores.

What is the prescription eye drop?

Polytrim eye drops is the most common prescription. The dosage is 1 drop per eye applied 3 times per day for up to 7 days.
You can stop the eye drops as soon as the eye as improved.
The dosage is the same for all age children and adults.
If your child is in daycare/school, the drops can be administered before school/daycare, after school/daycare, and at bedtime.
Please note Dr. Hirsch always sends in refills so you can access the eye drops in the future for any child without having to call the office.

How can I keep conjunctivitis from spreading in my house?

To prevent conjunctivitis (or any other infection from spreading), good hygiene – in particular frequent hand washing after touching the eyes – is important as well as disinfecting objects and surfaces that may come into contact with other family members.
Fortunately even if several family members have the same conjunctivitis infection, it is not possible to get reinfected by the same infection.

My child may have seasonal allergies so is it possible the pink eye is from allergies?

Yes, “allergic conjunctivitis” can also cause similar symptoms as a viral pink eye infection.
Eye allergies often come with very itchy eyes and a clear runny nose.
Typically eye allergies are not seen in infants and do not start until at least age 2-3.
You can treat allergic conjunctivitis with over the counter Zaditor eye drops. The dosage for children age 3 and older is 1 drop into each eye 2 times per day spaced 8-12 hours apart.

PDF HANDOUT Everything You Need to Know About Treating Pink Eye and Conjunctivitis

Vomiting

Why is my child vomiting?

DON’T PANIC! Though vomiting may look scary the most common cause of vomiting in children is from a viral illness (“stomach bug”) and can easily be managed at home. Vomiting caused by a viral illness can also cause diarrhea and fever.
Note: Please see Dr. Hirsch’s other handouts on diarrhea and fever for additional guidance on these topics. Other common causes of vomiting include reflux in infants; and toddlers that have a cold may vomit after coughing a lot.

How long will the vomiting last?

Typically vomiting from a viral illness will last 3-5 days, though it can be intermittent for up to 7 days. Please schedule an appointment if your child is vomiting for more than 7 days.

How do I treat the vomiting?

It is important to keep your children hydrated with the 6 step Hirsch Pediatrics Vomiting Protocol (see below). This protocol will guide you in fluid and diet management. Note: If your child vomits only once and otherwise looks well, you can hold off on the vomiting protocol.
Dr. Hirsch does not recommend any over-the-counter nausea, vomiting, or diarrhea medications for children.

When can my child go back to school or daycare?

Your child can return to school or daycare if your child has not vomited for 24 hours, does not have a fever for 24 hours, and overall looks well.

How do I know if my child is dehydrated?

This is very important. The most important measure of hydration is your child’s activity level. In general, even if your child has vomited multiple times, your child is not dehydrated if your child is still playful and active in between the vomiting episodes. Even if your child is refusing most food and drink and continues to vomit, active and playful children are not dehydrated and can be managed at home even if they have less urine output.
Your child may be dehydrated if he/she is very lethargic in between the vomiting episodes and cannot tolerate fluids on the vomiting protocol.

When do I need to worry?

Please call us for an appointment if your child appears dehydrated; vomits bile (greenish tint to vomit) or blood more than once; or has worsening and persistent belly pain. In these situations your child may need intravenous fluids or additional tests done. If it is after hours please proceed to the Emergency Room (or contact Dr. Hirsch for additional advice if you are not sure). Also please make an appointment during regular hours if the vomiting persists more than 7 days.
Also please call us if your child is under 2 months old has persistent vomiting.

Hirsch Pediatrics Vomiting Protocol

Step 1: Do not give any solids or milk products.

Step 2: Begin hydration with Pedialyte. You can also use diluted juice or juice mixed into the Pedialyte if your child will not take Pedialyte. Do not give water by itself (especially to infants) as this does not have the necessary electrolytes and calories. For infants that breast feed only and will not take a bottle, you can try to breastfeed for shorter periods of time every 2 hours.

Step 3: Give the following small amounts of Pedialyte every 20 minutes:

infants should take 2 teaspoons (10 ml)
toddlers should take 2 tablespoons (30 ml or 1 ounce)
school age children should take 2-4 tablespoons (30-60 ml or 1-2 ounces)

Important note: Even though your child may be very thirsty and want more fluid, it is important to start with the recommended small amount to get the vomiting under control.

Step 4: After 2 hours of no vomiting, you can gradually increase the amount of fluids.

Step 5: After 8 hours of no vomiting, you can offer your child small amounts of bland foods (i.e. rice, apple sauce, toast, soup).

Step 6: After 24 hours of no vomiting, you can resume a regular diet.

** Note: If at any step along the way, your child vomits again then wait 20 minutes and return to step 1. It is common for children to look well and seem better but then start vomiting 1-2 days later when they eat too much.

Everything You Need To Know About Vomiting

Treating Constipation

Is constipation common in children?

YES, IT IS VERY COMMON IN CHILDREN OF ALL AGES from the newborn through teenage years.
Constipation tends to peak around the age solid foods are introduced (age 5-12 months) and during potty training (age 2 – 3 years).
Most constipated children have particularly efficient colons that remove too much water from the poop before the poop can be eliminated. Other children may become constipated if they have not yet acquired the skill of pooping regularly (newborns) or actively withhold their poop (toddlers).

What are some of the ways that constipation presents in children?

Your child has poops that are hard pellets or balls.
Your child may pass exceptionally large poops that can even block up the toilet or seem enormous for a small child.
Your child may have pain when pooping and even refuse to poop due to the pain.
Your child may have vague belly pain or occasional nausea and may even vomit.
You notice blood streaks on the stool due to hard stool causing small tears in the rectum.
Your child has difficulty urinating on a regular schedule (dysfunctional voiding). This can present as children who suddenly need to urinate small amounts every 15 – 30 minutes despite having normal urine tests.
Your child has a urinary tract infection due to excessive stool in the colon which puts pressure on the urethra leading to incomplete emptying of the bladder.
You notice behavior changes such as increased fussiness and hyperactivity as well as poor sleep quality that are often related to your child’s pooping habits.
You see leakage of poop (encopresis) into the underwear without the child knowing. (Note: Though this leakage may seem like the child is having diarrhea, it is actually a sign of severe constipation.)
Your child is having difficulty staying dry overnight (enuresis) due to excessive stool in the colon pushing on the bladder leading to limited capacity for the bladder to hold urine.

If I do not treat my child’s constipation, will it just work itself out as my child gets older?

USUALLY NOT. Unfortunately, many children whose constipation is not managed early and aggressively can have long-term stretching of the colon which can lead to a colon that is ineffective long-term.

Can I use dietary changes instead to treat constipation?

Though adults are sometimes successful at managing constipation with dietary changes (i.e. increasing water and fiber intake), children rarely respond long-term to dietary changes alone.

What dose Dr. Hirsch recommend to treat mild constipation?

Age 2 weeks – 1 month:
- Apply rectal stimulation with a Q-tip or thermometer that has Vaseline on the tip. This can be repeated two or three times in one day.
- If your child still has no poop in another 24 hours, then you can use a “sliver” of a Pedia-Lax Glycerin Suppository.
- In addition, the Windi (made by the same company as the NoseFrida) is a non-medicated remedy that is exceptionally helpful for small infants and is available online, at local pharmacies, and at baby stores.
- Call Dr. Hirsch during regular hours if you have tried the above interventions and your child still has not pooped in another 24 hours.

Age 2 – 12 months:
- Start with prune juice 2 – 4 oz per day per day. The prune juice is the regular adult full strength prune juice and is much more effective than other juices or pureed prunes. Prune juice can be given in a bottle or mixed in cereal for children already on solid foods. Some children will only need prune juice for a few days while others may need it continuously for several weeks or months as their colons mature.
- If your child is still constipated despite maximizing the prune juice dosage or is now refusing to take the prune juice, then you should begin Miralax powder with a starting dose of ¼ capful up to a typical maximum dose of ½ capful per day.

Age 1 year and older:
- Give Miralax powder with a typical starting dose of ½ capful up to a typical maximum dose up to 1 capful per day.

Is it safe to give my child Miralax every day for several months (or longer)?

Miralax can be used safely even if given daily for many years.

How does Miralax work?

Miralax (generic name is polyethylene glycol) is a powder that can easily be dissolved in any amount of liquid. The dissolved powder is not digested and stays in the colon as an osmotic agent. This means it retains water in the colon keeping the stool from becoming hard and therefore difficult to pass. Because Miralax is not absorbed into the body, it will not have any systemic side effects. It will also not cause malabsorption of other nutrients and vitamins.

Will my child become “addicted” to Miralax?

No, Miralax is non-habit forming and you child cannot become addicted to Miralax.

I have been using Miralax but I think my child is still is very constipated. What should I do now?

In order for moderate or severe constipation to be treated, you often need a “clean-out” phase. For the clean-out phase, it is best to use sennosides which are a natural, gentle stimulant. In my experience, the easiest and most effective form is an adult ExLax Regular Strength (15 mg) chocolate chew given at bedtime.
Children age 2 – 6 can chew 1 piece at bedtime. Children 6 and older will need 1 – 2 pieces at bedtime. Typical duration of use for a “clean-out” is 2 – 5 nights until the poop no longer appears constipated.
After the clean-out phase, make sure you continue your Miralax. Note that your child may have some nausea and belly pain during the ExLax clean out phase.

My child is having intense bouts of abdominal pain. What should I do now?

Fortunately, as opposed to constipation, serious emergency causes of intense abdominal pain such as bowel obstruction or appendicitis are very rare. In general, children with emergency causes of abdominal pain will continue to have significant pain in between the cramps with minimal or no relief, will not be playful in between the cramps, will eat very little, and will get no relief from a Pedia-Lax Enema.
Children with intense pain due to constipation will look and appear relatively well in between the bouts of severe pain, will be playful in between the cramps, will continue to eat fairly well, and will get immediate and significant relief from a Pedia-Lax Enema.
If the pain is most consistent with constipation, you should immediately give a Pedia-Lax Enema (ages 2 – 4 give ½ bottle, ages 5 – 11 give full bottle).
Note: If the intense pain is not consistent with constipation, you should make an immediate sick visit if during regular hours or go to the emergency room if during after-hours.

How do I know when my child is not constipated?

Your child is not constipated when the poop is soft, normal sized, easy to pass, and comes every 24 hours. You should not notice any poop balls or pellets.
The consistency of non-constipated poops can be formed but soft or as loose as a milkshake.

When my child is no longer constipated, when can I stop the medications?

The most common mistake in managing constipation is to stop the treatments as soon as the poops are normal causing the child to have frequent future setbacks.
Daily treatment will typically continue for several weeks, months, or even years depending on the duration of constipation before successful interventions were started. Dr. Hirsch will work with you to figure out an optimal schedule for reducing and stopping medications.

What can I do to encourage good stool habits that may expedite the process of weaning medications as well as encourage long-term success?

It is helpful to have your child sit on the potty three times per day after meals, even if your child does not have to go potty. The child should sit on the potty for at least 1 minute for every year of age. For example, a 4 year old should sit on the potty for at least 4 minutes. You can make this a fun time with books and even a sticker reward chart. Use a step stool for your child’s feet since dangling feet make it harder to relax your muscles to poop.
Minimize foods that are higher in fat (non-skim milk products, cheese, etc) since these can contribute to constipation. Encourage water and a good variety of fruits and vegetables.
The book Mommy, I Have to Go Potty: A Parent’s Guide to Toilet Training by Jan Faull is a relatively short and easy to read book full of additional tips and strategies to encourage long-term pooping and potty training success.

What if we have tried the above interventions and my child is still constipated?

Most likely this means we have not yet found the appropriate dosage and combination of medications. Note that some toddlers actually require doses of medications that are equivalent to or greater than typical adult doses.

When is a referral to a specialist indicated?

Referral to a pediatric gastroenterologist is indicated when constipation continues to persist despite several attempts to optimize the medication. If necessary the specialist will be able to rule out other rare causes including food allergy, obstruction, celiac disease, and hypothyroid. Please contact us for a list of local pediatric gastroenterologists.

Everything You need To Know About Treating Constipation

Asthma and Wheezing

Hirsch Pediatrics is excited to announce our Asthma Quality Initiative (QI), launched in 2015 in collaboration with Children’s National Health System. The goal of this QI is to identify and track all children in Hirsch Pediatrics with a history of asthma or recurrent wheezing and to optimize your child’s care through the use of “best practices” described by Children’s and national guidelines.

Please see below important links with videos and documents that are useful for our QI as well as your child’s “asthma team appointment.”

Hirsch Pediatrics Asthma QI Welcome Letter

Asthma Diagnosis and Management (Extensive Handout Written by Dr. Hirsch)

Allergy Management (Additional Handout Written by Dr. Hirsch)

Two Great Videos Showing “What is an Asthma Flare?”

KidsHealth Video (2:26)
Children’s Hospital Asthma Clinic (1:34)

Asthma Flare Diagram

“Why Use a Spacer with an Inhaler?” Diagram

Asthma Medication Chart

Asthma Assessment Questionnaire: Pediatric Asthma Control and Communication Instrument (PACCI)

Note: This brief 12 question survey can be completed online before your appointment Hirsch Pediatrics CHADIS account. To access the PACCI, select “asthma/wheezing” for appointment type after logging in to CHADIS.

Stepwise Approach to Managing Asthma

Video Showing Effective Spacer Use (2:49)

Asthma Action Plan Templates (customizable):

Age 0-4 Asthma Action Plan
Age 5-11 Asthma Action Plan
Age 12 and older Asthma Action Plan

Basic Asthma Action Plan for Maryland

Two Great Websites with Asthma Information:

KidsHealth Asthma Control Center
Asthma Care Guidelines (from University of Michigan Health System)

Managing Allergies

How do I know if I child has allergies?

Allergy symptoms include recurrent runny nose/congestion/itchy nose (allergic

rhinitis), itchy/watery/swollen eyes (allergic conjunctivitis), and cough.

When left untreated for several weeks, symptoms can progress to a sinus infection with very thick mucous and even a fever. This is usually treated with an antibiotic.

Though some allergies such as food allergies can be seen an infants, environmental allergies (i.e. animal, pollen, dust, etc) typically start around age 3 years.

Allergy symptoms should worsen when exposure to the allergen.

Allergy symptoms should improve with allergy medications.

What time of year are allergies worse?

Most environmental allergens occur in the Spring and Fall in three waves.

First wave is EARLY SPRING TREE allergens
- peek in April and better end of May
- can stop meds when school is out

Second wave is LATE SPRING GRASS allergens
- peek in May – June
- can stop meds about July 4

Third wave is FALL WEEDS/RAGWEEDS
- peek in August – September
- can stop with first frost

What medications can I give my child?

Fortunately there are many safe and effective over the counter allergy medications for children.

Runny/itchy nose symptom

- Take Claritin or Zyrtec with first sniffle.
- Dosage for age 2-5 years is 5 mg (5 ml or 1 tsp).
- Dosage for age 6 – 11 years is 5 – 10 mg.
- Dosage for age 12 and up is 10 mg.
- Usually best to take in morning though occasional side effect of sedation can be managed by taking in evening. Zyrtec is often more effective but can cause more sedation.

Congestion symptom
- Take Flonase or Nasacort with persistent cough/congestion.
- Dosage for age 2-12 is 1 spray per nostril per day.
- No significant side effects and safe to take entire allergy season if needed.

Watery or itchy eyes
- Take Zaditor 1 drop per eye up to twice per day (age 3 and up).

Wheezing/asthma
- Dr. Hirsch will work with you to figure out the best medication regimen.

What else can I do besides medications to help my child?

If the cause of the symptoms is Spring/Fall seasonal allergies,
- Thoroughly wash your child’s hands and face (particularly around the eyes) as soon as your child comes inside the house.
- Keep windows closed and run air conditioning. This will remove allergens from the indoor air.

Frequent nasal saline nose rinses used 3-4 times per day can significantly improve the ability to clear out the congestion.

When should I see an allergy specialist?

I recommend referral to an allergist if symptoms persist despite adequate medication management described above. The allergist can often do skin prick testing and blood testing to better understand the cause of the symptoms.

Hirsch Pediatrics Allergy Management Patient Handout

Traveling with a Child

Car Travel –

Your car trip may take a lot longer. Plan on taking a break at least every 1 and 1/2 hours unless the baby is sleeping–then stop as soon as your baby wakes up.

Remember to always use a car seat when you take your baby in the car.
When travelling on north-south routes during the day, the sun may be particularly strong on a side seat so you may need to have a car window shade.
Bring extra wipes in the car for unexpected (or expected) big messes.
Bring healthy snack foods in case your baby decides to sleep through scheduled meal stops and you decide to make time rather than stop and wake the baby up.

Air Travel –

You may notice that your ears “pop” with pressure changes during takeoff and landing. Fortunately, though this temporary discomfort may be felt by a baby, it is usually very mild and does not require any special preparation. In fact, the next time you fly and feel your ears pop, you will notice that most babies are still calm and comfortable. If your baby does show significant discomfort, you can try feeding since sometimes swallowing helps equalize the air pressure. Note: It is safe to fly even when your child has a cold.

Despite recommendations from other family members or friends, you should NOT give your baby any special medications or sedatives to make him/her sleepy on the flight. Because many babies will not be able to stay asleep on a long flight, those that have been sedated can become extremely overtired and scream from exhaustion.
Some airlines may offer special discounts when booking a seat for children under 2. Children under the age of 2 years travel free on most airlines, but this means that they may have to sit on your lap if the plane is full.
There are FAA-approved car seats. Check on this when purchasing your car seat. A car seat is generally not counted as a carry-on item as long as your child is sitting in it. If you stow it in the overhead because your child is sitting on your lap, it may be counted as a carry-on.
If possible, reserve a bulkhead seat (just behind the bulkhead that separates coach and first class) because it has the most room. For international flights find out if the airline can provide you with a bassinet that can attach to the bulkhead wall.
Give yourself plenty of time at the airport.
If you are traveling by yourself and will not be met at your destination, a portable stroller is a lifesaver. You can generally fold it up and check it at the plane to be ready for you as soon as you step off of the plane.
For takeoff and landing, put the seat belt just around you and hold your baby on your lap or put the baby in a front carrier. Do not place the seat belt around the baby.
Car rental agencies generally have infant seats available with their cars. You need to reserve the seat when you reserve the car as well as call ahead to the local agency where you will pick up the car to confirm that the car seat is available.

Hotels –

Though you can reserve a crib at most hotels, many families find it much easier to bring your own “pack n’ play” when travelling. Bring a few familiar items that the baby has in his crib at home (such as rattles or stuffed animals). Note: If your baby is used to sleeping in his/her own room, you may need to sit quietly out of sight while your baby is falling asleep. You can even sit in the bathroom and read while you wait.

Ask if there is a refrigerator in the room. Some hotels will put a temporary refrigerator in your room for an extra charge.
Follow your baby’s normal eating, sleeping, and bedtime routine as much as possible.

Travel Immunizations and Medications –

Certain special vaccines are necessary to prevent diseases you might be exposed to during travel to other parts of the world. These vaccines include typhoid fever, yellow fever, meningitis, and Japanese encephalitis. If you are going to a part of the world where malaria is common, you may need to take medicine to prevent malaria.

To get up-to-date travel information on travel immunizations and medications, please review the following two resources at least 2 months prior to travel:

Centers for Disease Control and Prevention (CDC) via the Traveler’s Health Hotline at 1-877-FYI-TRIP or online at http://www.cdc.gov/travel

Travel Health Online: http://www.tripprep.com

Note: If you still have questions or will need a travel vaccine, please schedule an appointment with a specialty travel clinic. Travel clinics are very common in the DC area. The following clinic is located ½ mile from Hirsch Pediatrics.

Travel Advisory and Immunization Clinic

www.travelclinicmd.com

15005 Shady Grove Road, #450
Rockville, MD 20850
tel 301-738-6420