Stubborn Staph

Q My son has had recurrent staph infections in his skin with MRSA. He gets bolls and impetigo. We keep giving antibiotics, and they keep coming back. Is there any way to get rid of staph for good?

A Staph has become a very tricky bacteria- it's become more invasive and destructive, and is resistant to many common antibiotics. It also seems to be able to become dormant and recur In many people. Over just the past few years of practice, our approach to staph has changed, and we still have more to learn about the best way to handle it.

By staph, you probably mean the bacterium Staphlococcus aureus. The new variety that's causing a lot of mischief is abbreviated "MRSA" for methiclllln-resistant Staphlococcus aureus, sometimes pronounced "mer-sa." The typical MRSA variety found in communities is resistant to many antibiotics, but certainly not all of them; an even nastier, hospital-based "su per- M RSA" has become resistant to almost all antibiotics.

MRSA infections are usually found In the skin, either causing a deep abscess or boil, or an infection just atop the skin called "impetigo." Deep infections are tender and warm, and have a raised, tense feeling. Impetigo looks like areas of broken skin with honey-colored pus. Sometimes these infections can occur together. More serious, invasive infections with MRSA can include bone or joint infections, pneumonia or abscesses in deep organs.

Treatment begins with getting rid of the pus. Impetigo should be thoroughly washed at least once a day (ordinary soap is fine, with plenty of running water). Deep abscesses will usually have to be drained, which may require a cut through the skin. After drainage, sometimes a small wick of fabric or a small length of hollow tube is left in place to prevent pus from re-accumulatlng.

A well-drained abscess may not need any antibiotics, but other kinds of infection do. Antibiotics that are reliably effective against ordinary community MRSA include Bactrim and clindamycin, or doxycycllne (for older kids only). Between drainage, cleaning and antibiotics, an acute MRSA Infection can usually be knocked out.

Often, MRSA infections recur. Antibiotics treat the acute infection but don't do a great job getting rid of the bacteria for good. Strategies to eliminate staph carriage can include using topical antibiotics in the nose (staph likes to hide there), soaking in a diluted bleach solution, using special medicated soaps, decontaminating bedsheets, or treating asymptomatic family contacts with topical or oral antibiotics. Unfortunately, even combinations of these techniques aren't nearly 100% effective at permanently eradicating staph.

A staph eradication plan should be established with your physician, who knows your case and family well. Though it may not be possible to guarantee success, usually a combination of strategies will help at least reduce the chance of staph Infections.

Cough

Q What is causing my child to cough so much? He's had a cough for at least three months, and my pediatrician is out of ideas.

A Chronic or frequent coughing is a fairly common complaint, and it's not always easy to figure out the cause. Though there are probably hundreds of potential causes of prolonged coughing, most kids have one of these things going on:

Asthma-This is far and away the most common cause of frequent or prolonged cough. The cough tends to be worse at night and with exercise.

One cold after another- Also very common, especially In day care kids, a seemingly endless string of colds is most often seen in the winter.

Allergies-Most commonly causes congestlon/sneezing/ltchy nose. environmental allergies also cause cough.

Chronic or recurrent sinusitis- Sinusitis causes a cough from mucus drip, usually worse at night.

Habit cough- Sometimes also called "psychogenic cough," this is the cough that disappears when kids fall asleep.

Reflux- Gastroesophageal reflux can be sneaky, and can trigger a cough that's especially bad at night, even without obvious symptoms like heartburn.

Pertussis- In many communities, "whooping cough" is making a comeback, thanks in part to families who choose not to immunize. Protect yourself and your children from this "100-day cough"- though the vaccine isn't 100% effective, it's the best protection we've got. Once the cough of pertussis sets in, no treatment is effective.

The key to the diagnosis Is almost always In the history. To help figure out the cause of cough, the most important "test" is a good, careful log describing when the cough is better and worse. Keep track of when the cough occurs, what time of day or night, and what your child is doing during the cough. What makes it better? What makes it worse? What other symptoms might be going on, like fever, nasal drip or congestion, abdominal pain, shortness of breath? Go over the details with your pediatrician to help figure out the most likely culprit.

If necessary, high-tech tests might include a chest X-ray, blood tests, or endoscopy. If your child does undergo these or other tests, keep track of the results to share with other specialists that might get involved.

Meanwhile, help a coughing child feel better with some comfort care. Though OTC medications don't work very well, steamy showers, a humidifier or honey can help. Whatever the cause, coughing can Irritate the throat, leading to more mucus production, more swelling, and more cough- so soothing lozenges (for older kids), popslcles or Ice cream can be far more effective than any medication. Stay away from regular use of narcotic-based prescription cough syrups, which can be habitforming and potentially dangerous especially In young children. A cough can linger and annoy, but don't use a remedy that's worse

Colicky, or Just Cranky?

Q My baby seems to cry a lot, especially in the evenings. She's three weeks old, and the pediatrician says it's colic. How do I know there isn't something seriously wrong? Are there natural remedies that will work?

A Crying is a part of life for any parent, but some babies seem to cry a whole lot more than others. In most cases, there's no medical problem at all- they're just blowing off some steam, working through the ordinary transition that babies have to make. Other times, crying can be a sign of a more important problem. Excessive newborn crying Is often called "colic."

How much crying Is considered "excessive?" The official medical definition of colic requires a baby to be less than four months old and 1) cries for more than 3 hours a day for 2) more than 3 days a week for 3) more than three weeks in a row. In reality, whether a baby cries too much really depends on the parents- a practical definition of colic is "more crying than parents feel they can deal with."

The most Important questions about a fussy baby are "Does the crying mean that anything Is medically wrong?" and "How can the parents help their crying baby feel better?"

Understanding colic starts with understanding babies. It's tough being a newborn. You've been warm and snug underwater for your whole life. Then, your world turns literally upside down. All of a sudden there's light and air and your arms and legs stretch and wag around. Your tummy- for so long, quiet and unmoving- now churns, moves, makes gas and who knows what else. Try to Imagine such a huge transition. You'd cry, too, if it happened to you (well, you did when you were born!).

It's tough being a newborn's parent, too. You're not sure what to do, and you're not sure if things are going right. Lack of sleep makes nothing easier. And babies, even newborns, can tell when their parents are stressed. Combine stressed, tired and worried parents with anxious, frazzled babies, and you've got to expect some crying.

The excessive crying of ordinary, healthy babies who are just blowing off steam follows a specific pattern. These babies cry at a set interval each day, almost always In the evenings. Many parents will say they can set their clocks by the crying period. The crying peaks at about 4-6 weeks, and goes away by the time the baby is three or four months old. It's still exhausting, but it's reassuring to know that there is no medical problem that occurs only at set hours in the evenings.

If a baby's excessive crying doesn't fit into the classic, evening crying pattern, then It's more likely that there is a genuine medical issue going on. These babies are more likely to be "fussy all the time" or "fussy at random times."

Some problems that might cause constant or unpredictable crying include:

* Reflux, which can lead to pain and heartburn. All babies spit up some, and If it's not causing pain, this doesn't need treatment. But spitting that's causing heartburn needs to be discussed with the pediatrician.

* Food allergy, either formula Intolerance or a problem with something in mom's breast milk.

* Temperamental fussiness. This refers to babies who have a hard time settling down, are anxious, and cry a lot. These babies need extra reassurance, and their parents need extra support. Sometimes, this kind of crying is referred to as "gas pain"- though when you think about it, passing gas doesn't really hurt. It's more that it feels funny, and makes some babies worry and cry. The best treatment for "gas" is reassurance.

* Constipation. It's not common In little babies, but if your infant has firm and painful stools, then that needs to be addressed. Note that many babies (especially breastfed) can go days without stool- that's not constipation, as long as the stool is soft.

* Maternal health problems, which includes post-partum depression. This can cause or be caused by excessive baby crying.

* Other rare medical problems.

The first step for parents of fussy babies is to work on getting some respite care. You especially need time to unwind and get some rest. If there's no family in town, then you may need to rely on a neighbor, close friend or a hired nursery helper. No matter what the underlying cause of the fussing, you'll be able to deal with it better if you have a chance to catch your breath once in a while.

Then, make sure that your pediatrician gets the whole story and conducts a good complete physical exam. Bring notes with a log of the fussiness- when is it? How does it relate to meals and bowel movements? What have you tried that has helped? In my experience, the answer to the mystery of a fussy baby is much more likely to be found In clues the parents provide than in any sort of medical tests.

Some techniques can soothe a fussy baby. A nice, tight swaddle helps a baby feel like she's "back in the womb" and can be reassuring. A pacifier, swing, and/or buzzing bouncy seat can also help. Some babies like a ride in the car, or like to sit near a clothes dryer as it spins. A small white noise generator makes a soothing, rainlike sound that many babies find relaxing.

As for "natural" remedies, a study published in the March 2011 issue of Pediatrics looked for evidence that supplements and other alternative-medicine modalities help colic. The authors reviewed published data on sugar water, preblotic and problotic supplements, herbal teas, massage, reflexologyguided therapy and chiropractic.

The bottom line: none of these have been shown to work. Other studies have looked at moretraditional "medical" therapies, like Myllcon gas drops, and have also found disappointing results. Likewise, formulas advertised to help with colic or ease digestion probably won't do any good, either.

Babies, especially newborns, cry a lot. Most of the time, it's just exhaustion and blowing off steam rather than any medical problem that needs medical attention. Look for the pattern of the crying as the best clue to know If there's anything to worry about, and visit your pediatrician for a good history and physical to make sure you're taking the best steps to help your crying baby feel better. The best "cure" is time- these babies will outgrow their fussiness, and parents don't have to waste their money on "natural" or even "medical" therapies that won't work.

Author affiliation:

By Roy Benaroch, MD