I’m Hearing A Lot About Dry Drowning. Should I Worry?

Posted on May 14, 2020August 18, 2020

Posted by Dr. Monica Wonnacott | May 14, 2020

Recent publicity surrounding “dry drowning” has sparked a number of phone calls from worried parents in my office. While it can and does happen, I want to send a message of general reassurance. The average kiddo who gulps or even inhales a mouthful of water while in the bathtub or while swimming and has a coughing fit afterward will probably not experience dry drowning.

Dry drowning is one of those topics where when you hear about it, you’ll freak out and worry, but once you really know enough about it, you’ll be reassured.

SO WHAT IS DRY DROWNING?

Dry drowning happens when a fluid (e.g., water) going down the airway causes the vocal cord to spasm and close off. This closes off the airway so the child can’t breathe. It’s called “dry drowning” because the fluid doesn’t get in the lungs. Technically speaking, in the world of medicine, “dry drowning” as a diagnosis doesn’t exist. All doctors know what is meant by the term, but use the general term “drowning” instead. Drowning is defined as “a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium.” (Idris et al. 2003). Drowning replaces all the confusing terms like “near-drowning,” “secondary drowning,” “passive drowning,” “silent drowning,” “wet drowning,” and “dry drowning.”

IS DRY DROWNING COMMON?

No. Dry drowning is really rare. If you consider “dry drowning” a type of “drowning” it only makes up 1-2% of all cases. “Drowning,” however (in the traditional sense that people think of) is unfortunately really common. In the US, it is the second leading cause of accidental death in the US (and leading cause in children 12-23 mo. old). In my career, I have had the very sad responsibility of caring for many patients who have drowned. None of them were the result of “dry drowning.”

WHAT ARE THE SYMPTOMS OF DRY DROWNING?

Coughing
Chest pain
Trouble breathing
Extreme and sudden tiredness or drop in energy (the brain isn’t getting enough oxygen)

WHAT TO DO?

What to do depends on your child’s situation.

If your child went under the water momentarily or fluid seemed to go down the wrong tube…

Never stopped breathing, and looks ok now, then carefully watching at home is reasonable.
Continues to cough, turned blue, has trouble breathing, or looks worrisome, then seek medical care.
Looked ok for a while and later starts having trouble with more cough or trouble breathing,then seek medical care.

When in doubt, seek medical care. It’s always better safe than sorry.

WILL MY KID’S LUNGS BE DAMAGED IF FLUID GETS IN THERE?

The body is amazing in its ability to recover from things. A small amount of inhaled water can be absorbed by the body with time. Usually it doesn’t cause any long-term problems. Sometimes really dirty fluid or lots of it can create a problem (like pneumonia). Clearly, copious amounts can cause drowning. But the average gulp or mouthful isn’t a huge deal.

PREVENTION

Prevention rather than treatment is always the best scenario. When it comes to water safety, keep these tips in mind:

Always keep an eye on your child when he/she is in or around water (resist the urge to look at your phone or run quick to grab something in the other room). This holds true for all water (bathtubs, pools, little inflatable yard pools, houseboats, etc.).
Never let your child swim alone (no matter the age). I took care of a teenager once who drowned in water where he could touch (with no signs of substances or foul play)
Make everyone get out of the pool if you have to take a younger one to the potty (and there isn’t another responsible adult to watch while you leave).
Take safety measures (life vests on boats, fences and pool covers with home pools, etc.)

Age: 15-16 Years

Posted on October 6, 2019August 18, 2020

Posted by Dr. Monica Wonnacott | October 6, 2019

Middle adolescence is a great time, filled with growth and maturity. Most girls at this age are nearing the end of puberty, while most boys are in the middle of the process. Peers and acceptance is the predominant focus of most 15 and 16 year-olds. This is the age in which most teens are internalizing their moral values and deciding what really matters to them.

SAFETY

Substance use/abuse: This topic must be addressed. Clearly educate about the dangers and the misconceptions (e.g., many teens believe marijuana is not addictive or vape is a safe alternative to smoking). It is not unreasonable to have the expectation that your child should NOT use tobacco, drugs, alcohol, inhalants, diet pills, etc. If your child is already involved, seek help. Discuss what happens at parties and strategies to avoiding situations where drugs and alcohol are present.
Car: Establish rules for teen drivers. Fact: Accidents are the #1 cause of death in teens
1. Drivers and passengers must always wear seat belts.
2. Educate about the dangers of distracted driving, especially texting and driving.
3. Have a “Call me ANYTIME for a ride” rule, which applies to any situation where your teen is compromised (e.g., they or their friends have been drinking, are in danger, someone is being abusive with them, etc.). Make sure your teen understands that if called, you will remain calm and not get mad. It is most important that they understand they are loved and that you care most of all about their safety.
Smoking: Make sure your home and cars are smoke-free zones. Discuss the dangers of nicotine, both smoking and vaping. Also, check smoke alarms to ensure that they work properly, and change batteries annually.
Helmets: Wear a helmet on all things a kid can ride (e.g., bicycles, scooters, go carts, skateboards, dirt bikes, ATVs, etc.).
Guns: Lock guns with ammunition separate and in a gun safe. (Disturbing Fact: More children are killed from guns every year than are intruders.)
Abuse: Teach your teen strategies to protect themselves from abuse of any type (physical, emotional, sexual/rape). Make sure they seek help if they feel they are in danger.
Media: Family computers and laptops should be in an easily seen place in the home.
1. Install safety filters/safeguards to prevent inappropriate material/predators from entering your home via your computer.
2. Continue offering guidance navigating social media. Follow your teen’s accounts.

NUTRITION

Eat 3 nutritious meals a day and healthy snacks. Reinforce the importance of breakfast.
Limit high fat and high sugar foods. Limit soft drinks/soda, instead encourage lots of water.
Reinforce the importance of eating a balanced diet, including lots of fruits, vegetables, whole grains, and good sources of protein.
Milk should be low fat. Aim for 3 servings of dairy/day (or calcium rich foods like almond milk, dark leafy greens, etc.). If not, you may need a separate calcium and vitamin D supplement.
Eat meals as a family (around a table with no media). Not only does eating together as a family develop good nutritional habits, it has multiple lasting effects on the social support of a family.
Model good eating habits. Teach the concept of listening to our body’s hunger cues (e.g., eat when you are hungry, stop when you are satisfied). Watch for any signs of disordered eating.
Keep in mind it is very difficult to eat healthy when eating out (especially at fast food restaurants).
Give a multivitamin daily only if your teen is not eating a balanced diet. Consider a woman’s multivitamin with iron if your daughter has heavy periods and doesn’t eat an iron rich diet. Other supplements are not necessary unless specifically directed by your physician.

SLEEP

Most teens need 8-10 hours of sleep a night (unfortunately few are getting it). Help make adjustments where possible to accommodate this sleep need. Getting enough sleep has dramatic improvements in academic performance and mood, as well as decreasing risk of obesity.

ORAL HEALTH

Continue to brush twice daily and floss once a day
Should continue to see a dentist every 6 months.
Don’t smoke or chew tobacco. It ruins teeth and gums (among other harmful effects).

SEXUALITY

Continue discussions about sex, contraception, STI’s, masturbation, and pornography. It is a common misconception that discussing it is condoning it. Quite the contrary, education is empowerment. Educate your child. Tell him or her what your beliefs and expectations are.
Recognize that sexual feelings are normal, but sex should be a well thought out decision. Engaging in sex comes with a lot of responsibilities and consequences; one should delay having sex until mature enough to handle it.
Learn how to “say no” to sex. Warn against feeling pressured.
Educate that abstinence, it is the only 100% effective STI and pregnancy prevention method.
If your teen is already sexually active, you must discuss safe-sex practices (e.g., contraception, condoms).
If teens are concerned or confused about their sexual feelings (for the same or opposite sex), they should talk with their doctor or a trusted adult.
Keep in mind, your physician is a good resource if you are uncomfortable having any of these very important conversations (including the need for birth control) with your teen.

OTHER

Mental Health: Teach teens to trust their feelings. Listen to the ideas of good friends and trusted adults. Seek help if teens are regularly feeling angry, hopeless, or depressed. Learn constructive ways to deal with stress. Learn to set and achieve goals.
Media Exposure: Set limits. Create media free zones/time (e.g., no media at the dinner table and in bedrooms or after a certain hour). Interesting Fact: The AAP states that the average teen consumes >11 hour of media a day.Yikes! Consider making a family media use plan (www.healthychildren.org/MediaUsePlan). Be selective about what media your teen consumes. Counsel your teen on appropriate engagement in social media, give clear direction on what is appropriate to post, comment on, and follow, and make sure you follow his/her accounts.
Phones: Most teens have their own cell phones at this age. Set clear limits and expectations. Establish that the phone is a privilege that has responsibilities associated with it. Interesting fact: The AAP reports the average teenager sends >100 texts a day and 20% either send or receive sexually explicit images. Now is not the time to be complacent in parenting.
Social Interactions: Praise your teen for accomplishments. When correcting, make the clear distinction that the choices the teen is making, not the teen him/herself is bad. Be available to discuss concerns, feelings, and experiences at school and with friends. Know who your teen is hanging out with and have their cell phone numbers. Make a contingency plan for when your teen is a situation where he/she feels unsafe/uncomfortable that he/she can contact you.
Family life: Respect family members and family rules (e.g., curfew). Spend time with your teen both individually and together with siblings. Expect your teen to make time to participate in at least some family activities. Provide personal space for your child at home.
Exercise: Aim for a minimum of 30-60 mins of physical activity a day. Model and encourage an active lifestyle.
Chores: Give your teen chores and household responsibilities (e.g., do the dishes, wash and put away own laundry, mow the lawn, etc.). Having predictable, set jobs every day/week help with consistency and setting expectations. Just because a teen is involved in more activities doesn’t mean he or she shouldn’t contribute to the household.
School: Emphasize the importance of school. Make sure your teen is staying on top of his/her own homework, course selection, attendance, and extracurricular activities. Discuss openly any frustrations he or she may be having at school. Start discussions of life post high school (e.g., college, military, vocational options, etc.).

ILLNESS

Treat fever and minor illnesses at home as long as your teen looks and acts ok. Bring your teen to the doctor if: symptoms are severe or prolonged (e.g., fever beyond 5 days, bad cough, etc.), your teen reports specific symptoms (e.g., sore throat, painful urination, etc.), or you are concerned.

YOUR NEXT VISIT

Your teen’s next well check is in 1 year. If shots were not given this visit (15), plan next year (16). If a Bexaro shot (for meningitis) was given today, a booster shot should be given in 1+ months. Depending on the time of year, your teen may also need an annual flu shot.

Don’t Be Victim To Medication Mistakes

Posted on April 4, 2017August 18, 2020

Posted by Dr. Monica Wonnacott | April 4, 2017

Everyone makes mistakes. The problem with medicine is that the mistakes can be potentially really harmful. As a parent, you just expect that your doctor never makes a mistake when prescribing medications for your child. But the truth is, it happens. The problem is that you’re stuck trusting that your doctor did it right. So here’s some insider’s tips into helping you double check your doctor. (If you think something may be off, don’t be afraid to speak up. Doctors aren’t trying to make mistakes, but it’s easy to get distracted and dosing medications for kids can be tricky).

Most pediatric medications are weight-based

Almost all oral (and IV) medications are weight-based in kids. After all, some 2 year olds are the size of 5 year olds and some teens are adult sized.

Make sure your child was weighed during the check in. Unless the medication is topically applied, chances are the doctor will need your child’s weight.
Medications are based on kilograms (kg), not pounds (lb). In our office, the electronic medical record system automatically converts lbs. to kgs. FYI, there are 2.2 lbs. in 1 kg. (e.g., a 22 lb. child weighs 10 kg.). If the doctor is doing the calculation manually, it is easy to skip the conversion step and your child can be way over dosed.

Frequency of the medication

As a general rule, most doctors opt for medications that can be given less frequently (we know it will increase the chances of people remembering to take the medications). With this in mind:

Most medications are prescribed once or twice a day. There are some exceptions, like eye drops, medications for skin infections, etc.
Clarify/double check with the doctor anytime the medication is given 3+ times a day.
Most medications for acute problems are prescribed for 5-10 days (with most antibiotics being 10 days). Occasionally medications will be for a shorter period (like a 3-day course of steroids) or longer (like a 14-day course for a serious bacterial infection or a continuous medication for a chronic problem). These situations are the exception rather than the rule and warrant clarification with the doctor.
If the medication is a long term medication, clarify if the medication is supposed to go beyond a month and should you utilize refills to continue the medication uninterrupted. All the medications used for chronic conditions fall into this category (e.g., asthma medications, heart medications, psychiatric medications).

Liquid medications come in different concentrations

A common place to make a mistake is in prescribing the “right amount”(volume) of a liquid medication, but choosing the wrong concentration. In our office, all prescriptions are done electronically. This reduces the chance for errors and allows quick reference to see what has been previously prescribed. The problem is that in many liquid medications, I have to click the concentration I want. For example, amoxicillin comes as 125 mg/5 mL, 250 mg/5 mL, 200 mg/5 mL and 400 mg/5 mL. It’s easy to see that 5 mL (which is a teaspoon) could mean 4 different doses of medication. As a general rule, use more concentrated medications in older children so they don’t have to take as much volume of the medication.

Same medication with different doses for different conditions

If I do come across a mistake (e.g., a patient of mine was prescribed a medication at an Urgent Care over the weekend), the mistake often falls under this category. Sometimes, the very same medication is used at different doses for different problems. There are lots of subtle nuisances to dosing medications in children. If the doctor doesn’t work with kids often, it’s easy to see how this happens.

A common example of this is with amoxicillin (one of the most prescribed antibiotics in the world of pediatrics). Amoxicillin is used for Strep throat, ear infections, and pneumonia (among other things). When prescribed for strep throat, amoxicillin is dosed at 50 mg/kg. When prescribed for an ear infection it is dosed at 80mg-90mg/kg (significantly higher due to bug resistance and difficultly penetrating the affected area). For example, take a 35 lb. (16 kg.) 3 year old. If the child has a strep throat, the dose will be 5 mL twice a day of amoxicillin (using the 400 mg/5 mL suspension). The same child would get 8-9 mL twice a day for an ear infection (using the same amoxicillin 400 mg/5 mL).

Max out at adult dosing

As mentioned previously, most medications in pediatrics are weight-based. If, however, the child tends to be on the heavy side, it is quite possible that the dose per kg (weight) may exceed the standard adult dose. As a general rule (again, there are exceptions with certain medications/circumstances), don’t give a child more than you would give an adult. I know this seems very basic, but you’d be surprised how often I see this happen.

Example: You and your child get strep throat. Your doctor prescribes amoxicillin 875 mg tablets twice a day for 10 days for the parent. Your 100 lb. (45.5 kg) 11 year-old also gets strep. Strep is dosed 50 mg/kg, so a total daily dose of 2,275 mg. If you divide that in two, because it’s dosed twice a day, you get 1,137.5 mg which exceeds the adult dose. So in this case, I would prescribe the adult dose.

Allergies

Know your child’s allergies. Don’t assume your doctor will remember your particular child’s medication allergies. Be vocal. Anytime a prescription is going to be written for your child, reiterate allergies (especially if the nature of the reaction was anaphylaxis). Doctors should ask/review, but sometimes they forget to ask. So speak up-even if the medication seems different (sometimes, they are in the same drug class or cross react which is equally risky as the original offending medication).

Safe guards

Maybe I’m an optimist, but I don’t think medication mistakes happen a lot. There are a number of safeguards to help prevent erros.

New electronic medical record/prescribing programs have all sorts of safe guards and dosing calculators built into them to help catch/prevent errors.
Pharmacists (although it technically isn’t their responsibility) will often catch mistakes when a prescribed medication or dose seems out of the ordinary for a child.
Parents. I think parents are savvy. They remember how much they took of a medication for a particular problem or what another child of theirs took. So keep up the good work. You can help keep your doctor on his/her “A-game.”