Sunday, September 18, 2016

My son just stuck a toothpick up his rectum: the joys of pediatric on-call weekends.

Is this something you should be eating? Think before putting it in your mouth.

I'm on call and getting quite a few calls tonight. Most are straightforward and I can answer. I sent a baby to the ER for a fever. It's probably routine -- I hope it IS routine -- but the fever was high enough that I didn't feel that meningitis could be ruled out.  I can't give out a lot of info even in this semi-anonymous blog because if someone were onto me, I could be up to my neck in HIPAA violations. Suffice it to say that I've received calls that I myself would have made as a parent if I were not a doctor, but some of the calls that have come to me either were stupid calls or calls that could have waited for the light of day or even for regular office hours on Monday.

I had an allergy call where I could hear wheezing so profound that I told the father to hang up and call 911 immediately. I also called 911 myself just in case the parent couldn't get through and to let the switchboard operator  know that it wasn't a hysterical parent calling needlessly, and that paramedics needed to get there STAT. Additionally, I told the father to administer the Epi-pen, which he fortunately had on hand. This was a several hours ago. It was a nut allergy. Sometimes it's trial and error in terms of what nuts a kid who has a peanut (which is not actually a nut, but that's a story for another day) allergy can tolerate. He had eaten an almond apparently at school (which his parents knew nothing about) and had done fine with it (thank goodness!), but that gave him the confidence to try a hazelnut when no one was looking, which was apparently NOT  OK.  By the time both the actual physician backing me up and I got to the hospital, epinephrine had been administered and he was much better. He's still spending the night in the hospital for observation, but he should be fine. He's ten and should have known better, but even adults do stupid things at times. I hope he learned something from this.

I have strong opinions related to nut and peanut allergies and how they should be handled.  The onus should be on the parent and/or care provider early in a child's life.  At the same time, the child should be taught that a nut or peanut can kill him from very early in his life, as in staring at about two. By the time a developmentally normal child is three, the concept should be firm in his or her mind what a nut or peanut is, that it is highly hazardous to his or her health, that it is unseen in many different foods, and that to be safe, he or she probably shouldn't eat ANYTHING without consulting a parent or care provider.  You still do not trust a three-year-old to self-monitor for his or her peanut or nut allergy, just as you wouldn't trust an unsupervised toddler around a swimming pool whether he or she had been given swimming lessons or not, but the seed must be planted. 

By the time a child is old enough for kindergarten, the concept should be so firm in his or her mind that you could leave him or her alone in a room full of peanuts and peanut butter, chocolate covered or otherwise, and he or she would run in the opposite direction rather than expose himself to the stuff. You should teach him that all sorts of candy and cookies contain peanuts, and that he must not eat any of such things without parent approval.  Also, unless the child has a very specific medical reason he or she absolutely cannot have products containing sugar, a kid with a nut allergy should not be denied sweets. If a child is totally denied access to sweets, he or he will sneak or steal them. The sweet the kid purloins won't be one the parent has checked or approved, and the child's life may be at risk. Perhaps even before you conceived your first child, you had lofty ideals of perfect nutrition for the children you would one day have. If your kid has a nut or peanut allergy, forget it.  A child's desire for something sweet is essentially innate. It's better to control the sweets your allergic child consumes than risk having him or her grab whatever he or she can reach on the sly. And if your child has a double-whammy of being diabetic as well as allergic, you'll need to invest in decent-tasting sugar-free treats. A diabetic child CAN have some sugary sweets, but it shouldn't be a habit. You don't want to build up insulin resistance.

By now, your nut- or peanut-allergic child is ready for kindergarten, or first grade if your school has half-day kindergarten. Some schools have nut-free policies for their cafeterias even for those students who bring their own lunches. If you think your child is therefore safe, think again. No one at school inspects the contents of every child's home-prepared lunches. Some parents are simply non-compliant. In other cases, someone other than the usual caregiver prepares a lunch for a child and is unaware of the peanut- and nut-free policy. In other cases, a child grabs a treat from his parents' stash and puts it in his or her pocket. YOUR CHILD MUST BE FULLY INDOCTRINATED TO NEVER ACCEPT FOOD FROM ANOTHER CHILD IN THE CAFETERIA.  The burden here is on you and on your child, assuming your child has no developmental delays. If developmental delays are present, additional supervision is in order.

Some schools do not ban peanuts or nuts. In such cases, parents have been fairly warned. Most school lunches no longer serve peanut products, and perhaps an allergic child can be seated among those eating school-provided lunches. This may minimize risks of allergic reactions related to peanuts and nuts, but it cannot eliminate them entirely.  Parents of allergic children must be vigilant in educating their children as to the dangers of peanut or nut ingestion. 
A child of normal intelligence who is old enough for school is old enough to be taught to steer clear of the things that are seriously harmful to him or her, whether it's rat poison or nuts. If your child is disobedient, use discipline, scare tactics, or whatever you must use.  Your child must know by the time he or she is of school age that he is not to eat nuts or peanuts, and furthermore, he or she is never to eat ANYTHING not approved by his parent, primary caregiver,   or teacher. 

Whether or not your child's school has a peanut- or nut-free policy,  your allergic child will have to behave smartly if he or she wishes to survive. Several years ago in Virginia, a peanut-allergic child seven years of age accepted a few peanut M&Ms from another child on a school playground. It resulted in the death of the allergic child. While the parent sought and probably received a whopping settlement, the fault, in my opinion,  belonged to the child and the child's caregiver. Seven is old enough to know better. Two supervising adults on a playground with one hundred or so children, vigilant as they may be, cannot possibly prevent every possible exchange of less than a handful of candy that might occur on a playground. Even if you doubled the level of supervision, transfer of small food items would still be possible. Most schools don't allow food on playgrounds, period, but children break rules, and they're not always caught.

The child I sent to the hospital tonight didn't do something terrible. He really thought the hazelnut was safe because the almond had been safe. The parents weren't terribly at fault either, as they had told him until they were purple in the face not to eat nuts. (His known allergy was peanuts, but it's wise to void all nuts with a peanut allergy until a board-certified allergist tells a parent otherwise.) Still, the incident underscores the need for caution on the part of those with peanut and nut allergies. 

The Reverend Alexis, Grand Vicar of the Church of Nut Allergies, has concluded her weekly sermon. Go now to love and serve the Lord, and to avoid any food to which you are allergic, and, perhaps more importantly, to teach your affected children to do the same. I must now consult with a parent whose child ate half a gummy bear, then stuck the remaining half up his nose. Why I'm not hearing about this until 5:00 a.m. is one of life's great mysteries.

P.S. I checked on the feverish baby while at the hospital. It's meningitis, though it is not yet known what type. Please pray for him or send positive thoughts. He's only four months old.
It may be cute and it may look harmless, but some people should not eat t.


  1. Wow... it is amazing to me how many people have nut allergies these days. When I was a kid, I lived on peanut butter.

    1. I find it amazing, too. It always existed, I'm told, but made a huge jump between 1887 and 2008. 9It must have made a huge jump between 1970- and 1997 as well, because my dad tells me it was practically unheard of then. The FDA and other researchers are trying to blame it on antibiotics, but unless there's something very different in modern antibiotics than the standard cillins, tetracycline-based antibiotics, and sulfa-based antibiotics, that's not the likely culprit. From the early 1960's (maybe even late '50s) though the mid 70's if a person, especially a kid, went to the doctor with an illness, he or she received a shot of antibiotics. If antibiotics in general were causative, the jump would have been seen then, as opposed to since the 80's, when doctors began to fear the creation of antibiotic-resistant strains of bacteria and began to take a much more conservative approach to prescribing antibiotics.

      It in all likelihood has something to do with the immune system, and there is a lot more of all sorts of garbage in the environment that might act on a person's immune system. It culd even have something to do either with baby food (the jar stuff or baby cereal) because evidence is once again showing that children who subsist or breast milk or formula alone develop fewer food allergies, nut or otherwise. (That was the school of thought in the 80's and 90's, then they contradicted it; now they're back to implicating early introduction to solids and semi solids in the devlopment of food allergies. It also could be 9and I HATE!!!!! to say this) relted to a particular vaccine. They're looking at what new vaccines were intoroduced or what existing ones were changed when the increase in nut allergies occurred. I REALLY hope they don't find a connection. The last thing in the world we need is an epidemic of polio because of idiot parents thinking their kids might possibly develop nut allergies from vaccines. We have too much of that school of thought already. I suspect it has as much connection to the pathogens in everything we eat, drink, and breathe as anything, but I wouldn't rule out early introduction to solid foods as being partially responsible.

      The baby is holding his own. The next 24 hours will be critical.