Saturday, October 04, 2014

Respiratory Virus

Dear Lisa,

I am worried about the Respiratory Virus that I keep hearing about in the news.  My son is three years old and had a couple of bouts of wheezing, but my Pediatrician said he did not have Asthma.  I heard children are dying from this Respiratory Virus and I am worried about my son.   Is there anything that I can do to prevent him from catching it?    I heard that it is only a problem if your child has Asthma.  Since my son doesn’t have Asthma does that mean he won’t catch it?

“Worried about the Respiratory Virus”

The Respiratory virus that has been causing children to become ill in the Midwest is due to Enterovirus D68.   Enteroviruses are very common and typically affect children during the summer and fall months.  Enteroviruses have been circulating in the community for a very long time.  Poliovirus, Coxsackie Virus and Echoviruses are all examples of viruses in this category.   This particular Enterovirus D68 was first identified in California in 1962.  There has been an increased number of children needing hospitalization due to  severe respiratory symptoms caused by this virus.  According to the CDC, there have been 538 cases in people in 43 states and the District of Columbia (1).  Enterovirus D68 has been detected in specimens from four patients who died (1).

The virus can be found in an infected person’s respiratory secretions including nasal discharge, respiratory droplets from coughing or sneezing, saliva, or sputum.  Since the germs are spread through respiratory secretions it is important to cover mouths during coughing and sneezing and to dispose soiled tissues properly.  The virus may also spread from person to person from surfaces touched by an infected person.  These surfaces may include toys, counter tops, doorknobs, desks, or hand held electronic devices.

Measures to take in order to help reduce the spread of infection include limiting contact with other children who are ill.  Do not let your child share toys, drinks or food with other children, especially if they have symptoms of a cold or virus.  Avoid hugging or kissing people who show signs of illness.  Eliminating practices that promote hand mouth activity, such as using a pacifier can also help avoid the spread of germs.  Caretakers should exercise caution and maintain good hand washing and proper disposal of contaminated items (such as dirty tissues) to help decrease the spread of infection.  It is also important to clean and disinfect surfaces, especially in child play areas, including the toys in order to reduce the spread of infection. 

Yes, it is true that children infected with Enterovirus D68 who also have Asthma or a history of wheezing tend to suffer from more severe symptoms.  I understand your concern since your child has a history of wheezing.  Even if he is not officially diagnosed with Asthma, he is still at risk because he has a history of recurrent wheezing.   But there are some measures that you can take to protect him.  First of all, it is important to follow your doctor’s direction regarding treatment for his wheezing. 

Some children have medication on hand to use as needed for episodes of wheezing.  Medication to relieve acute symptoms include Albuterol, ProAir Ventolin or Xopenex.   These medications are bronchodilators and work by opening up the bronchial tubes and promoting the clearance of mucus and secretions from the airways.  Inhaled steroids are another category of medication that is used in children to treat Asthma and wheezing.  This type of medication addresses the inflammation that is present in the airways of children with Asthma.  Examples of this type of medication include Flovent , Qvar and Pulmicort. 

If your doctor has prescribed these medications it is important to use them as directed.  Questions you should ask your doctor include; when should I give the medication, how often do I give it, and for how long.  It is also important to make sure the medications that you have on hand are not expired and the equipment is in good working order, especially if you have a nebulizer or spacer device.  Make sure you keep the follow appointments as prescribed by your doctor.  It is a good idea to take a pen and paper to the doctor’s visit  and write down instructions regarding medication administration, follow up appointments and any questions that you may have.  The most important thing to do is trust your instinct.  If your child does not appear well, seems to be having difficulty breathing, turns grayish, pale or blue, you should seek medical attention immediately. 

Be assured that the health departments, doctors and nurses are monitoring the situation and will communicate outbreaks.  In some cases there may be recommendations to avoid large crowds or to stay home from school or daycare.  It is important that parents and caregivers follow the direction from the public health department and health care professionals.   The instructions may be inconvenient, but the goal is to ensure the spread of infection.  It is essential that children with signs of illness stay home from daycare and school during their illness.  In particular, children should stay home from school and daycare until they are fever free for 24 hours, without the use of fever reducing medication.  

I wish you the best.

Lisa-ann Kelly R.N., P.N.P.,C. Certified Pediatric Nurse Practitioner 


(1)The Centers For Disease Control.   Enterovirus D68 in the United States, 2014. Available at:  Accessed October 4, 2014.

Sunday, September 28, 2014

Video Game Addiction

Dear Lisa,

 My nine year old son plays his video games constantly.  He rather play his video games then go outside and play with friends.  If I tell him to stop, he gets really upset.  I am afraid that it is becoming an obsession.   I don’t know if I am overacting or not.  Is there a problem with children playing too many video games? 

“Worried about Video Addiction”

Dear “Worried about Video Addiction”,

Your concern is quite common.  I come across a lot of children, especially boys who seem excessively interested in video games.  Many parents complain that playing video games consume all of their time and limits their interest in other activities.  Our world has become so dominated with electronics that it doesn’t surprise me that children choose to play video games instead of playing outside.   

Video gaming has become such an issue that the editors of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) proposed the addition of Internet Gaming Disorder (IGD) as an official diagnosis.   There was controversy over the plan and as a result the addition of Internet Gaming Disorder was added to the section on “Conditions for Further Study”.   So it seems that excessive video gaming goes beyond the issue of parental concern and more research needs to be done regarding this behavior.    

Internet Gaming Disorder is characterized by persistent and recurrent use of the internet to engage in games leading to clinically significant impairment or distress.  Children at risk seem preoccupied with the games, experience withdrawal symptoms when the game is taken away, experience loss of interest in previous hobbies, use games to escape or relieve a negative mood and deceive others regarding the amount of time they spend playing videos.   International studies show that heavy users tend to play 20 to 30 hours and sometimes more than 40 hours per week(1).  Most video gamers are male and often play well into their twenties.  These young adults often jeopardize their relationships with significant others, or lose educational and job opportunities because of their game playing.

In one study of 1,178 U.S. school aged children; pathologic gamers were more likely to have attention problems in school, involvement in physical altercations, and health problems worsened by gaming, including extremity pain(2).  In addition, children that excessively play video games have a greater likelihood of having Attention Deficit Disorder.  Excessive gaming has also been linked to sleep problems.   Adolescents experience lower-quality sleep, have problems achieving deep levels of restorative sleep, and take a longer time to fall asleep(3). 

There has been much debate in the media regarding the relationship between violent video games and violent behavior in children.  Studies have shown a positive relation between violent video game play and aggressive thoughts and behaviors, delinquency and lack of empathy towards others(4,5).  Some may argue that children with these attributes are attracted to the video games and it is not the video games that causes the child to become violent.  Clearly more research needs to be done in this area.  Since some of the most popular video games that children play are rated M, it is important for parents to become aware of the rating system and monitor the games that they are playing.  Rated M games contain mature content which may include intense violence, blood and gore, sexual content and strong language.  Exposure to these topics is not intended for children under 17 years old.

Being that your child is only nine years old, it seems that the problem has not become out of control.  It is a good idea to monitor your child and understandable that you are concerned about the negative implications of excessive gaming.  You did not mention how often your child plays video games or if the gaming interferes with his relationships or school work.  If the gaming interferes with your child’s sleep, school performance or family life it would be a good idea to discuss this with your Pediatrician or Nurse Practitioner. 

According to The American Academy of Pediatrics, screen time should be limited to 2 hours per day.  Simple measures to assist parents in curtailing video gaming include removing gaming devices from your child’s bedroom, not allowing your child to play games until homework and chores are finished and using a timer to limit the time playing.   Removing the game from the child’s bedroom will prevent the child from sneaking to play games, keep the child from being tempted to stay up too late at night and will decrease the exposure to light during bedtime which may interfere with sleep. 

In order to encourage outside play and socialization with other children parents may consider signing up their child for extracurricular activities such as sports, school clubs or musical instrument training.   Parents can set up a system that allows the child to earn hours playing the video game, by collecting points for engaging in outside activities or exercise.  Some parents may perceive this idea as being too controlling, but in some cases it is necessary if children can’t seem to control their time away from the screen on their own.   In addition, it gives children the message that the balance of many activities is healthy, human contact is enriching, and time management is essential for success. 

Most importantly, children learn by what they see, not necessarily simply by what they are told.  Many times I observed parents give their child a video game when they are misbehaving in order to keep them quiet.  In essence, what they are showing their children is that an electronic game is necessary to keep them busy and quiet.  Although, this may seem like the only option at the time, the message may not be beneficial, especially for children who already have an issue with impulse control or socializing with others.  One option is to play verbal word games (21 questions, Eye Spy) with your child in situations when they need to stay focused or quiet.  Being a role model will help your child understand the importance of balance.  If a child sees their parents spend an exorbitant amount of time on the computer, not socially connected to others and little time outdoors exercising, they will likely follow their example.  A family trip free from electronics, or an electronic free day visiting friends or family may be a good way to teach your child the importance of human contact and face to face communication.  

(1)Knapp S, Swager L, Nield L. Consultant for Pediatrics.  Game Over:  Helping a Teenager Quit a Video Game Addiction.  2014.  June:266-268.
(2)Haagsma M, Pieterse M, Peters O.  The Prevalence of Problematic Video Gamers in the Netherlands.  Cyberpsychol Behav Soc Netw. 2012:15(3):162-168.
(3)King D, Gradisar M, Drummond A, et al.  The Impact of Prolonged Violent Video-gaming on Adolescent Sleep: an Experimental Study. J Sleep Res. 2013:22(2)137-143.
(4)Anderson C, Dill K,  Video Games and Aggressive Thoughts, Feelings and Behavior in the Laboratory and in Life.  J Pers Soc PSychol.  2000;78(4):772-790.
(5)Anderson C, Shibuya A, Ihori N, et al.  Violent Video Game Effects on Aggression, Empathy and Prosocial Behavior in Eastern and Western Countries: a meta-analytic review.  Psychol Bull.  2010;136(2):151-173.

Lisa-ann Kelly R.N., P.N.P.,C. Certified Pediatric Nurse Practitioner