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The end of summer marks a new season and the time to return to school.  This transition is made easier by beginning your preparations during the second half of the summer.  Returning to the school year sleep and wake schedule should be accomplished at least 1-2 weeks before school starts. Healthy and successful sleep routines make mornings better and learning easier.  A healthy diet and a consistent schedule also help. Make sure all summer reading has been completed and talking about the positive aspects of returning to school are also important topics. This summer to school transition can be a fun time filled with new friends and new opportunities. Address school related fears with non-judgmental understanding and support. Patience and optimism are essential.

This is also a good time to make sure your child is up to date on immunizations and make sure there are no vision or hearing concerns. A visit to your pediatrician during the summer is a good place to start. Talk about safety issue relating to strangers and traveling to and from school. Bus, car, bike and walking safety tips are also good topics to discuss.  Healthy behaviors including the importance of a healthy breakfast and lunch as well as the use of a backpack that is not too heavy and is fitted properly are also important.

The return of school is a time when overanxious patterns, separation issues and anxiety often appear. These patterns must be recognized and addressed.  Everyone experiences change. Children must develop the ability to accept and cope with change. Entering school for the first time, returning to school and leaving for college are opportunities for both parent and child. Your response as a parent is very important. Your physical and emotional responses have direct and indirect effects on you and your child. During periods of moderate to severe stress negative physical and emotional changes occur in you and your child. Your ability to modulate stress affects long term health and well-being.  You are the best model of positive and adaptive behavior for your child. Periods of change marked by a return to school foster independence, exploration and decision making in your child.

Anaphylaxis is dangerous. Up to 1000 people die each year in the US due to anaphylaxis. Foods are the most common cause. 30% of the time the trigger is a food allergy, and 90% of the time it is due to peanut or tree nut exposure. These reactions are difficult to predict since the severity of an allergic reaction to food cannot be predicted by history or by skin prick or allergen-specific IGE level testing. 25% of the time the first episode of anaphylaxis has not been preceded by any prior food reaction.

The most common symptoms are skin, respiratory, gastrointestinal, and cardiovascular symptoms.  Skin symptoms include hives, itching, flushing of the skin and swelling of the lips, tongue or uvula. Respiratory symptoms include shortness of breath, wheezing, stridor or a low oxygen level in the blood. Gastrointestinal symptoms include crampy abdominal pain and vomiting. Cardiovascular symptoms include fainting, collapse, low blood pressure and urinary incontinence.

Injection of epinephrine into the thigh is the best treatment. The dose is .15 mg for persons less than 55 pounds and .3 mg for those weighing more. Having two doses available is important since 20% of the time a second dose is required. Many people do not know that in 20% of the cases there is a biphasic pattern to symptoms with symptoms returning after initial treatment success.  Other treatments include placing the child supine on the ground with legs elevated or in a position of comfort. Oxygen and intravenous fluid therapy may be needed. Antihistamine treatment with a medication like Benadryl only treats skin symptoms and has no cardiovascular benefits.

Management of food-induced anaphylaxis at school is very important. School staff must be aware of food-allergic children and an emergency action plan for treatment must be in place. Medication must be available and staff must be trained to administer the medication and notify emergency personnel.  Safe food practices must be maintained with only designated foods being available and surface and hand washing before and after meals.  No food sharing is allowed. Prevention strategies are age and maturity dependent.   In the US children with a diagnosis of anaphylaxis are protected by the American with Disabilities Act that prevents discrimination based on disability. Children with food allergies are often bullied due to issues with social isolation brought on by food limitations.

The majority of people who have a severe episode of anaphylaxis also have asthma.  Exercise and alcohol also increase the severity of anaphylaxis.

Allergies are very common. Over fifty million people in the US have some type of allergy and thirteen million adults and four million children have asthma.  If you have asthma you have an 80% risk of also having allergies. Most asthma symptoms begin after exposure to specific allergens and in children viral infections are the most common cause of an asthma episode.  Itchy and watery eyes or nose, sneezing, coughing and wheezing are the most common symptoms. Skin rashes including hives are common as are gastrointestinal symptoms. If one parent has a history of allergies a child has a 25% risk of also having allergies. If both parents have allergies this risk increases to over 60%.

In addition to general discomfort other consequences to allergies include an increased risk for infection, school absence and work loss. Life threatening consequences due to anaphylaxis although uncommon are also possible.

An allergy is caused by an overreaction of the body’s immune system. The immune system functions to fight off infection. In the case of allergies it becomes activated to a harmless substance called an allergen.  Antibodies (IgE) are produced that cause a cascade of events leading to the release of many chemicals such as histamine from allergy cells in the body. An allergy is not a disease. It is a reaction to something eaten, breathed, touched or injected.

The most common reactions include wheezing, skin reactions like hives, contact or atopic dermatitis, eczema, food allergy and hay fever. Common airborne allergens are pollens such as trees, grasses and weeds or molds, dust mites and animal dander. Food allergens include cow’s milk, eggs, soy milk, wheat, peanuts and tree nuts, seafood and shellfish. Medication, chemicals and the saliva from stinging insects are also common allergens.

The most serious reaction is anaphylaxis. After allergen exposure there is a rapid onset of skin, gastrointestinal, respiratory and cardiac symptoms that can lead to death if there is not rapid intervention with epinephrine. This is done through the use of an EpiPen or a Twinject.  An antihistamine like Benadryl is also given. In children the most common causes are peanuts, tree nuts, cow’s milk, soy, eggs, fish and shellfish. Insect stings from bees, wasps, hornets and fire ants can also cause anaphylaxis.

For mild to moderate symptoms avoidance and environmental accommodations are best. The best treatment is to determine the cause of the allergy symptoms and then to focus on avoidance measures. Options include vacuuming and dusting, carpet avoidance, the use of air conditioning, damp mopping, a HEPA filter and humidity control. Dust mites and molds thrive in a moist environment.  Indoor plants, smoke and pets can also cause allergy symptoms.  Working with your doctor and close observation are essential to develop the best action plan to treat your child.  Mild symptoms can often be managed with avoidance and over the counter antihistamines. For chronic or moderate to severe symptoms further allergy intervention including skin testing, prescription medications and immunotherapy (allergy shots) are often needed. Treatment is available. The proper intervention can alleviate or eliminate life threatening reactions and symptoms that make your child’s life very difficult.

Here are some tips to improve your child’s hospital stay: 

• Bring any medications your child takes with you if you go to the emergency room or if your child is admitted to the hospital.
• Write down your doctor’s name and address/ phone number and give it to the doctor who admits your child to the hospital.
• Bring a notebook with you and write down the name and phone number of every doctor you speak to at the hospital. Ask them to write down their findings and any suggestions or recommendations they have for you and your child.
• Take care of yourself. Parents often neglect their own needs when their child is admitted to the hospital. Make sure you bring any medications you may be taking, a change of clothes and a basic self-care kit with a brush or comb, toothbrush, toothpaste and hand sanitizer. Make sure you eat enough. Bring a healthy snack if you can since you may miss a meal.
• Keep washing your hands and use hand sanitizer. Viruses are not eliminated as well with hand sanitizers as by washing them down the drain while hand washing.
• Bring a list of your child’s immunizations and try to remember the last time your child was seen by a doctor and the last yearly check-up.
• There is nothing wrong with being a strong advocate for your child. Watch what medications are given and when. If you see something you are surprised about or do not feel comfortable with a situation or treatment immediately speak up. Ask to speak to a nurse or doctor and voice your concerns. Write down the names of all the nurses and staff caring for your child.
• Always ask what tests or studies are being performed on your child and why they are being done. Write this down in your notebook with the result of the test or study.
• When you think of a question you want to ask your doctor or nurse write it down in your notebook. Leave a space so you can write down the answer when your questioned is answered. Make sure you write down the name of the person who answers the question.
• Pay special attention to any medications ordered for your child and verify that is the medication being given to your child when the nurse administers the medication.
• If your child is receiving intravenous medication or fluids and there is an alarm do not worry. It may need to be plugged in or a fluid may need to be changed. Push the nurse notification button or walk out to the nursing station to notify staff of the beeping.
• If your child is on a heart rate or oxygen monitor and there is an alarm contact the nurse immediately. If your child looks fine then it likely is a routine alarm and does not signal any major problem.
• If oxygen is used for your child it is important to help the respiratory therapy and nursing staff find the best way to administer the oxygen. Nasal cannula oxygen is preferred. This is a small tube that goes directly into the nostrils and wraps around your child’s head. Most children get used to this sensation soon after it is started.
• If a nebulizer is used to administer medication it is important your child holds the end of the tubing (T-piece) firmly in the mouth and breathes through the mouth and not the nose. If a T-piece cannot be used then a mask is used. Blow by treatments are given in the rare situation where your child becomes upset to the point of added respiratory distress.
• If your child is in a gated crib with side rails make sure they are always up and securely fastened.
• Always ask the floor nurse before allowing a child to sleep with you in a chair or bed rather than sleeping in their own crib or bed.
• Place your chair close to your child’s bed or crib so they can see you and you can touch them.
• Make sure all hospital staff in contact with your child wash their hands or use hand sanitizer before touching your child or administering any medication.
• Do not be worried if hospital staff  wear gloves when they come in contact with your child. This is necessary if there are concerns about infection. They might also use a mask and a gown and this is standard practice in certain situations.
• Do not worry if a team of doctors comes to examine your child. In teaching hospitals care is provided by a team that consists of an attending physician and several residents. The number of doctors present does not indicate the severity of your child’s illness.
• Change of shift times (7am/ 4pm/ 11pm) are especially important due to staff changes. Find out the names of the staff on the new shift and write down their names.
• Try to have a family member stay with your child if you need to leave the hospital for a brief period. If your child has an extended stay then consider working with your spouse or another family member to tag team caretaking and allow everyone to go home to rest, eat, sleep, take a shower and change clothes. This allows parents to return to the hospital refreshed and ready to deal with any stress their child is experiencing.
• When you leave your child’s room always tell them where you are going and when you will return. If they are asleep make sure someone is in the room until you return. It can be frightening for a child to fall asleep with a parent present only to wake up alone after the parent left the room for a cup of coffee or a bathroom break.
• Ask the nurse if any volunteer support staff is available if you need to leave the room.
• Prepare yourself to identify and respond to any stress your child deals with during the hospitalization or after the hospitalization. An admission can be a very scary experience for a child. Your love, support and stability allows hospitalization and post hospitalization psychological issues to me dealt with.

Executive function is the name given to the process where a person controls his cognitive processes and is a crucial component of your child’s development. It permits and manages the planning and carrying out of goal directed activities. Various components include goal setting, the use of strategies, self-monitoring, inhibition and self-control and the purposeful allocation of attention and memory.

In order to be successful in day to day activities your child must learn to suppress behaviors that lead to immediate rewards in order to obtain a more long term and desired reward. This is called delayed gratification and is an important part of development for every preschool and school aged child. For preschoolers distraction is the typical way gratification is delayed. For the older child inhibition and cognitive awareness are the primary techniques.

Studies have found children and teens involved in strenuous daily aerobic activities have improved scores in tests of creative thinking, planning, attention, simultaneous and successive processing. The planning benefits are indicative of executive function benefits. Neuroimaging studies using functional MRI have revealed an increase in neural activity in the prefrontal brain regions in pre-teens involved in intense aerobic activity. Other studies have shown a similar gain in working memory measures which is associated with success in reading and mathematics.

In some studies the benefits have been less visible and may be associated with the benefits of short bouts of physical activity. In most studies, however, children and teens who participate in rigorous daily physical activity scored higher in achievement testing or in academic grades received.

Although the reason for the potential benefits to academic performance and cognition have not been determined, these benefits when added to the known benefits of avoiding obesity and cardiovascular disease provide added reason for pursuing an active healthy lifestyle.