Why Is My Child Always Sick?

Podcast Transcript

Speaker 3: Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Jackie Bjelac: Welcome back to Little Health. I'm your host, Dr. Jackie Bjelac, and I'm a pediatric allergist immunologist at Cleveland Clinic Children's.

Today is part of our season on pediatric allergy and immunology I really wanna highlight the second part of our specialty and talk about a topic that keeps a lot of parents up at night. Why is my child always sick? You might be wondering if you can boost their immune system and how else you can help.

We'll be discussing what's normal, what's not, and really importantly, the most effective ways to support your child's natural defenses in a safe way. So our guest today is Dr. Jack McDonnell. He is a my colleague, a friend, and a wonderful pediatric allergist immunologist at Cleveland Clinic Children's. And importantly, Jack specializes in children with immune system issues.

So welcome to Little Health, Dr. McDonnell.

Dr. Jack McDonnell: Thanks, Dr. Bjelac. I'm happy to be here and talk about the immune system, which is a topic I'm pretty passionate about.

Dr. Jackie Bjelac: So big fan of the immune system. Tell the listeners a little bit about you.

Dr. Jack McDonnell: Well, I had a long career. I was in the military for a while. I was a Navy pediatrician and then a pediatric hospitalist, and I ultimately did fellowship in allergy and immunology at Cleveland Clinic.

And then I did an extra year of just immunology at Cincinnati Children's. And I've been back for the last three years or so at Cleveland Clinic in a staff role. I realized pretty quick in my fellowship that I really liked the immune system and immune deficiencies as the main thing I wanted to focus my efforts on, and so I kind of just tailored my education to really emphasize that.

Dr. Jackie Bjelac: Mm-hmm. Thank you for your service, and we're so glad to have you as part of our team. And just share with the listeners if you feel comfortable who lives at home with you, because I know so much of what I share with patients and their families in my office visits is actually based on what I do for my own kids.

So tell the listeners why you have all the credibility in the world.

Dr. Jack McDonnell: I do have some street cred 'cause I have seven kids and the oldest is 14, the youngest is two and a half. And so, and sometimes in the McDonnell house we certainly understand how illnesses can spread very easily. 'cause you know, some kids are in daycare, kids are at school, and so seven children.

Dr. Jackie Bjelac: Yeah. Which are awesome and helps you know how frustrating it can be as a parent when it seems like your kid is always sick.

Dr. Jack McDonnell: For sure.

Dr. Jackie Bjelac: So I wanna get us back to the most basic of basics and just what is the immune system? What does that even mean when we talk about the immune system?

Dr. Jack McDonnell: The immune system, it's a system of the body that's mostly devoted to fighting infection, so like foreign invaders in your body.

It also has some other secondary roles that are also very important in terms of wound healing and also surveillance for malignancy. So there's a part of your immune system that monitors if your cells are starting to go through changes that might be the start of a cancer. Your immune system would be part of the response to that right away.

Dr. Jackie Bjelac: So important, obviously, and as a parent, you know, when your kid's getting sick all the time, I'd love to hear what's normal. Like how often does a child with a normal immune system get sick?

Dr. Jack McDonnell: That's a great question. On average, I would say eight to 10 illnesses a year are pretty typical. Um, these might be something where there's fever for the first couple days, maybe even up to four or five days, and then cough, congestion. That kind of pattern in children tends to last longer, so even up to a couple weeks, much longer typically than what we would have as adults.

So that's an important thing to remember, that kids are kind of often, they'll have a period where they're asymptomatic, but then they're starting to get sick, and then they'll be the couple weeks while they're sick and then they'll be post sick and they might get hit with another virus during that period.

And so we definitely do see that. Now, it may even be more than that in some cases, if the kids in daycare or factors like that, that can kind of play into that.

Dr. Jackie Bjelac: Older siblings too, for sure.

Dr. Jack McDonnell: Older siblings, seven siblings.

Dr. Jackie Bjelac: The more siblings, the more often you get sick. But if I'm doing my math right, as you're talking, you're saying it is normal for a kid to be sick for at least a few weeks at a time up to 10 times a year. So it is within the range of normal for our kids to be sick half of the year?

Dr. Jack McDonnell: It is, and I certainly, again, feel it personally 'cause my kids are all, are sick at least half the year too. And, and really the type of infection matters too.

So it would be pretty normal to be sick maybe half the year if it's colds. [Mm-hmm]. It's not normal to have, say nine ear infections in a single year. So sometimes what helps us know what's normal and what's not is the type of infection. Where bacterial infections tend to be more concerning for an immune system problem than than most viral infections.

Dr. Jackie Bjelac: Okay. So when you talk about a bacterial infection, is that what we use antibiotics for?

Dr. Jack McDonnell: Yeah, exactly. So antibiotics are typically directed against bacterial infections because a virus will just generally, you know, get in your system and then pass through and be done. Your immune system will take care of it.

Sometimes for bacterial infections, your body needs the extra help of antibiotics, so this would be something like a sinus infection, which kids can get. It's not as common as an adult, but kids can get it. Also, you know, ear infections, pneumonia, things like this where you're needing to take antibiotics.

Dr. Jackie Bjelac: So I meet a lot of families who come to clinic because their little one has recently started preschool or daycare, and they've needed antibiotics a few times a year, and they seem to be getting sick a lot more. I think a really important question that many of them have is when do we worry?

As an immunologist, what sorts of things do you hear in your clinic that really increase your level of suspicion for an actual problem with the immune system and not a kid who's just getting sick within the range of normal?

Dr. Jack McDonnell: So one thing that's really concerning is the number of courses of antibiotic a child has been on. Now, the problem with that is sometimes we can be in situations where the doctors might prescribe an antibiotic out of an abundance of caution. Oh, well, seems like this is more severe. I'm just gonna cover you with antibiotics and maybe that was really a virus.

So you can't just look at a sheer number and say, well, this is the cutoff. But I look for a pattern where a child is needing a lot of antibiotics, potentially needing antibiotics for infections affecting certain critical areas that we see. So we call it sino pulmonary infections.

So most immune deficiencies, if you have one, will affect your ability to fight sinus infections, ear infections, and pneumonias. So antibiotics especially as directed to those areas, which are the highest proportion of cases that we're gonna see if they have an immune deficiency.

Also, infections with unusual organisms.  Deep seated infections. Infections that don't respond to antibiotics appropriately or that need longer courses. And in studies, the need for IV antibiotics or something other than like oral antibiotics has been associated with potential immune deficiency.

Dr. Jackie Bjelac: Yeah. So needing to be admitted to the hospital, getting, you know, antibiotics through an IV instead of being able to use them by mouth, a signal that your immune system needs more help than maybe they would.

Dr. Jack McDonnell: Exactly.

Dr. Jackie Bjelac: Okay. This is really helpful I think for a parent perspective, how soon could you know that a child has a problem with their immune system?

Dr. Jack McDonnell: You may know right away. One of the things that's been really groundbreaking for the field of immunology has been the newborn screen. So on the standard state newborn screen, which all 50 states have there is now an assay that looks at a thing that has to do with your immune system called T receptor excision circles, Trecs.

The details of those are not important other than to say if your trecs are abnormal, abnormally low, that could indicate a problem with your immune system that's serious. And that particular immune problem it's way better to diagnose early rather than later.

So we're finding cases now of infants who have a serious immune deficiency diagnosed right away, long before they're symptomatic with infections and stuff. Long before then we're being able to pick it up because of that great assay that's on the newborn screen. So I definitely recommend every infant get a newborn screen.

Dr. Jackie Bjelac: And how does the newborn screen get done when your baby's an infant?

Dr. Jack McDonnell: It just is collected after the first 24 hours of life, typically in the nursery, and it just takes a tiny little poke, not even a needle going into a vein, but rather just a heel stick.

We can get that drop of blood. It's put on a piece of paper and sent to the state lab, and it tests for a number of rare diseases and conditions, including the disease I'm alluding to, which is severe combined immune deficiency.

Dr. Jackie Bjelac: So that's honestly really cool that just a poke on the heel with a super small poker yeah, gets a drop of blood that can diagnose a lot of things that if we intervene quickly, can really improve outcomes for babies.

Dr. Jack McDonnell: It's been really kind of revolutionized the field because some immune deficiencies are difficult to diagnose and you basically only start to suspect them potentially after the kid's gotten sick a lot. [Mm-hmm.] And then it's gonna be way harder to fix the problem because if it's something that needs a transplant or something like that, all those infections are gonna make it more complicated.

Whereas now we're being able to pick people up really early. That is not to say that every baby with an abnormal trec, however, has this immune deficiency. There are kind of false positive results we see. Luckily there's not a lot of false negatives, but we do see some babies who end up having abnormal trecs and we evaluate them in our clinic and they're fine, but we like to do the evaluation and take it very seriously.

Dr. Jackie Bjelac: That's great. So this has been, I think, really helpful in understanding that it is normal for a kid to get sick a lot. And then there's the spectrum of normal, and then there's kids who fall outside of that who absolutely deserve evaluation.

So what would you recommend to families who are concerned about how frequently their kid's getting sick? Where should they start? Who should they talk to?

Dr. Jack McDonnell: I would always start with your primary care. That's gonna be your first line of information about what's normal and what's not. And if you think about it, the average pediatrician or family practice physician is gonna have a lot of experience evaluating sick people and is going to know what's normal and, and they'll be able to advise further if something is out of the, kind of, out of those bounds of what's considered to be normal.

However, if there's a concern and the, and the family talks to their physicians about it and it's an ongoing issue, or if they just have it on their brain and it's like, maybe it's something that's bothering you, we're always happy to see those patients in allergy and immunology. Myself, or any of my colleagues can get that process started.

Dr. Jackie Bjelac: I think it's always at least a helpful conversation to help families piece out what we would need to do, and it can be reassuring for everyone just to have the conversations or do some screening testing.

Dr. Jack McDonnell: For sure.

Dr. Jackie Bjelac: Because I, we've all been there right this winter when all four of the Bjelac children were sick and on antibiotics and probably out of the scope of this conversation, you know, I am not a fan of antibiotics. I was like, do you guys have functioning immune systems? Like what is happening? And, and that frustration can be overwhelming sometimes. So we're always happy to see families just to have those conversations.

So that being said, you know, just like any body system, I think there's things that we can do that support normal healthy immune function. And would love to hear your perspective as an immunologist. What are some things that you guys do at your house or that you would recommend to patients and families to help support a healthy immune system?

Dr. Jack McDonnell: That's a great question. So one thing I always kind of tell patients is it's kind of the things that really boost your immune system are often things that like maybe you heard from your mom growing up.

So getting enough sleep, having less stress. These are sometimes hard to do, but sleep, stress, physical activity, like having kind of reserve of exercise in your background, that will really help prevent against infections taking on more, more severity in many cases.

As far as our particular house, in addition to encouraging physical activity in our children and trying to get them on a good sleep schedule, we also personally do do a multivitamin. [Mm-hmm.] People debate whether that's truly necessary. With the average American diet, you should be getting ample quantities of multiple vitamins, but just in case, I think it's a reasonable thing to be on a multivitamin.

What we don't really find very helpful is supplementing or hyper supplementing certain vitamins due to a perceived benefit. So in other words, people talk about vitamin C and get my kid a lot of vitamin C. Will that superpower their immune system? It really won't. It will help you if you're deficient to make you normal, but it won't if you're normal, make you superpowered.

So it really, generally speaking, a multivitamin is reasonable. And then all those good, healthy living things that we heard from our moms growing up.

Dr. Jackie Bjelac: Mm-hmm. Whole foods, fresh fruits and vegetables well balanced diet and sleep, which is so hard. Sleep is so restorative. And I tell families that if the most important thing they can do to quote unquote boost an immune system or support an immune system is help their child get adequate sleep.

Dr. Jack McDonnell: Absolutely. And then the other thing that's important to mention is the standard childhood immunizations, which are extremely important for protecting you. Some of the things on the immunization schedule are more rare processes, but some, like for example strep pneumococcus, which is part of the Prevnar series, preventing that infection. [Mm-hmm.]

That is a major player still in kids getting ear infections, sinus infections, lung infections. So getting the standard childhood vaccines is really a critical part of it in protecting your child as much as possible.

Dr. Jackie Bjelac: And I think there's a lot of information, especially, you know, I scroll through my socials about concern for safety of vaccines and would love to hear your thoughts on how we identify safety issues with vaccines and why we still recommend them if there could be safety issues with a vaccine.

Dr. Jack McDonnell: The standard series of vaccines have been very well tested over many, many, many years. Now, whenever someone has any kind of adverse effect of a vaccine or that's something that could be attributable to the vaccine, it can be entered into a system called vares, which is like a vaccine adverse event reporting system.

Mm-hmm. And sometimes my patients will look up things on inves and say, well, what about this side effect? What about that side effect? And it's definitely true that, I mean, I don't know, maybe the vaccine could cause that one random side effect in one person. But it's equally true that a lot of things that are in the vares database, which is a catchall for every kind of possible reaction that could have happened with vaccines, might not have had anything to do with the vaccine at all.

We do know that certain shots because it's been studied and because doctors are continuing to look at studies regarding vaccines and safety and efficacy, we know that certain possibilities exist. There are rare cases of Guillain- Barre syndrome with certain vaccines. We know that MMR Varicella can in some patients lead to like febrile seizures as a temporary thing, so we know that they're not completely perfect in every way.

But on the whole, they're extremely safe and extremely effective and it'll be go a long way in protecting against immune deficiency. And I have many patients who can't get vaccines for various reasons, who are kind of like wishing they could. They know that measles is really going crazy in the state of Ohio and elsewhere that they're visiting and they're asking me, what can I do to protect my kid?

And for those patients, we're really relying on the herd immunity from everyone else getting as protected as possible.

Dr. Jackie Bjelac: I think that's important. And I think as parents, you know, our only goal is to always do what we think is right for our child, and I think it's always an important conversation to talk about that the potential for risk of pursuing these vaccines has been shown time and time again to be outweighed for the benefit.

Hear us say it's not no risk, and there's a huge benefit not just to your family and your child, but also for patients and families who aren't able to get the vaccines or who might not have responded to the vaccine as their immune system was supposed to.

Dr. Jack McDonnell: Absolutely.

Dr. Jackie Bjelac: Yeah. These risk benefit things are for everything. Tylenol, vitamins, different foods and vaccines. And this is, I think, really hard as a parent. 'cause I know, again, on all of my socials, lots of information from people who seem to really know what they're talking about are really convincing. But as an immunologist do all of your kids have their vaccines?

Dr. Jack McDonnell: Yep. We're very compliant with kind of the vaccine schedule, recognizing that it is for most patients, very safe, very effective, and we're trying to give my wife and I, who's also a physician, we're trying to give our kids every bit of chance for success without being dragged down by needless infection.

Dr. Jackie Bjelac: Mm-hmm. Understood. So, would love to hear your thoughts on should your kids get dirty.

Dr. Jack McDonnell: Yeah, so that's a good question. Certainly I think there's something to be said for exposure to antigens or, or to things in the environment that challenge your immune system. And I think that what we've noticed is that it's actually protective to be exposed to different challenges.

And so certain, for example, even certain allergies are not as prevalent in an environment where there's more exposure to antigens that challenge the patient. [Mm-hmm.] So I think it's generally good. It maybe can be overstated in terms of you don't have to like, make your kids go through filth in order to just challenge their immune system.

But yeah, there's something to be said about being exposed. Yeah. You know, not worrying so much. Also recognizing that for most immune system problems, it's not really environmental infections that cause a lot of problems. Right.

So like my kid playing out in the dust or in the dirt somewhere is not likely to lead to an infection unless my child is completely immune deficient and has no T cells, for example. Like your immune system can swat away those kind of environmental infections quite easily. Those are not the kind of things that are probably getting a kid a pneumonia or an ear infection or a sinus infection, for example.

So, but at the same time, by being exposed to those things, we know it is healthy for your immune system dealing with both infection risk and also allergy risk. There's a lot of good evidence, which you're well aware of, that by exposure to food antigens that may otherwise be challenging for the immune system. By early exposure, you actually kind of prevent some food allergies.

So, yeah, I, I, I think within reason, it's good to be exposed to a variety of things and certainly we don't want any patient living in a bubble [mm-hmm] metaphorically speaking.

Dr. Jackie Bjelac: Right. Do you guys use antibacterial soap at the McDonnell home?

Dr. Jack McDonnell: We don't. We like just regular old soap. I think for most purposes you don't need antibacterial soap. And of course we're learning more and more about the mysterious thing known as the microbiome, right? [Mm-hmm.] So like you having the correct proportion of good bacteria, for example, in your gut, we don't wanna do anything that throws off that balance inadvertently.

Like an antibacterial soap that wipes out certain good bacteria in your gut. So that's something I think that for most purposes, we don't need antibacterial, specifically soap. We just need generic soap.

Dr. Jackie Bjelac: Mm-hmm. And you're mentioning the gut bacteria and the microbiome, and this is a huge area of interest in the allergy world, but also frankly, the immunology world.

Can you comment a little bit on how the microbiome impacts our immune system?

Dr. Jack McDonnell: Well, your microbiome is very important for immune tolerance. So in on the one hand, your microbiome by its competitive nature, you have the good bacteria. If you think about them being in some tension with the bad bacteria, the good bacteria being there period, helps prevent certain infections from developing because the good bacteria is out competing for resources. If you wanna think of it like that.

The other thing that's really important however, is, you know, we think about immune systems that aren't so much sometimes deficient, but maybe overactive like autoimmunity or immune dysregulation. Well, the good bacteria are important for that too because they're keeping a state of immune tolerance going on in the in the gut, and that's informing the entire body and the entire immune system.

So like you, if you kill off the good bacteria, that helps keep the overactive elements of the immune system in check. It really goes a long way for maybe preventing the onset of autoimmune or dysregulation.

Dr. Jackie Bjelac: And a lot of families kind of along those lines, ask me about probiotics. What do you think as an immunologist about a probiotic?

Dr. Jack McDonnell: I think it's fine now, especially if there's a time where you have a particular need for it. So for example, like my kids get sick sometimes we, and they're on amoxicillin for 10 days for an ear infection. We'll often start a probiotic for that 10 day period.

As far as longer term use, probably a low harm intervention. I'm not sure that studies have shown that it's, you know, be very effective, but it's certainly gonna not harm most people in most situations. Right.

But in the McDonnell household, if we're using that as a case study, we would use probiotics in the context of, you know, my kid has an ear infection, he's on antibiotics, we want something, 'cause we know he tends to get a little bit of diarrhea with the antibiotic. We want something to help prevent that. And we found it to be anecdotally helpful.

Dr. Jackie Bjelac: Yeah. And there's that risk benefit all over again. Right. Pretty low potential for harm, especially in a kid with a normal immune system and possibly a good benefit. 'cause who wants their kid to have diarrhea.

Dr. Jack McDonnell: Exactly. Not us. We don't want that.

Dr. Jackie Bjelac: We're antidiarrhea at the Bjelac house as well.

Dr. Jack McDonnell: Antidiarrhea for sure. Yeah.

Dr. Jackie Bjelac: And then one other thing thinking about, you know, gut health. We have chosen to use fiber in our house as a supplement instead of a long-term probiotic, just to kind of feed the gut microbiome in a way that feels a little more non-specific and letting our immune competent kids let their gut microbiome choose.

Dr. Jack McDonnell: Yeah, that's a good idea.

Dr. Jackie Bjelac: You think so? Okay, good.

Dr. Jack McDonnell: And I think there's good evidence that people don't have quite enough fiber in our diets that will even help your, your gut in other ways.

Dr. Jackie Bjelac: Awesome. This is really helpful. So this, I really hope for our listeners is a helpful summary that a lot of the things that we heard from our moms are true.

We need good sleep, we need.

Dr. Jack McDonnell: Moms are smart.

Dr. Jackie Bjelac: Moms are so smart. We need to move our bodies and exercise. How does exercise and trying to reduce stress help the immune system? Why did my mom know that that was helpful?

Dr. Jack McDonnell: So I wish I had a better answer for that. I don't know exactly how it helps. We just know that it does really help and that people, for example, who are sleep deprived, people who are eating an extremely unhealthy diet, they just don't have quite the reserve to deal with infections that they otherwise would. And that's not an immune deficiency.

Any kind of like other factor, nutritional environmental factors, that's much more likely to temporarily dampen your immune system than an actual single gene defect, like what I normally treat and try to study. It's much more common that some factor that your mom knew about for maybe not knowing why.

No one totally knows why that those factors are gonna be much more relevant for most people. So again, the sleep, the exercise, the stuff that maybe you roll your eyes when the doctor says it and you're like, yeah, yeah, I've heard that before. But that's really the important stuff for most people, most of the time.

Dr. Jackie Bjelac: And it's not just helping our immune systems, but lots of other body systems too. I'm sure all of our colleagues who go on this podcast would agree that a healthy diet, good sleep and good exercise are important.

Dr. Jack McDonnell: Yeah. And maybe we, moms know this because anecdotally they've experienced it, right? Like we have all had a situation where a kid isn't sleeping well or isn't, you know, eating particularly healthy, and then it just seems like they're not their normal selves. So just the experience of it. In the real world.

Dr. Jackie Bjelac: That's so great. I wanna thank Dr. McDonnell so much for joining us and sharing his expertise. I lean on him so heavily in my day to day and practice, so I really hope that this was helpful for our families listening today.

And we do wanna take time to reassure our listeners, that while it is normal for kids to get sick, they can be empowered to focus on good nutrition, adequate sleep, regular activity, and managing stress to try and support natural defenses. And if ever you're concerned, we would be happy to see you and talk to you.

So if you'd like to schedule an appointment with one of our pediatric allergist immunologists, please call 216.444.KIDS. That's 216.444.5437. Next time on Little Health, we will be discussing Eczema in children.

Speaker 3: Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit Cleveland Clinic Children's.org/little-health.