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Daily Dose

Dry Drowning

1:30 to read

It seems that at least once a week this summer I have seen a child in my office with a concern of “dry drowning”. In each case the child (anywhere from 2-6 years old) has been swimming and has had not had any issues…just a fun day in the pool.  But, the following day they “seemed tired, and didn’t want to play”, but were content to watch cartoons or play video games. A few of the children I have seen were sitting on my exam table eating a lollipop and playing on their mother’s I-phones.Thankfully, none were having any difficulty with breathing!

 

So…their concerned parents have seen media reports and are worried that this “fatigue and lethargy” is the presentation of “dry drowning”. In most cases they have also searched “dry drowning” on the internet and the first thing they see is WebMD’s definition of “dry drowning” which would concern most parents!  The article at the top of the Google search includes this.. “putting your child to bed after swimming and they never wake up in the morning”???  Who wouldn’t be worried….

 

But, if you ask most doctors (certainly all of the ones I know) they do not understand what “dry drowning” is, and have never seen a case like the one described by WebMD.  This small survey of mine included pediatric ER docs as well.  Actually “dry drowning” is not even mentioned in pediatric textbooks, and it is difficult to find the term in medical literature when doing a journal search. It is more likely to be found in media articles. 

 

As I understand it, the term “dry drowning” was first discussed in animal studies from years ago, in which animals died after ingesting water and experiencing laryngospasm, and it occurred 1-2 minutes after the immersion in water. None of the articles discussed “dry drowning” in children….but articles did discuss drownings!

 

In a pediatric study looking at data from over 15 years and “immersion related deaths- drownings” it was found that most drownings occurred at home and over 90% were due to lack of supervision.  There were no deaths reported from “dry drowning”. 

 

I am not concerned about any of my patients and “dry drowning”, but I am concerned about drowning!! 

 

Take home message….take your children to swim but be vigilant in watching them…..and you will not need to worry about any immersions or drownings!!  Drowning is preventable. 

 

 

 

 

 

 

 

Daily Dose

Baby Bling Can Be Dangerous!

1:15 to read

I recently saw a TV segment on “blinging” your baby and toddler. It seems that the latest craze is decking out not only little girls, but also little boys. Being the mother of three sons I can understand wanting to “dress up” boys as well (little boy clothes can be a bit boring) but a few of the models on TV were wearing necklaces. 

Now, a boy wearing a necklace doesn’t bother me at all, but a baby or toddler with a necklace worries me!  This isn’t about gender, rather about safety.  

A necklace is a real choking and strangling danger for babies and young children. I know that many parents receive necklaces for their babies on the occasion of a baptism and in some cultures an infant is given a necklace made of string or beads to wear soon after birth. 

But, whenever a baby comes into my office with a necklace on I discuss the possibility, even if remote, of the child suffocating if the necklace gets caught or twisted around the child’s neck. There is no reason to even risk it! 

Baby bling is great if you want to put your child in cute shirts, hats, or even trendy jeans. Go for it!  But I would never put a necklace on a child. It is akin to the adage about peanuts...when should a child be allowed to eat peanuts?  When they can spell the word!  

We pediatricians are no longer worried about peanut allergies in the young child, it is the choking hazard that is the real concern. It’s the same for a necklace. Let your child wear it when they can spell the word, or put it on when your 3 year old plays dress up, but take it off once finished. There is no need to ever have a young child sleep in anything like a necklace, or anything that has a cord until they are much older. 

Children ages 4 and under, and especially those under the age of 1 year, are at the greatest risk for airway obstruction and suffocation.  So, put the necklace back in the jewelry box for awhile. You can re-wrap for re-gifting and re-wearing at a later date. Safety before bling! 

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Daily Dose

Medicine Dosing Errors

1:30 to read

How do you give your baby/toddler/child their medications? In a recent article in Pediatrics it was found that up to 80 percent of parents have made a dosing error when administering liquid medicine to their children.  The study looked at children eight years old or younger. 

 

In the study both English and Spanish speaking parents were asked to measure different amounts of liquid medicines using different “tools”, including a dosing cup, and different sized syringes. They also were given different instructions with either text only or text with pictures. The different dosing tools were labeled with either milliliters/teaspoon or milliliters only.  Lots of variables! 

 

Not surprising to me, the parents who used the texts/picture combination instructions and who also used the milliliter only labeled dosing tools had the lowest incidence of dosing errors.  When parents had to use any math skills to calculate the correct dosage there were more dosing errors.  Most dosing errors were also overdosing rather than under-dosing the liquid medications.

 

This was an important article not only for parents to realize that it is not uncommon to make an error when giving their child medication, but also for doctors who write the prescriptions.  Before electronic medical records and “e-prescribing” I would typically write medication instructions in milliliters and teaspoons…in other words “take 5ml/1 tsp by mouth once daily”.  With electronic record you can only make one dosing choice which I now do in milliliters. But, with that being said, I still get phone calls from parents asking “how many teaspoons is 7.5 ml?”.

 

Previous studies have also shown numerous dosing errors when parents use kitchen teaspoons and tablespoons to try and measure their child’s medication. 

 

Some over the counter drug makers have tried to cut down on dosing errors with their liquid medications by making all of their products, whether for infants or children, the same strength. The only difference is the dosing tool that accompanies the medicine (syringe vs cup).  Interestingly, these medications may have a price difference when they are actually the same thing.  

 

This study may help to find strategies for comprehensive labeling/dosing for pediatric liquid medications, which will ultimately reduce errors.  Stay tuned for more!

 

 

 

 

 

Daily Dose

Kids Who Snore

1.30 to read

Does your child snore?  If so, have you discussed their snoring with your pediatrician.  A recent study published in Pediatrics supported the routine screening and tracking of snoring among preschoolers.  Pediatricians should routinely be inquiring about your child’s sleep habits, as well as any snoring that occurs on a regular basis, during your child’s routine visits.  

Snoring may be a sign of obstructive sleep apnea and/or sleep disordered breathing (SDB), and habitual snoring has been associated with both learning and behavioral problems in older children. But this study was the first to look at preschool children between the ages of 2-3 years.

The study looked at 249 children from birth until 3 years of age, and parents were asked report how often their child snored on a weekly basis at both 2 and 3 years of age.  Persistent snorers were defined as those children who snored more than 2x/week at both ages 2 and 3.  Persistent loud snoring occurred in 9% of the children who were studied.

The study then looked at behavior and as had been expected persistent snorers had significantly worse overall behavioral scores.  This was noted as hyperactivity, depression and attentional difficulties.  Motor development did not seem to be impacted by snoring.

So, intermittent snoring is  common in the 2 to 3 year old set and does not seem to be associated with any long term behavioral issues. It is quite common for a young child to snore during an upper respiratory illness as well .  But persistent snoring needs to be evaluated and may need to be treated with the removal of a child’s adenoids and tonsils.

If you are worried about snoring, talk to your doctor. More studies are being done on this subject as well, so stay tuned.

Daily Dose

Hip Dysplasia In Newborns

1:30 to read

Developmental Hip Dysplasia (DDH) occurs in 1 in 1000 births.  In a normal hip the upper end (ball) of the femur (thigh bone) fits firmly into the hip socket.   DDH refers to different abnormalities of the hip noted in infancy when the hip joint has not formed normally. This may   range from a mildly unstable hip in an infant to an infant that is born with a completely dislocated hip.   DDH is screened for from the time an infant is born until they are walking, in hopes of picking up any abnormality at a young age. 

 

The majority of babies with DDH are female (75%), and it is also more common in infants who are in the breech (butt down) position during the 3rd trimester of a woman’s pregnancy.  Other risk factors for DDH include: a family history of DDH and improper swaddling of an infant. 

 

You may notice that your pediatrician examines your baby’s hips at every visit.  They will perform the Ortolani maneuver and the Barlow test where the doctor is trying to see if they can feel a dislocated or unstable hip. In these tests they are actually putting pressure on the hip to check for a “click or clunk” which suggests a hip problem or instability.

 

For female babies who have been breech it is recommended that they not only have a physical exam checking for DDH, but that they also undergo an ultrasound of the hips after 6 weeks of age and prior to 6 months.  Ultrasound for male babies who have been breech is not “routinely recommended” but may be ordered if the baby has any signs of hip instability.

 

The incidence of hip instability and dysplasia seems to have also increased since parents began routinely swaddling their babies. It is now recommended that babies sleep in a sack rather than having them swaddled with their legs extended. For the hips to develop normally a baby needs to be able to move their legs around which will drive the femur into the hip socket, so that the socket gets deeper. A shallow, flat hip socket may lead to hip dysplasia.

 

In most cases that are detected early the treatment is a brace called a Pavlik harness that will hold the femur into position within the hip socket. A baby stays in the harness for 6-12 weeks in order that the hip joint will develop normally. For babies that may develop hip dysplasia after 6 months of age an orthopedist will probably recommend closed reduction to put the hip back into place. This is done under anesthesia and then the baby is placed in a cast that also pushes the femur into the hip socket.  The baby may have to wear this cast for 4 - 5 months. 

 

Every time your pediatrician takes off your baby’s diaper during their exam it is not really about a diaper change. That hip exam is really important!

 

Daily Dose

Summer Viruses

1:30 to read

June….now seems like officially summer, although there are still some schools around the country in session, and even a couple in Dallas.  So, with summer here it is check up time in my pediatric office.  That means most days I am seeing very few sick patients, and most of the patients who come in for a visit other than a check up have a rash, a bug bite or maybe a swimmer’s ear.

 

But, with that being said there are also always some of those pesky summer viruses hanging around and many of them appear with just a fever. Many of the “sick” children I am seeing only have a fever, some of whom have a temperature as high as 103-104 degrees, with very few other symptoms.  Although these kids have a significant fever, once they are given an over the counter product like acetaminophen or ibuprofen they feel pretty well and even play for awhile. 

 

Fever is often just a symptom of a viral infection and these summer viruses have names…enterovirus, adenovirus, and even some left over parainfluenza virus.  We are definitely out of flu season….at least till next year.

 

Some of these summer viruses may have associated rashes which are more common with summer viral infections than winter viruses.

 

I have seen some kids with these summer viruses with prolonged fever, even 5-7 days which is a bit longer than a pediatrician and a parent want to see. But, with that being said, when I have seen these children they appear to look well and have not had any other physical findings.  I have often seen them again after having 5 or more days of fever, and it seems that many of them have adenoviral infections.  Adenovirus may also cause a myriad of other symptoms than just fever, including pink eye, sore throat, abdominal pain and vomiting and diarrhea and tummy cramps.  Rarely, some children will develop blood in their urine without having a urinary tract infection. 

 

Parents often ask me….where did they catch this? Remember that these are just viral infections and that there is not a vaccine for adenovirus. Once we see one virus in the community I know I will continue to see more and more children as it is “passed around”.  Best thing to do is to keep up good hand washing and keep your child home from the pool or summer activities if they have a fever.  

 

Daily Dose

When Bug Bites Get Infected

1.00 to read

It is the season for bug bites and and I am seeing a lot of parents who are bringing their children in for me to look at all sorts of insect bites. I am not always sure if the bite is due to a mosquito, flea or biting flies, but some of them can cause fairly large reactions. 

The immediate reaction to an insect bite usually occurs in 10-15 minutes after bitten, with local swelling and itching and may disappear in an hour or less. A delayed reaction may appear in 12-24 hours with the development of an itchy red bump which may persist for days to weeks.  This is the reason that some people do not always remember being bitten while they were outside, but the following day may show up with bites all over their arms, legs or chest, depending on what part of the body had been exposed. 

Large local reactions to mosquito bites are very common in children. For some reason, it seems to me that “baby fat” reacts with larger reactions than those bites on older kids and adults. (no science, just anecdote). Toddlers often have itchy, red, warm swellings which occur within minutes of the bites. 

Some of these will go on to develop bruising and even spontaneous blistering 2-6 hours after being bitten. These bites may persist for days to weeks, so in theory, those little chubby legs may be affected for most of the summer. 

Severe local reactions are called “skeeter syndrome” and occur within hours of being bitten and may involve swelling of an entire body part such as the hand, face or an extremity. These are often misdiagnosed as cellulitis, but with a good history of the symptoms  (the rapidity with which the area developed redness, swelling, warmth to touch and tenderness) you can distinguish large local reactions from infection.

Systemic reactions to mosquito bites including generalized hives, swelling of the lips and mouth, nausea, vomiting and wheezing have been reported due to a true allergy to the mosquito salivary proteins, but are extremely rare. 

The treatment of local reactions to bites involves the use of topical anti-itching preparations like Calamine lotion, Sarna lotion and Dommeboro soaks.  This may be supplemented by topical steroid creams (either over the counter of prescription) to help with itching and discomfort. 

An oral antihistamine (Benadryl) may also reduce some of the swelling and itching. Do not use topical antihistamines. Try to prevent secondary infection (from scratching and picking) by using antibacterial soaps, trimming fingernails and applying an antibiotic cream (polysporin) to open bites. 

Due to an exceptionally warm winter throughout the country the mosquito population seems to be especially prolific. The best treatment is prevention!! Before going outside use a DEET preparation in children over the age of six months, and use the lowest concentration that is effective.  Mosquito netting may be used for infants in strollers.  Remember, do not reapply bug spray like you would sunscreen. 

Daily Dose

It’s The Season For Bug Bites & Stings

1:30 to read

Children love to be outside in the spring and summer when the daylight is longer and the backyard, playground, or campsite can become a magical play space. Insect bites are bound to happen. Most are just an annoyance, but make sure you know which ones to be concerned about and which ones may just require a hug and a kiss.It’s that time of year when insect bites and stings start showing up on your kids. Knowing how to prevent and treat common insect bites and stings, and knowing when to not overreact, can help keep your kids safe and healthy.

Babies and children may be more affected by bites or stings than adults. Let’s start with some common spring and summer insects. Spider bites Most spider bites do not actually penetrate the skin, and the majority of spiders found in the U.S are mostly harmless with the important exception of the black widow spider and the brown recluse spider, which are both dangerous to humans. Spider bites are fortunately uncommon. In many cases, presumed spider bites are actually due to another skin condition or an insect sting. The black widow spider is said to feel like a pin-prick, and some victims do not even realize they have been bitten. Sometimes you may notice double fang marks on the skin. The most common symptoms where the bite occurs are immediate pain, burning, swelling, and redness. Other symptoms may include chills, fever, nausea and vomiting, and severe abdominal pain. While black widow spider bites are hardly ever fatal, rare deaths have occurred from brown recluse spider bites and are more common in children than in adults. At first the bite of a brown recluse spider leads to a mild stinging, followed by local redness and severe pain that usually develops within eight hours but may occur later. Some reports of brown recluse bites describe a blue or purple area around the bite, surrounded by a whitish ring and large red outer ring in a "bull's eye" pattern. A fluid-filled blister forms at the site and then sloughs off to reveal a deep ulcer that may turn black. If bitten by a brown recluse or black widow spider - Cleanse the wound. Use soap and water to clean the wound and skin around the spider bite. - Slow the venom's spread. If the spider bite is on an arm or a leg, tie a snug bandage above the bite and elevate the limb to help slow or halt the venom's spread. Ensure that the bandage is not so tight that it cuts off circulation in your arm or leg. - Use a cold cloth at the spider bite location. Apply a cloth dampened with cold water or filled with ice. Seek immediate medical attention. Treatment for the bite of a black widow may require an anti-venom medication. Doctors may treat a brown recluse spider bite with various medications.

Bee Stings In most cases, bee stings are just annoying and home treatment is all that's necessary to ease the pain. But if you're allergic to bee stings or you get stung numerous times, you may have a more serious reaction that requires emergency treatment. Most of the time the symptoms from a bee sting will be minor. Your child may experience a burning pain, a red welt, and slight swelling. Some children may have a stronger reaction with extreme redness and swelling that gets bigger over a couple of days. Children, adolescents, and adults who are allergic to bee stings may have a severe reaction called anaphylaxis. About 3% of people who are stung by bees quickly develop these anaphylaxis symptoms. - Skin reactions in parts of the body other than the sting area, including hives and itching and flushed or pale skin (almost always present with anaphylaxis) -  Difficulty breathing -  Swelling of the throat and tongue -  A weak and rapid pulse -  Nausea, vomiting or diarrhea -  Dizziness or fainting -  Loss of consciousness -  Convulsions -  Fever -  Shock may occur if the circulatory cannot get enough blood to vital organs. For most Bee stings you can apply an ice pack or cool compress, a meat tenderizer solution which can be made by mixing one part meat tenderizer and 4 parts water. Soak a cotton ball in the solution and apply to the bite for 15020 minutes. A baking soda paste works well or a topical anti-itch cream such as Calamine lotion. Talk to your pediatrician about ways to prevent bee stings and possible immunotherapy if your child is allergic. Multiple stings can be a medical emergency in children, older adults, and people who have heart or breathing problems. If your child is allergic to bee stings always have an EpiPen available and use it right away as your pediatrician has directed. Wasps, hornets, and yellow jacket stings are similar to bee stings.

Fire Ants A bite that will get your child’s attention quickly belongs to the fire ant. Fire ants are so named because their venom induces a painful, fiery sensation. When disturbed, fire ants are very aggressive. To help children avoid fire ants, parents should regularly check their yards and their children's play areas for the presence of the ants and their mounds. Then they should either eliminate the ants or make sure children avoid them. If a child is stung, apply ice to the bite site for 10 to 15 minutes. Elevate the extremity where the child was bit. Clean and clip the child's fingernails to prevent any secondary infection that can result from scratching the bite. Check with the child's pediatrician for the correct dose of an oral antihistamine to reduce itching and inflammation A small percentage of children stung -- probably less than 0 .5 percent -- experience a severe (anaphylactic) reaction. These occur within minutes of a sting and vary in severity. A child who is stung and within minutes begins to experience hives, weakness, dizziness, wheezing, difficulty swallowing, shortness of breath or confusion should be taken immediately to the nearest emergency room. Watch the area for signs of infection over the next couple of days.

Ticks Ticks are common in grasses and wooded areas. If you have pets make sure they are tick free. Ticks are usually harmless but they can carry Lyme disease. To remove a tick begin by taking a cotton swab or cotton ball. Dip the swab or cotton ball in a small glass container that you will be throwing out after use. Place a small amount of rubbing alcohol in the bottom of your container. Use at least 2 tablespoons of alcohol. Dab on the site of the tick on the child or pet. Do not let it run, that is why you are dabbing it rather than pouring it on the site. If there is excess, dab it with another cotton swab or cotton ball. Let this cotton ball or swab sit on the tick for 3 minutes. This suffocates the tick and he will back out for retrieval with tweezers. If that method is unsuccessful, use the alcohol swab again and let the area dry. Then take a clean, unused cotton swab and glob a dollop of Vaseline petroleum jelly on the site where you see the tick. Let this stay on top of the tick for 3 minutes. You will then remove the tick and the Vaseline petroleum jelly.

Mosquitoes Probably the most common insect bite in the spring and summer come form mosquitoes. Ivillage.com has these tips for treating and preventing mosquito bites. The usual reaction is a local skin inflammation that is red, raised and very itchy. If your child scratches the bite, it may become infected as well. Here's what you can do for your children to help ease the itch and pain caused by mosquito bites. Treatments: Apply anti-itch creams like calamine as needed to help prevent scratching • Use anti-inflammatory creams like cortisone cream to help ease the inflammation and itching • If there is severe itching and multiple bug bites use antihistamines like Benedryl. Because they tend to make children drowsy, they work particularly well at night. •  Antihistamines like Claritin, Allegra, and Zyrtec tend to be much less sedating, buit check with your pediatrician about the correct dosage and whether these products are safe for children. Other Suggestions:
 Keep your child's fingernails cut short to prevent scratching • Apply cold wet compresses to the area to ease discomfort • Have your child wear long pants and long sleeves (if the temperature is bearable) • Make sure window screens are used if you keep windows open in your home • Use insect repellant to help prevent bites from occurring Choosing an Insect Repellant DEET is the best insect repellant in terms of effectiveness against flies, gnats, chiggers, ticks and other insects. The higher the DEET concentration the better it works. For children, however, the EPA recommends a concentration of 10 percent or less to prevent side effects and toxicity.

Scorpions Scorpion bites are painful but mostly harmless. The only dangerous scorpion in North America, probably the most venomous of all North American bugs is the bark scorpion. Bark scorpions are found in all of Arizona, extending west across the Colorado River in to California and east in to New Mexico. Scorpions are related to spiders, ticks and mites. Usually, they only sting to protect themselves or of they feel threatened. Scorpions can get caught up in bedding or crawl in to shoes so always check your child’s clothing and bed if you suspect scorpions may be around.  Scorpion stings without a serious reaction can be treated with ice on the sting and over-the-counter pain medication. Bark scorpion anti-venom is available only in Arizona. Any sting that shows signs of a bark scorpion needs to be treated at a hospital. Anti-venom has been shown to significantly reduce the effects of the sting. Children love to be outside in the spring and summer when the daylight is longer and the backyard, playground, or campsite can become a magical play space. Insect bites are bound to happen. Most are just an annoyance, but make sure you know which ones to be concerned about and which ones may just require a hug and a kiss. For pictures of several types of insects such as Black Widow and Brown Recluse spiders, check out http://www.webmd.com/allergies/slideshow-bad-bugs

Daily Dose

Brown Spots on Your Baby?

1:30 to read

I was examining a 4 month old baby the other day when I noticed that she had several light brown spots on her skin. When I asked the mother how long they had been there, she noted that she had started seeing them in the last month or so, or maybe a couple even before that.  She then started to point a few out to me on both her infant’s arm, leg and on her back.

These “caramel colored” flat spots are called cafe au lait macules, (CALMs) and are relatively common. They occur in up to 3% of infants and about 25% of children.  They occur in both males and females and are more common in children of color.  While children may have a few CALMs, more than 3 CALMS are found in only 0.2 to 0.3% of children who otherwise do not have any evidence of an underlying disorder.  

Of course this mother had googled brown spots in a baby and was worried that her baby had neurofibromatosis (NF).  She started pointing out every little speckle or spot on her precious blue eyed daughter’s skin, some of which I couldn’t even see with my glasses on. I knew she was concerned and I had to quickly remember some of the findings of NF type 1.

Cafe au lait spots in NF-1 occur randomly on the body and are anywhere from 5mm to 30 mm in diameter. They are brown in color and have a smooth border, referred to as “the coast of California”. In order to make the suspected diagnosis of NF-1 a child needs to have 6 or more cafe au lait spots before puberty, and most will present by 6 -8 years of age.

For children who present for a routine exam with several CALMs ( like this infant), the recommendation is simply to follow and look for the development of more cafe au lait macules. That is a hard prescription for a parents…watch and wait, but unfortunately that is often what parenting is about.

Neurofibromatosis - 1 is an autosomal disorder which involves a mutation on chromosome 17 and may affect numerous organ systems including not only skin, but eyes, bones, blood vessels and the nervous system. Half of patients inherit the mutation while another half have no known family history.  NF-1 may also be associated with neurocognitive deficits and of course this causes a great deal of parental concern. About 40% of children with NF-1 will have a learning disability ( some minor, others more severe).

For a child who has multiple CALMs it is recommended that they be seen by an ophthalmologist and a dermatologist yearly,  as well as being followed by their pediatrician.  If criteria for NF-1 is not met by the time a child is 10 years of age,  it is less likely that they will be affected, despite having more than 6 CALMs.

The biggest issue is truly the parental anxiety of watching for more cafe au lait spots and trying to remain CALM…easier said than done for anyone who is a parent. 

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DR SUE'S DAILY DOSE

Baby bling is cute, BUT....

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