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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

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

Head Flattening on the Rise!

1:30 to read

A recent study published in the online edition of Pediatrics confirms what I see in my practice. According to this study the  incidence of positional plagiocephaly (head flattening) has increased and is now estimated to occur in about 47% of babies between the ages of 7 and 12 weeks.  

The recommendation to have babies change from the tummy sleeping position to back sleeping was made in 1992. Since that time there has been a greater than a 50% decline in the incidence of SIDS. (see old posts).  But both doctors and parents have noticed that infants have sometimes developed flattened or misshapen heads from spending so much time being on their backs during those first few months of life.

This study was conducted in Canada among 440 healthy infants.  In 1999, Canada, like the U.S., began recommending  back sleeping for babies. Canadian doctors had also reported that they were seeing more plagiocephaly among infants.  

The authors found that 205 infants in the study had some form of plagiocephaly, with 78% being classsified as mild, 19% moderate and 3% severe.  Interestingly, there was a greater incidence (63%) of a baby having flattening on the right side of their heads.  

Flattening of the head, either on the back or sides is most often due to the fact that a baby is not getting enough “tummy time”.  Although ALL babies should sleep on their back, there are many opportunities throughout a day for a baby to be prone on a blanket while awake, or to spend time being snuggled upright over a parent’s shoulder or in their arms.  Limiting time spent in a car seat or a bouncy chair will also help prevent flattening.

Most importantly, I tell parents before discharging their baby from the hospital that tummy time needs to begin right away. It does seem that some babies have “in utero” positional preference for head turning and this needs to be addressed early on. Think of a baby being just like us, don’t you like to sleep on one side or another?  By rotating the direction the baby lies in the crib you can help promote head turning and prevent flattening.  

Lastly, most cases of plagiocephaly are reversible. Just put tummy time on your daily new parent  “to do list”.   

Daily Dose

Winter Season & Eczema

1.30 to read

I received these nice pictures and a question via email the other day. The mother was concerned as she had found this “spot” on her 6 year old son’s back. He was otherwise well and she did not see any other “spots” or rash.   

Her son complained that the “spot” was itchy so being the good mother she applied some over the counter cortisone cream for several days (which I always tell patients to try). After 2 days of it not improving, but not worsening, she thought it might be ringworm (also a good thought) and she applied an OTC anti-fungal cream.  Again, the rash was not better, but really not worsening or spreading.  That is an important part of the history. 

Now in medicine you learn about red herrings, which are part of a patient’s history that may not really have any bearing to their current problem....but one has to consider it. In this case, her dog developed a lesion and was taken to the vet and was diagnosed with a staph infection, but the vet told the mom that the dog was not contagious to humans.  Red herring or is that the problem? 

After looking at all of the pictures (which is never as good as seeing a rash in person), I am thinking that this may be nummular eczema, (nummular means coin shaped, hence the round)  The history is right as is was not bothersome other than being itchy, and eczema is often called the “itch that scratches”.   

With all of this cold dry weather and heaters on full blast all over the country eczema is having a heyday.  I have seen a ton of these little inflamed patches on skin of all ages (my own hands are a mess).   The treatment of choice is to moisturize the skin and also the use of a topical steroid. But, it takes a long time to see an improvement in the spots and they may change on a daily basis depending  on the weather, bathing and how much lubrication and moisturizing you are doing.  

I would use an OTC moisturizer that contains ceramides (Cetaphil Restoraderm, Cerave, Aveeno for eczema) and use it liberally and frequently.  I would also apply an OTC steroid several times a day (under the moisturizer). Eczema also sometimes requires a stronger topical steroid that is prescription. 

Hope that helps.....but if not improving after 7-10 days it may be worth a visit to your pedi for up close and personal diagnosis.

Daily Dose

Easing Anxiety Over First Periods

I saw a number of “tweens” this week so that meant a lot of discussions about development, puberty and periods.

Once a girl begins her first periods, which typically occur around the age of 12 ½ years, it is not uncommon to have irregular menstrual cycles. I try to explain this to young girls before their periods start, so that they are not concerned if they have their first period and then worry if they don’t have another one in 28 days. A “normal” menstrual cycle occurs every 28 days +/- 7 days. In other words everyone is a little different and some women have 22-day cycles, while others may have 34-day cycles and these are both considered to be normal variations.  Not everyone is the same, so that is important to explain to a young girl, as they are comparing notes with friends all of the time. When a girl has her first period (menarche) she typically may not have regular cycles due to the fact that she does not ovulate regularly. Many menstrual cycles in the first two years are described as being anovulatory. This actually occurs anywhere from 55 to 85 percent of the time during those two years after menarche. Even after five years of menstruation, 20 percent of cycles may be anovulatory. All of this leads to the reason that young girls often have quite erratic cycles, and it really “bugs” them. Another interesting fact is that girls that begin their periods at a younger age have a shorter duration of anovulatory cycles, and may therefore be telling their 13-year-old friend “I have regular periods already, what is wrong with you?”  Again, you just need to understand that we are all different. The hormonal changes that occur with ovulation are different than those during an anovulatory cycle and that is why bleeding may be different and irregular. You need “mature” hormonal feedback to ultimately begin regular cycles. Other events in a woman’s life such as stress, lack of sleep, an illness or extreme weight loss may even effect menstrual cycles. Explaining all of the “nuances” of periods is important because many girls think they will get a period, and they will bleed every 28 days for many years. They really do get quite “freaked” out if things are different than they expected. Giving them a little anticipatory guidance seems to put them more at ease and will hopefully prevent anxiety, which may only mess up their periods a little more. Oh what a tangled web! That’s your daily dose, we’ll chat again tomorrow! Send your question to Dr. Sue!

Daily Dose

Concussion The Movie

1:30 to read

As the end of football season is upon us, with bowl games for colleges and play offs for the NFL, a week does not go by that we don’t hear about a player who has been diagnosed with a concussion.   The debate surrounding football players and concussions will only get louder after the movie “Concussion” debuts over the Christmas weekend. The movie starring Will Smith will have broad appeal for kids and adults as it is a “sports thriller as well as a medical drama”.  “Concussion” is the story of the doctor, Bennet Omalu, and his discovery that concussions cause long term neurological consequences and his persistence in fighting the NFL. He forced the NFL to admit to the problem and his groundbreaking research has led to ongoing changes in the treatment of concussions both on and off the field. 

As a parent of 3 sons (full disclosure here), I must admit that  our youngest son played football. We had somehow managed to “dodge the football bullet” until the third boy came along. He was the most athletic ( is brothers would tell you that is because they taught him to play “up” with them in any sport”), and starting playing football while in elementary school. ( we are from Texas where football is king). Fortunately or unfortunately, he was good, as was his team, and they all went on to play through middle school where they won the league championship, and then into high school.  He loved the sport, begged us to keep letting him play and despite numerous conversations and our dismay that he wanted to continue to play football, he did play.  Of course we “bought him the best helmets” (not knowing then that studies would show that that is not enough) and we prayed every time he took the field that he would not get hurt.  He did get hurt. During his senior year he suffered a shoulder injury, had major surgery  taking a tendon from his knee to put into his shoulder,  and vowed never to play again!  He also figured out , “that he was not the best player on the team” which does not mean you can’t get hurt.

But, with all of the new studies and good data on CTE (chronic traumatic encephalopathy)  related to head injuries and concussions I called and asked him if he thought he had ever had a concussion???  Certainly, we never noted anything, but again this was 8-10 years ago. But to my surprise and in retrospect he thinks he probably did “have a couple of concussive like events” but he never told anyone about his symptoms…not his parents, coach or trainer…he only missed the end of his senior year due to his shoulder injury, not a concussion.  Thankfully he seems to be okay and is currently getting his MBA and does not even play recreational football.

So after reviewing all of the new data and the guidelines for return to play (RTP) and the the kids I have screened for concussions and kept out of games, I am not sure what I would do today if our child wanted to play football. That is the biggest question that parents are now facing….do you LET your child play football knowing about the risk of head injuries and the possibility of long term injury to a still developing brain??   Injury that may not be reversible?

Th AAP has recently come out with a zero tolerance policy for headfirst hits in football and the Council on Sports Medicine and Fitness has written the policy on tackling in youth football (Pediatrics. 2015 Oct 25) which includes seven recommendations to help make football safer. As Dr. Gregory Landry one of the lead authors states, “participants in football must decide whether the potential health risks of sustaining injuries are out-weighed by the recreational benefits”, and who is to decide, the parent, the under age child or both????

Good questions, but many differing opinions on the answers.

Daily Dose

When Parents Date

1.30 to read

I recently saw some patients of mine who are now teens. They were brought in for their check ups by their father who i had not seen in some time.  He has a boy and a girl about 16 and 14 years old.  I knew that there had been some “issues” within their family, but is had actually been several years since i had seen them.

As it turns out the parents had divorced, the mother had some problems with addiction and the father now had custody of the children. He was trying to get “everything back on track”, including visits to the pediatrician.  

After seeing each of the kids alone and talking to them, they actually seemed to be doing extremely well. They had seen a counselor during some of the more tumultuous times and were happy to be in a “stable” environment and had “less family stress” as they put it. They were both doing well in school, had lots of friends and were involved in different sports and school activities.  They said that their sad had been instrumental in getting things “back to normal”, or back to a “new normal”.  

I also visited with the dad and he told me he had a new concern.  He was really happy about how well his children were doing, all good.   It seems that he had just started dating agiain, and he was not quite sure how to handle the subject with his kids.  He told me that he had had several dates and his kids wanted to know....what’s next?

I had to laugh a bit, as we had just discussed his children dating.  My response was, “be honest with them”.  If you asked your teen after 2 dates “where is this going?”, they would probably reply, “dad, who knows, we’ve only had 2 dates...I’m not getting married!”.

I told him I would tell his children the same thing,  in a manner of speaking. I would acknowledge that I was enjoying dating, that I had no plans to get married any time soon, and did not even know if i was ready to be “exclusive” ( is that the adult version of Facebook official?) with anyone at this point.  

I would also make it clear that I would keep them updated if and when things changed, but in the meantime they did not need to worry. Their dad would be there everyday to get their breakfast, have dinner with them and continue their “new normal”. It was just such a good feeling seeing all of them happy!

Daily Dose

No More Food Battles

1.30 to read

Seems that I spend several times a day discussing “food battles” with my patients and their families.  I guess the longer I practice the more I don’t think we should even have to discuss how often parents “battle” with their kids about eating.  

From the early days of parenting when a baby is first offered either breast or formula, they are not asked “do you like this?”.  It is taken for granted that an infant will eat and grow and  there you have it.  The easiest days of parenting, correct? (except for a few months of sleep deprivation).  But once that baby begins to eat the discussions start about “he makes a face when he eats spinach”, or “she will only eat chicken tenders from Chik-fil-a”, or “he only likes pasta and won’t eat meat”, or even “I make 3 diferent meals for my 3 kids”.  If you have a child older than 9 months you understand what I am talking about. 

Food is necessary to nutrition, growth and health. But, with that being said, parents have to trust that a child WILL EAT when they are hungry.  Really, hunger drives us all to eat, eventually.  That bowl or cereal, or the steamed vegetables or even the dreaded chicken breast will get eaten if your child gets hungry enough. I remember reading somewhere that , “ a parent’s job is to provide food for their children at appropriate meal times, and child’s job is to decide if they will eat it.”  In other words, make the meal whether for your toddler or teen and “forget about it”.  Meal time needn’t be a battle but more a gathering to enjoy being together eating is just a bonus.  

As an adult, when you go to a dinner party, you don’t ask what they are serving before you accept, nor do you tell the host/hostess, I hate lamb!!  (my example).  You just smile and find something to eat and there is not a battle.  We all need to approach family meals as a dinner party. Our children are our guests, and sometimes they like what we fix and other times they push some food around their plate and choose not to eat.  The good news for most children is that there is another meal to follow. 

So, think about it and don’t let certain food likes and dislikes dictate mealtime. The more foods young children are exposed to the better chance they have of EVENTUALLY becoming a well rounded eater.  Children’s taste buds change with time as well, so you will find some foods that a 3 year old loved is no longer the favorite at 13 years of age.   

Well balanced, nutritious, colorful meals are the family goal and “food battles” can be left out of the vocabulary.   

Daily Dose

What a "Bald Spot" Can Mean for Kids

I saw a patient the other day whose mother brought him into the office after her son had found a “bald spot” on his head. It is alarming for parents or a child to find an area of hair loss or a “bald spot” on their head.

One of the reasons for hair loss is called alopecia areata. Alopciea areata is a non-scarring, solitary or multiple circular patch of hair loss. The areas are often described as "coin-shaped", often the size of a nickel or quarter, but may be larger. Alopecia areata is an immune disorder typically seen in children and adolescents. It can run in families and stress may play a role as a trigger. The areas exhibit no scaling, scabbing or irritation, there is simply hair loss. In older adolescents and young adult males the disorder can occur in the beard areas around areas of hair loss. Most of the lesions will resolve within a year, but patients often have repeat episodes. Rarely the hair loss can progress to total loss of scalp and body hair. Parents often confuse the hair loss with the fungal disease known as "ringworm", but alopecia areata is not related to a fungus or any other known contagious disorder. There is no cure for Alopecia areata, but there is treatment. The most common treatment consists of steroid injections into the areas. There can be significant psychological issues associated with the cosmetic consequences of alopecia areata and parents should be aware of that when deciding whether to treat the areas or wait for spontaneous resolution. In this case I sent him on to a dermatologist for further evaluation and treatment. The good news is that the majority of cases will resolve. Like so many things it takes time and patience and that is hard to have if you are a teen with hair loss. That’s your daily dose, we’ll chat again tomorrow.


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New report says not enough babies are getting much needed tummy time!


New report says not enough babies are getting much needed tummy time!

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