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Daily Dose

When to Worry About Bumps on the Neck

Have you ever been bathing your child and washing their head and neck and suddenly felt little “lumps or bumps” about he size of a pea or dime on their necks?Have you ever been bathing your child and washing their head and neck and suddenly felt little “lumps or bumps” about he size of a pea or dime on their necks? It makes your hand stop for a minute as you feel this small marble and of course “terrible thoughts” race through your mind. Well, it is not uncommon to feel these little lumps on a child’s neck.

Especially if your child is thin and they may have their neck extended for you to get underneath their chin for a thorough washing. The head and neck area is full of tiny lymph nodes and they are sometimes easily felt. Just because you can feel a lymph node does not mean you need to worry! Benign lymphadenopathy, as it is called in medical jargon is quite common. The lymph nodes of the neck “drain” the head and are often palpable around the jaw line, behind the ear, or even at the back of the neck. Benign (meaning, not to worry) nodes are small, mobile (in other words move around like a ball), non tender, and do not appear to be red or inflamed on the surface of the skin. These nodes are usually pretty small, again like a pea or dime. If your child is sick with a cold or has a “zit” on their face or a mosquito bite in their scalp etc, the node or nodes in fact may be a little bigger and some kids may say it is a little tender to the touch, (usually only to the mother’s hand as when I feel them of course they say “they no longer hurt“). That is like taking the car to the shop, gets better once you are there and have waited your turn! Most notably about benign lymphadenopathy is that the node does not really change. You watch it for several days and it is still small, non-tender and mobile and then forget about it for a while. In most cases by the time you think to check it again it is gone. The node should not grow in size, become hard and fixed (again you want it to move around beneath your fingers) and should remain asymptomatic. So, don’t jump to conclusions if you feel one of these and if in doubt let your doctor feel it. We all also have nodes beneath our arms, and in the groin area. Same thing goes for those in most cases, check to see if there is a cut, scratch, or bite nearby and watch the node for a few days. Things that are changing are worth a trip to the pediatrician. Peace of mind is often worth the wait. That’s your daily dose, we’ll chat again tomorrow.

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Daily Dose

Ear Infection Season

With it being winter and cough and cold season it is also ear infection season. It is most common to see ear infections in young children from about four months to 24 months old. Ear infections, also known as "otitis media" typically occur after a child has had cold symptoms with runny and congested nose and cough. Most ear infections occur after the child has been sick for several days as fluid from their cold accumulates in the eustachian tube and then becomes infected.

There is not one sign or symptom that lets a parent know that their child's ears are infected. People talk about children pulling on their ears, or not sleeping at night, or not wanting to take their bottle, or fever as symptoms of an ear infection. The only real way to diagnose an ear infection is by using and otoscope and having the pediatrician examine your child's ears. Examination is the gold standard, you have to look. When young children are found to have an ear infection they will begin taking an antibiotic. Unfortunately, some ear infections may be due to viruses, like RSV and will not respond to antibiotics but the doctor cannot tell that when looking in the ear. An infection of the ear looks the same through the otoscope whether it is viral or bacterial. When your child has recurrent ear infections they will probably be given different antibiotics each time in hopes of preventing resistance and also provide a different spectrum of coverage. At this time of year some children may become candidates for tube placement, because of their frequent ear infections. That's your daily dose, we'll chat again tomorrow.

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Your Teen

Kids Still Pumping Up the Volume

A new survey has found that children and their parents who like to crank up the volume on their music would turn down the sound level or use ear protection if they were told to do so by a health-care professional. The survey, conducted by Vanderbilt University researchers in conjunction with MTV.com found that nearly half of those surveyed said they experienced symptoms such as tinnitus or hearing loss after being exposed to loud music. 32 percent said they considered hearing loss a problem. The survey is published in the July 13, 2009, online issue of Pediatrics.

About 75 percent of those surveyed said they owned an MP3 player, and 24 percent listened to it for more than 15 hours a week. Nearly half said they use a music player at 75 to 100 percent of its maximum volume, which exceeds government regulations for occupational sound levels. When surrounded by external sounds, such as subway or traffic noise, 89 percent of the respondents said they increase the volume on their music player, the study found. The people surveyed said the media is the most informative source about hearing loss prevention, and the health care community was considered the least likely source. However, they said they would change their music listening behavior if advised to do so by a health-care professional. "Hearing loss is so prevalent that it has become the norm," study author Dr. Roland Eavey, chairman of otolaryngology at Vanderbilt, said in a university news release. He noted that studies "show that 90 percent of males age 60 and over now have hearing loss." Since the researchers' last survey about loud music and hearing loss, which they conducted in 2002, "we have learned that enough people still are not yet aware, but that more are becoming aware, especially through the help of the media," Eavey said.

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Daily Dose

Treating Swimmer's Ear

1:15 to read

Swimming is one of the best ways to beat the summer heat, but that may also mean that your child will develop a painful swimmer’s ear, also known as otitis externa. Swimmer’s ear is a common summer infection of the external auditory canal, in other words the part of the ear that connects the outer ear (where the Q–tip goes, but really shouldn’t) to the inner ear.

Swimmer’s ear often develops in school age children that spend much of their summer in the water, whether in a pool, lake or even the ocean. The ear canal just never gets a chance to dry out, and the constant moisture disrupts the skin’s natural barrier to infection. The skin may then develop micro abrasions, which allow bacteria to penetrate, and a painful infection develops.  The most common bacterial infection is due to the bacteria Pseudomonas aeruginosa.

A child with a swimmer’s ear usually complains when you touch their ear or tug on their ear lobe. They will often complain when they are lying down and roll over on that ear. Swimmer’s ear may be extremely painful and awaken your child from sleep. When you have an inner ear infection (otitis media) the ear itself is not painful to the touch. In severe cases the ear canal may be so swollen that it appears smaller than usual, and appears red and tender. At some times you may see discharge from the ear canal due to the infection and subsequent inflammatory response.

The treatment of swimmer’s ear is to use an antibiotic drop instilled into the ear canal. I often use an antibiotic drop in combination with a steroid to provide anti-inflammatory effects too which will help to reduce the local swelling and irritation. In severe cases it may be difficult to get the dropper into the ear due to the swelling so the doctor may place a “wick” into the ear that will open the ear canal and allow the drops to enter. A child may also need pain control with either acetaminophen or ibuprofen. At the same time you are using topical drops the child needs to keep water out of the ear!! This is the hard part as they are such water creatures at this age. This also means not to get the ear wet when bathing or showering. I usually say for four to five days before returning to the water.

To help prevent swimmer’s ear you can either buy a premixed solution called Swim Ear, at the pharmacy or mix up your own thrifty bottle made with 1/2 white vinegar and 1/2 alcohol. It is handy to keep this by the back door if you have a pool or in the beach bag. At the end of swimming apply a few drops to each ear and wiggle the ear around. This will help dry out the ear. Once your child is a “fish” and their heads are under water a good deal of the time, this a good time to start using this product. It is unusual to see a your-baby, toddler etc with swimmer’s ear, as they are just not under water all day. But prevention is the key, a painful ear is not fun and staying out of the pool just adds insult to injury! That’s your daily dose, we’ll chat again tomorrow.

Send your question to Dr. Sue!

Daily Dose

Earaches Are Painful

1:30 to read

I just managed to catch yet another cold from my cute, little patients who felt that they could “squeeze in” one more cold before officially closing out the sick season!  Parents are so SICK of their children being SICK and I must agree...it is time for everyone to stop coughing and sniffling and get well, and that means fewer ear infections as well.

Ear infections are one of the most common reasons that a parent brings a child to their pediatrician.  But, not every child that has a runny nose, cough, fever, or pulls on their ear will have an ear infection. In fact, most will not.  

Several important facts about an ear infection: a child’s ears typically do not get infected on the first day of a viral upper respiratory infection, most ear infections occur between day 3-7 of a cold. Most children who will develop an ear infection will have a runny nose, congestion, cough and often develop a fever.  It is not unusual for a child to have a fever for the first few days of a cold, but a fever that develops 3, 5, 7 days after the beginning of a cold may be a red flag for an acute ear infection.

The newest guidelines on ear infections are quite clear and state that the pediatrician needs to distinguish between an acute otitis media (AOM), with a bulging and opaque ear drum versus those children who simply have serous otitis media (fluid behind the ear drum).  Antibiotics are only recommended for those children with and acute ear infection who are symptomatic.   

For children under the age of two years, especially those in day care or school situations who have a first AOM, amoxicillin is still the recommended drug of choice. It is inexpensive and well tolerated (and tastes good too). For children with recurrent ear infections second line drugs will be used.

For a child over the age of two years who is not running a high fever or in exquisite pain, the newer guidelines advise “watchful waiting” with treatment beginning with topical ear drops for pain and acetaminophen or ibuprofen.  In the older child the infection is less likely to be bacterial and more likely viral and therefore will not respond to antibiotics.  I will give the parents a prescription for an antibiotic with instructions to begin it if the child seems to be worsening over several days, and to call me to let me know they started the antibiotic. In over 75% of my patients, they never begin antibiotics and the symptoms improve and the ear infection resolves on its own.

Discuss options for treatment with your own pediatrician and remember, judicious use of antibiotics is very important.  Not every child who pulls on their ear or who has a “bad night” of sleep will require an antibiotic. All children must be seen to decide who has an ear infection. it is not a telephone diagnosis!

 

Daily Dose

Middle Ear Issues

1:30 to read

I just read a really intriguing study on children who have persistent middle ear fluid (otitis media with effusion) in The Canadian Medical Association Journal. Persistent middle ear fluid is fairly common and is often a reason that children will undergo a day surgical procedure to insert tympanostomy tubes (ear tubes).  In fact, my 11 month old granddaughter just had tubes placed.

The treatment for middle ear fluid is often to just “watch and wait” and in many cases the fluid will resorb on its own and the problem is solved. But for persistent fluid surgery was often recommended. For older children I often would see if they could learn the “valsalva maneuver” which would increase the pressure in the nasopharynx and help open the eustachian tube. This is the same maneuver you use to “pop” your ears after an airplane flight.  The only problem is that some children don’t seem to be able to understand how to do this as there is not a way to really let them know how it feels when performed correctly.

In this study, 300 children aged 4 -11 years who had had recent ear symptoms and persistent fluid in one of both ears were randomized to “usual care” or were taught to use a nasal balloon.  The nasal balloon with auto inflation is a device which is inserted into one nostril while occluding the opposite nostril and the child blows up the balloon through their nose. By doing this they increase the pressure in their nasopharynx and open up the eustachian tubes and clear the fluid.  Genius…. the child can see that they are doing the maneuver properly as the balloon blows up….and it is both painless and fun!!

In the study the children, used the nasal balloon 3 times a day for up to 3 months and they were more likely to “achieve normal middle ear pressure” than the children who did not use the auto inflation balloon.  

This is certainly low cost and can be taught in the pediatrician’s office with minimal time and effort for both parent and child. Who wouldn’t want to try this rather than have a surgical procedure?

I am now going to look into where to purchase this product (wish I had thought this up) and try this on some of my own patients. I am sure there are plenty of kids that would love to blow up a balloon with their nose…perfect for a show and tell demonstration as well!

Daily Dose

Antibiotics May Boost Risk for Recurrent Ear Infection

1.15 to read

Did you know that repeated use of antibiotics to treat acute ear infections in young children increases the risk of recurrent ear infections by 20 percent? Researchers in the Netherlands found that 63 percent of children given the antibiotic amoxicillin had another ear infection within three years, compared with 43 percent of children given a placebo at the time of their initial infection. The results of the study are published online in the July edition of BMJ. Researchers looked at 168 children, aged six months to two years. In the group given amoxicillin, 47 out of 75 children had at least one recurrent ear infection, compared with 37 of 86 children in the placebo group. That equated to a 2.5 times higher risk of recurrent ear infection for the amoxicillin group. However, the study also found that 30 percent of children in the placebo group had ear, nose and throat surgery after their initial infection, compared with 21 percent in the amoxicillin group. The higher recurrence rate among children who took amoxicillin could be due to a weakening of their body's natural immune response as a result of taking an antibiotic at the initial stage of infection, the researchers said. Antibiotic use in such cases may cause an "unfavorable shift" toward the growth of resistant bacteria. Antibiotics may reduce the length and severity of the initial ear infection, but may also result in a higher number of recurrent infections and antibiotic resistance, the researchers stated. Because of this, they said, doctors need to be careful in their use of antibiotics in children with ear infections.

Daily Dose

Ear Tubes and Your Child

How do you if your child needs ear tubes?I received another email via our iPhone App from a mom who had read the ear infection articles and asked about the placement of ear tubes. That is a great question as this topic comes up often in children who have frequent ear infections.

The placement of tympanostomy tubes (“tubes”) in the ear drums for recurrent otitis media (ear infections) has been studied a great deal over the last 10 years. Tympanostomy tube placement is a surgical procedure that places a small tube into the eardrum to ventilate the area behind the eardrum.  These tubes also equalize the pressure in the middle ear. There are around 2 million tympanostomy tubes place in children in the U.S. each year due to chronic and recurrent ear infections. The most common time for a child to have ear tubes placed is between 6 months and 2 years of age.   When a child has an ear infection it typically follows an upper respiratory infection and  fluid accumulates behind the ear drum and may become infected.  This infection is routinely treated with antibiotics.  In some cases a child’s ear infection does not clear despite the use of numerous antibiotics, or a child may develop recurrent ear infections with each cold they get. Lastly, it is very common for a young child to continue to have fluid behind the ear drum (serous otitis) which may last for weeks to months. Each of these scenarios may be a reason for your doctor to refer you to an ENT (ear, nose and throat) doctor for “tube” placement. Placing tympanostomy tubes helps prevent recurrent ear infections by allowing air into the middle ear.  The tube also drains the fluid that had accumulated behind the ear drum.   It had previously been the consensus that early tube placement would also prevent hearing loss that might occur due to persistent fluid resulting in possible language delays. In recent years two articles in the New England Journal of Medicine looked at whether early tube placement vs later tube placement resulted in differences in language and cognitive development in children.  In both of these studies, there was no difference in language or cognitive development at either 3 or 9 years of age between  the two groups. There is not one answer to the decision to place tubes.  Each case for tympanostomy tube placement should be looked at on an individual basis.  Not only should the number of ear infections be considered (often more than 5-6 in a season), but the age of the child may also be important,  as younger children are more prone to frequent infections. In my opinion it is also important to look at the time of year the infections are occurring,  as a group of children will often clear up frequent infections and  persistent fluid once spring and summer months are upon us.  Again, delaying tubes for several months while deciding the appropriate course for your child has not been shown to cause developmental or language delays. If your child is having recurrent ear infections discuss tympanostomy tube placement with both your pediatrician and a pediatric ENT. That's your daily dose for today.  We'll chat again tomorrow. Send your question to Dr. Sue now!

Daily Dose

Oh, The Things That Get Stuck In Your Ear!

The adage "never put anything smaller than your elbow" rang true today in my office during a patient visit. But this time it was a patient's mom! I could not wait to get home from work today to write about my afternoon. Even as a pediatrician, I sometimes get “coaxed” into seeing an adult patient, usually the parent of one of my patients.

So, I got a phone call, an email and a text (how many ways can you find your doctor?) from an anxious adult.  This mother had been cleaning her own ears with a Q-tip and the tip of the swab had come off in her ear!!  She was “freaking out” and wondered if I might be able to look in her ear and get the swab tip out? After calling her back and chastising her for using a Q-tip, I told her to come in and we would attempt to get the cotton out of her ear. It wasn’t supposed to be a “big deal”. When she came in I looked in both her ears, they were the cleanest ears you could imagine. She told me she loved to use a Q-tip in her ears after a shower, even though she had been “told” not to use Q-tips in her own children’s ears, the old adage, “nothing smaller than an elbow should go in the ear”. At any rate, the entire tip of a cotton swab was lodged in her ear canal. Now it seems like it would be easy to get that big piece of cotton out of her ear canal, right? I mean I have taken beans, rocks, raisins, puzzle pieces, bugs and many other foreign objects out of ears…honest! This was an adult, who wasn’t squirming or crying, with a piece of cotton stuck and I thought this should be a piece of cake.  Well, I have to tell you, that very large piece of cotton Q-tip was as far back in the ear canal as you can get and it didn’t want to budge!! It can be quite uncomfortable to remove a foreign body from an ear, especially when it is deep in the canal and also touches the entire ear canal.  She had brought along her 5 year old daughter, who ended up serving as her hand holder and emotional support (role reversal).  After much to do, I could get the cotton moved up closer to the opening of the canal, but could not get it out. By now it was soggy and looked like a huge cumulus cloud in the previously very clean ear. So, I decided to abort the mission, and we would regroup the next day and decide if we might need the help of a friendly ENT. The best part of the story is listening to her daughter who kept telling her things like “ I can’t wait to tell all of my friends” or “didn’t the doctor tell us not to put stuff in our ears?”  Out of the mouth of babes has never been more true. The good news is that she saw the ENT today and she said the cotton just “slipped right out” after my mini surgery. I guess what I need to do is keep my practice limited to children, these adults are harder than you think!? Any crazy thing stuck in you or your child’s ear? Leave your story below and we’ll all laugh together! We’ll talk again tomorrow!

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