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Daily Dose

Migraines in Children

1.15 to read

I received an email via our iPhone App inquiring about migraines in children. Headaches are a common complaint throughout childhood, but pediatricians have recognized that children have many different types of headaches which include migraine headaches. 

Migraine headaches are best diagnosed by obtaining a detailed history and then a thorough neurological exam. There are several characteristics of childhood migraines that are quite different than adult migraines. While adult females have a higher incidence of migraine headaches, males predominate in the childhood population. 

Childhood migraines often are shorter in duration than an adult migraine and are less often unilateral (one sided) than in adults. Only 25-60% of children will describe a unilateral headache while 75-90% of adults have unilateral pain.  Children do not typically have visual auras like adults, but may have a behavioral change with irritability, pallor, malaise or loss of appetite proceeding the headache.  About 18% of children describe migraine with an aura and another 13% may have migraines with and without auras at different times. When taking a history it is also important to ask about family history of migraines as migraine headaches seem to “run in families”. 

Children who develop migraines were also often noted to be “fussy” infants, and they also have an increased incidence of sleep disorders including night terrors and nightmares. Many parents and children also report a history of motion sickness. When children discuss their headaches they will often complain of feeling dizzy (but actually sounds more like being light headed than vertigo on further questioning). 

They may also complain of associated blurred vision, abdominal pain, nausea and vomiting, chills, sweating or even feeling feverish. A child with a migraine appears ill, uncomfortable and pale and will often have dark circles around their eyes. It seems that migraine headaches in childhood may be precipitated by hunger, lack of sleep as wells as stress. But stress for a child may be positive like being excited as well as typical negative stressors. 

Children will also tell you that their headaches are aggravated by physical activity (including going up and down stairs, carrying their backpack, or even just bending over). They also complain of photophobia (light sensitivity) and phonophobia (sensitive to noises) and typically a parent will report that their child goes to bed in a dark room or goes to sleep when experiencing these symptoms. 

Children with migraines do not watch TV or play video games during their headaches. They are quiet, and may not want to eat, and may just want to rest.  Nothing active typically “sounds” like fun. To meet the diagnostic criteria for childhood migraine, a child needs to have at least 5 of these “attacks” and a headache log is helpful as these headaches may occur randomly and it is difficult to remember what the headache was like or how long it lasted, without keeping a log. 

There are many new drugs that are available for treating child hood migraines and we will discuss that in another daily dose.  Stay tuned! 

Daily Dose

Why Kids Faint

2.00 to read

Last week, we chatted about younger children and fainting so now it’s time to talk about older kids who faint. I’ve seen many teens that have fainted…even my own son (he fainted numerous times while he was an adolescent).   I decided to “read up” on causes of syncope (fainting) and I found out just how common it was. The highest incidence of syncope (and pre- syncope as in “I almost fainted”) occurs in up to 40% of adolescents and may be even higher among females!

The most common form of fainting among this age group is called “vasodepressor, vasovagal or neurocardiogenic” syncope. These terms all have the same meaning and describe the typical fainting event: a teen’s been standing for a period of time, and they begin to feel light headed and dizzy.

This often progresses to the feeling of having tunnel vision, the skin becomes pale, there may be the sensation of a rapid heartbeat, and feeling hot, although they may be cold and clammy to the touch. If these symptoms are not recognized and the teen does not sit down or lie down then fainting will occur.

The biggest fear from this type of fainting is really not due to the fainting episode itself (which usually does not last more than 15-30 seconds) but rather concern over a head injury when the patient falls. It is important to teach these “fainters” about the importance of paying attention to these symptoms and to sit down or lie down to prevent injury. Simple syncope will not hurt you!!

When seeing your child’s pediatrician it is important that a good history is taken.  I always ask my patients “when the fainting episode occurred, had they eaten, were they standing when fainting occurred and most importantly did the fainting happen with exercise or while at rest?  Did anything provoke the episode such as being anxious while standing to give a speech, or scared or grossed out during a movie etc.” Most patients have a good history as to why the fainting occurred.  Anyone fainting DURING exercise should be referred to a pediatric cardiologist for evaluation.

For all other fainters who have negative family history for sudden cardiac death, who have history consistent with simple syncope and who have a normal physical exam, the only test I order is an EKG, which should also be normal.  When all of this is done, I reassure both the patients and their parents that this is solely a fainting episode and may likely reoccur.

So, stay well hydrated, make sure not to skip meals, don’t get up too fast from bed first thing in the am and above all if you feel like you are going to faint, LIE DOWN.

That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Poison Control in Your Home

1:15 tow atch

Our office gets many calls from parents who are worried that their child may have swallowed a stray pill, or a berry or plant leaf.  The list is endless. Despite every parents efforts at childproofing their home (childproofing cabinets, electrical outlets etc, should begin as your your-baby starts to crawl) at times a toddler finds something stray and the first place it goes is in their mouth.

The phone number that needs to be at every parent's fingertips is the number to the Poison Control Center. That number is 1-800-222-1222 and should be on your speed dial or on a sticker on your phone.

The poison control center is the national source for information on poisoning and I have been so impressed with their professional, yet compassionate manner and their knowledge base. If your child does accidentally ingest a household cleanser, or a drug have the bottle handy when you call them so that you can read them the label. It is much easier for them to help you decide what to do for the ingestion with complete information. Telling them that it was a small white pill leaves millions of possibilities; so make sure that you do keep all medications, whether over the counter or prescription, in their appropriate bottle. Fortunately, many ingestions may be benign and require no treatment, but do not assume this until you have spoken with Poison Control. The use of syrup of ipecac, to induce vomiting after ingestion is no longer recommended. Thank goodness!

That's your daily dose, we'll chat again tomorrow.

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Daily Dose

Mumps Outbreak!

1:30 to read

The latest infectious disease outbreak is in the Boston area where several colleges have reported cases of mumps. Mumps is a viral illness that causes swelling of the salivary glands as well as other symptoms of fever, fatigue, muscle aches and headache.    Harvard University has been hit the hardest and has now documented over 40 cases this spring.  Boston is a city with numerous colleges all in close proximity, and there are documented mumps cases at Boston University, University of Massachusetts  and Tufts as well.  These Boston area colleges are all in close proximity and are merely a walk, bike or train ride away from one another, so these students, while attending different universities may all co-mingle at parties and athletic events.

Mumps is spread via saliva (think kissing), or from sharing food, as well as via respiratory droplets being spread after coughing or sneezing. It may also be spread via contaminated surfaces that will harbor the virus. People may already be spreading the virus for  2 days before symptoms appear and may be contagious for up to 5 days after their salivary glands appear swollen….so in other words there is a long period of contagion where the virus may inadvertently be spread. It may also take up to 2-3 weeks after exposure before you come down with mumps.

All of the students who have come down with mumps had been vaccinated with the MMR vaccine (mumps, measles, rubella).  Unfortunately, the mumps vaccine is only about 88% effective in preventing the disease. Despite the fact that children get two doses of vaccine at the age of 1 and again at 4 or 5 years….there may be some waning of protection over time. This  may also contribute to the virus’s predilection for young adults in close quarters on college campuses. Something like the perfect infectious disease storm!

In the meantime there are some studies being undertaken to see if adolescents should receive a 3rd dose of the vaccine, but the results of the study are over a year away.

In the meantime, be alert for symptoms compatible with mumps and make sure to isolate yourself from others if you are sick.  Harvard is isolating all of the patients with mumps for 5 days….which could mean that some students might even miss commencement.  Doctors at Harvard and other schools with cases of mumps are still on the watch for more cases …stay tuned.

 

 

 

 

Daily Dose

Fever Frenzy

1.30 to read

More about fever and all of those fears and myths.  

Treating the symptom of fever simply makes your child feel a bit better, it does not make them get better faster nor does it mask other symptoms. I see many parents not treating their child’s fever before bringing them to the office as they “want me to see how sick they are”.  Giving your child acetaminophen or ibuprofen will make them feel better and in turn “not look quite as sick”, but your doctor wants to see this behavior as it is reassuring. I promise you, I believe the mother who says to me, “his temp was 103.8 an hour ago!”. But seeing that child now playing with their parent’s cellphone  and eating one of those pouches (another topic), reassures me that this child is most likely not extremely ill.  Treating a fever does not mask the symptom of meningitis, or appendicitis, you have to trust me on that. 

Some parents have been told by grandparents and others that a fever means that your child can’t have milk or dairy products.  Again, if the only thing your child wants when they have a fever is a milk shake, let them have it. I am just concerned that a child is getting fluids when they have a fever, and it really doesn’t matter what that fluid is.  Food when you have a fever?  Sure, if your child wants to eat, great!  But, remember how your own appetite usually diminishes when you are sick (sad but true, good for quick weight loss).  Your child can go days without eating and be just fine as long as they are drinking.  Push popsicles, jello, juice, ginger ale, etc.  No rules about “healthy” when your child is sick....back to healthy eating rules once they’re child well.  

Lastly, you cannot feel your child’s head or chest and know what their body temperature is.  I can often tell a child has a fever by their heart rate, which goes up as your body temperature goes up, but even after more than 25 years of practice and raising 3 kids I cannot feel a forehead and be accurate.  So.....go buy a thermometer. I still like the “cheap’ digital ones, but you can buy the temporal thermometers or otic ones, whatever you prefer.  If your child is sick and you think they have a fever, take their temperature to document fever. You don’t need to do it all day long, or wake them up at night, but it is important to document at least once a day.  

Lastly, no school, day care or going places when your child has a fever. Please keep them home for 24 hours fever free, to help not spread their illness.  This is fact!

Daily Dose

A Germ-free Office?

To keep the germs at bay, it has been suggested to remove all toys & magazines from a doctor's office. Really? Aren't there germs on magazines in a lawyer, dentist or school office?I was just reading an interesting newspaper column in one of the advice columns carried in my daily newspaper. I just had to comment!  The writer had written in to suggest that doctor’s offices needed to change their practice of having magazines and toys for those in the waiting room.

Her feeling was that if doctors would discontinue having magazines in their offices, then patients would bring their own periodicals and that this would then reduce the spread of germs. The columnist also thought this sounded like a good idea and thanked the writer for such a great suggestion. I had to re-read the column as I really could not believe that someone would suggest that doctors should have empty waiting rooms!!!   Have we just gone overboard with “germ fears”?  I understand the need to wash your hands, and to try and keep your hands away from your face, to cover your mouth when coughing etc.  But taking magazines, newspapers, toys and books out of a waiting room seems a little extreme. There are also similar items in the waiting room of my dentist, lawyer, accountant, hairdresser etc.  I guess there could also be germs in those offices too, but no one is suggesting that these professions “sterilize” their waiting rooms and common areas. While I agree it is important to try and keep waiting rooms clean, especially in a doctors’ office (where not everyone is even sick), there is no way to keep any common area totally germ free. The magazines and books are not the only objects that may harbor germs. What about the chairs, the door knobs, the table tops, the counter tops, the fish tank glass, even the floor?  There is just not any way to keep the area entirely germ free, even with good cleaning. In my office we are very conscious about trying to keep the office clean to reduce the spread of germs. Our housekeeping staff that mop the floors and wipe the surfaces between morning and afternoon patients. To try and make an office germ free is as impossible as making a grocery store, a department store, a library or even a school germ free. It is just a fact of life that we will all be exposed to germs. To suggest that discontinuing the long standing tradition of having reading material in the waiting room of a doctor’s office in order to decrease the spread of germs just doesn’t seem to make common sense to me. If you (as a patient) are “afraid” to read a magazine at your physician’s office, then by all means bring your own. But to take away the books and magazines from everyone is just a bit too much. For many parents a trip to the pediatrician’s office is difficult enough without having to lug your own stash of toys and books. I have sweet moms who don’t even remember to bring diapers or wipes as they are just trying to get to their appointment.  Arriving to an empty waiting room to try and entertain 3 children waiting on their doctor seems like torture to me. Schools are full of germs too, but we send our kids there to learn (and occasionally get sick too). Getting sick is never fun, but germs are ubiquitous.  Don’t sweat the small stuff; remember there is a bigger picture. What do you think? I would love to hear from you! Feel free to leave your comments below.

Daily Dose

Confusion Over Cough & Cold Medicines

The confusion over cough and cold medications continues and I must admit I am a little confused too. The Consumer Healthcare Products Association recently announced changes to the labeling of over-the-counter (OTC) cold products to state "do not use in children under 4 years of age". The FDA monograph still states "do not use in children under 2 years". The American Academy of Pediatrics recommends not using OTC cough and cold preparations in children under six years.

Looking at the little research on these products two things come to mind:

  1. There have been multiple studies done on these products (in adults) that do not show them to be efficacious for treating common cough and cold symptoms.
  2. The research among children using these products show that dosing errors and accidental ingestions are the leading cause of adverse events.

This kind of leaves me thinking why use them at all in children? I really have never been much of a cold medicine giver in general, as I personally did not see my patients getting better any faster nor my own children. We continued to use the good old grandmother tested remedies of lots of rest, fresh squeezed orange juice (sometimes in pays to be sick), chicken noodle soup (canned or home made), and a vaporizer or humidifier in their rooms at night. I also know that younger children get more colds than anyone and no matter what you do you have to get through that too. But miraculously, as kids get older they get less colds and seem to tolerate them a little better. So... for this winter in our practice we are not recommending the use of any of these products for kids and trying the gold standards rest, fluids, cool mist humidifier and tincture of time. We'll see how it goes. That's your daily dose, we'll chat tomorrow.

Daily Dose

Wheezing & Respiratory Distress

2.00 to read

What is that hissing noise in the air? Plenty of wheezing and coughing ushering in upper respiratory season.  With all this noise, I’m on the lookout for respiratory distress. As I start to see more and more sick kids, my office becomes a cacophony of coughing.  While many of the coughs sound horrible, fortunately most of the children I will see do not have any real respiratory distress.

I will spend a lot of time this respiratory season talking to parents about respiratory distress and what to watch for. Just like so many things in parenting, observation is the key. Watching your child’s breathing when they are coughing or even wheezing is the most important thing you can do. But knowing what is “distress” or “shortness of breath” really often means you need to know what to look for.  

I just saw a precious little girl in the office, my first patient of the morning. She had a history of a few episodes of wheezing, and did have a nebulizer and medications at home. She had been well all summer and the mother hadn’t thought about wheezing, but noted that her daughter started to cough over the weekend and had then gotten worse and had coughed all night, which made her come to the office bright and early the following am.

When I walked into the room I immediately could see that the little girl was in a bit of respiratory distress. Not only was she coughing (which every other patient seems to be doing), she was also retracting or “pulling”.  She was still happy and playing but you could see that she was “working” to breath. Her tummy was moving in and out and you could see her ribs pulling in and out a bit. She was still well oxygenated and pink.  

Her mother had not looked at her chest and had forgotten about her daughter’s nebulizer (you know, out of sight out of mind), as she had not used it for 6 months and was not “clued” back into coughs and respiratory season.

A quick review and she remembered what we had discussed last winter and realized that she should have pulled out the nebulizer over the weekend. It is repetition that makes you remember “the home wheezing action plan” and if you only do it once a year it is easy to forget.

Any time your child is coughing, whether they are 2 days or 20 years old, you want to look at their color (pink, not blue) and at their chest. You want to see if they are using their ribs or tummy to breathe. The sound of the cough is not as important as LOOKING at their chests. Whether it is during the day or the middle of the night, take off their shirts, (turn on a light) and look. That is what your pediatrician is doing throughout the season.

Any type of retractions, pulling, or respiratory distress means a phone call and visit to the doctor or ER.  Coughs are usually okay, but never respiratory distress.

That's your daily dose for today.  We'll chat again tomorrow.

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.

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