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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

Ear Infections Can Develop Quickly

1:15 to read

One of the things that I sometimes see in my practice, which is interesting to me as a pediatrician, and was equally interesting when I had young kids, is how quickly a child's ear exam can change.

You are taught that in medical school, but when you really see it happen it with your patients or your own child you become a real believer. As the saying goes, seeing is believing. I can remember checking one of my boy's ears for an ear infection early in the morning before heading out to work, and declaring, "his ears are perfectly clear". How could it be, my husband would inquire, "that they seem worse after we have been at work all day" and lo and behold, I would re-check their ears and a normal morning ear is an abnormal evening ear. What a difference 12 hours can make! Not a very good warranty on ears and infections.

I was reminded of this yesterday when a patient called and said that her little boy had developed "disgusting" eye drainage which was worsening since I had seen them in the office a few days ago. They had just returned from taking both of their young children to Disney World, and she "couldn't believe they came home sick!" That's a whole 'nother column. At any rate, seeing that they lived fairly close I told them to swing on by and let me look at him again. I think she was just hoping I would call in eye drops. The two precious boys arrived at my doorstep on Saturday night and lo and behold after looking in the youngest child's ears, both of his ears were so infected. So, once again I was a believer in ears changing, and he did not need eye drops he needed to have oral antibiotics to clear up his ears (and subsequently his eyes). There are several lessons from all of this. Ears can change quickly, eye drainage in a toddler with a cold may often really indicate that their ears are infected, and house calls are a good thing.

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

Daily Dose

Diagnosing Diabetes

1.15 to read

I often see parents who come in worried that their child might have diabetes. I thought this would be a great opportunity to discuss the symptoms of type 1 diabetes, which was previously known as juvenile onset diabetes. 

While there is much in the news about type 2 diabetes, which is typically related to childhood obesity, the mystery of type 1 diabetes has not yet been totally elucidated. Type 1 diabetes affects about 1 in 400 children and adolescents. There does seem to be a genetic predisposition (certain genes are being identified) to the disease and then “something” seems to trigger the development of diabetes. Researchers continue to look at viral triggers, or environmental triggers (such as cold weather as diabetes is more common in colder climates). Early diet may play a role as well, as there is a lower incidence of diabetes in children who were breast fed and who started solid foods after 6 months of age.   

In type 1 diabetes the pancreas does not produce enough ( or any) insulin. Insulin is needed to help sugars (glucose) in the diet to enter cells to produce energy.  Without insulin the body cannot make enough energy and the glucose levels in the blood stream become elevated which leads to numerous problems. Children with type 1 diabetes are often fairly sick by the time they are diagnosed.  

The most common symptoms of type 1 diabetes are extreme thirst (while all kids drink a lot this is over the top thirst) frequent urination ( sometimes seen as new onset bedwetting with excessive daytime urination as well), excessive hunger,  and despite eating all of the time, weight loss and fatigue.  

Any time a child complains of being thirsty or seems to have to go the bathroom a lot, a parent (including me) worries about diabetes. But, this is not just being thirsty or having a few extra bathroom breaks or wetting the bed one night. The symptoms worsen and persist and you soon realize that your child is also losing weight and not feeling well. 

Although diabetes is currently not curable, great strides have been made in caring for diabetics and improving their daily life. I now have children who are using insulin pumps and one mother has had an islet cell transplant. The research being done is incredible, and hopefully there will one day be a cure. 

In the meantime, try not to  worry every time your child tells you they are thirsty or tired, as all kids will complain about these symptoms from time to time.  But do watch for ongoing symptoms.  

Lastly, eating sugar DOES NOT cause type 1 diabetes. Now it may lead to weight gain which can lead to type 2 diabetes....but that is another story. 

Daily Dose

Zika Virus

1:30 to read

If you are pregnant or planning on becoming pregnant in the near future you need to be aware of the Zika virus.  This virus is spread via the Aedes mosquito (as is West Nile Virus, Dengue fever and Chikunguyna), and has been found in Africa, Southeast Asia, the Pacific Islands , South America and Mexico.  The Zika virus was also just confirmed in Puerto Rico and the Caribbean in December.  There are new countries confirming cases of Zika virus almost every day, as the Aedes mosquito is found throughout the world.  

When bitten by a mosquito that has the Zika virus, only about 1 in 5 people actually become ill.  The most common symptoms are similar to many other viral infections including fever, rash, joint pain and conjunctivitis.  For most people the illness is usually mild and lasts for several days to a week and their life returns to normal.  Many people may not even realize that they are infected. 

Unfortunately, if a pregnant mother is infected with the Zika virus, the virus may be transmitted to the baby.  It seems that babies who have been born to mothers who have been infected with the Zika virus may have serious birth defects including microcephaly (small head) and abnormal brain development. There have been more than 3,500 babies born with microcephaly in Brazil alone…and just recently a baby was born in Hawaii with microcephaly and confirmed Zika virus. In this case the mother had previously lived in Brazil and had relocated to Hawaii during her pregnancy.  The virus to date has not been confirmed in mosquitos in the United States.

Because of the association of the Zika virus and the possibility of serious birth defects, the CDC has announced a travel advisory stating, “until more is known and out of an abundance of caution, pregnant women in any trimester, or women trying to become pregnant, should consider postponing travel to the areas where Zika virus transmission is ongoing”.  

Should pregnant women have to travel to these area they should follow steps to prevent getting mosquito bites during their trip. This includes wearing long sleeves, staying indoors as much as possible, and using insect repellents that contain DEET.

Researchers are continuing to study the link between Zika virus and birth defects in hopes of understanding the full spectrum of outcomes that might be associated with infection during pregnancy. There will be more data forthcoming.

At this point the safest way to avoid being bitten is to stay away from the countries who have had confirmed cases of the Zika virus.  But as the weather warms up in the United States and mosquitos become more abundant there is concern for Zika virus to be found here.  It only takes one infected mosquito to bite one person who then contracts the virus….should that person be bitten by another mosquito, that mosquito may acquire the infection and so it spreads.  There is not known to be human to human transmission of the virus.

Daily Dose

Irritable Bowel Syndrome

1:30 to read

Irritable bowel syndrome (IBS) is a common gastro-intestinal disorder in children. IBS is a functional gastrointestinal disorder which is characterized by abdominal pain or discomfort with associated changes in bowel habits. It is a diagnosis based on taking a good history and there are typically few physical findings.    

I recently saw a 10 year old boy with episodes of “recurrent abdominal pain” which had been intermittent over the last 6-12 months.  When questioned he complained of the sudden onset of
peri-umbilical pain (“around his belly button and in the middle of my stomach”).  The pain was sometimes related to meals, but not always, and it “just hurts”. He did not have any associated vomiting and he thought he “pooped on a regular basis”. The pain would last anywhere from 30 minutes to several hours, and he could not think of anything that made it worse, and he felt as if once he pooped he may get better for awhile.  His pain occurred at different times throughout the day and has happened at least every couple of weeks for months.  

His mother stated that he did not have associated fever, rash, nighttime awakening with abdominal pain or a family history of inflammatory bowel disease. He had never had blood in his stool, but she was “not sure” how often he had bowel movements or what they looked like. When he had the pain he would miss school, a sporting event or even a birthday party.  She was worried that “something was twisted in his stomach…”

Looking at my records I could see that he had not lost weight and was growing appropriately. He  was currently not having pain (he had the day before), and his physical exam was entirely normal: soft tummy, no point tenderness, and he giggled when I was “mashing around” on his abdomen. He also had a normal rectal exam (Yuck…but painless).  

His story is a perfect one for IBS…interestingly his mother also said, “I have had lots of stomach issues and have had lots of tests but they have never shown anything”.  “Don’t you think he needs a CT scan” she asked me?  “Maybe he has a blockage or twisted intestines?”  

 About 8-12% of children and a great number of adolescents meet the criteria for IBS.   It seems to become more prevalent with age. The problem is that IBS is probably due to some genetic and psycho-social factors as well as studies which are showing some underlying biologic factors within the gut. 

Best news for this little boy ( and his Mom) is that he doesn’t have to have a bunch of tests involving blood work or radiation exposure with X-rays and scans. It was also nice to reassure both of them that he did not have a “horrible” disease and that there were things to try to see if we could improve his pain, help him cope with the pain and  to let him know that this may be an issue for him intermittently.  

For some kids taking probiotics regularly seems to help. There are also some children who will have less episodes of pain on a low-lactose diet, a low gluten-wheat diet, or low fructose diet, and I usually try a trial for a couple of weeks to see if they are better with dietary changes….if no improvement why stay off of food, right?  I also try adding fiber to the child’s diet and in some cases prescribe an anti-spasmodic for short term use.

Most importantly is reassurance and some psychosocial interventions to help the child (and parents) deal with the pain. This may be done with a professional if necessary who can do some cognitive behavioral therapy.

In my experience just having validation that their pain is real, and listening to their story is the most helpful.  It is often a relief to know that this is not a serious problem and that you are going to work on ways to help alleviate the pain…..referrals to multiple specialists for IBS is not necessary.

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

Stomach Bugs Are Going Around

I am sick of vomit!! I thought I was tired of coughs, but early in this "sick" season I am tired of being thrown up on.I am sick of vomit!! I thought I was tired of coughs, but early in this "sick" season I am tired of being thrown up on. I must be showing my age. It seems that vomiting and diarrhea, also known as gastroenteritis, are in our community right now and it is hitting hard. Not only do the sweet little ones have this, so do the big kids and even their parents. I am just washing my hands feverishly and praying we don't succumb at our house. You know you are a real parent when your child awakens you at night and says, "Mommy, I'm sick", and then throws up all over you, the bedspread and the carpet. Boy, carpet cleaning companies must love this time of year.

So... if this hits your house, begin by not giving your child any fluids for at least 30 minutes after they vomit, even if they want something (I have learned that lesson the hard way, they beg, you relent and the throw up quickly follows). Then the key is to go VERY slowly with clear liquids, like pedialyte for a your-baby and Gatorade for older kids. You may need to start with as little as 1 TBSP or 1 oz. of fluids every 10 - 15 minutes in order that this small volume will stay down. Don't fill up a bottle or cup as your child will be thirsty and tend to gulp too much and lo and behold, here they go again. Once they are keeping down smaller volumes you can gradually increase the amount you give them and give it less frequently. As long as your child drinks enough to stay hydrated, with tears, wet mouth and urination, this nasty virus only seems to last about 12- 24 hours. If they continue to vomit despite your best efforts giving small frequent clear fluids, time to call the doctor. That's your daily dose, we'll chat again soon!

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Daily Dose

The Difference Between A Viral Sore Throat & Strep Throat

It only takes getting the kids back in school for the pediatrician’s office to see an upswing in illness. But this year it came on particularly early and we are definitely seeing more illness in the first week of fall than is typical.

Most of the illness being reported around the country is due to Influenza A, H1N1 (swine flu) and the majority of cases seem to be occurring in the five to 24 year old age group, in other words the school aged, elementary through college aged kids. To review again, flu like symptoms for all influenza strains are typically similar with fever, sore throat, cough, congestion, headaches and body aches. Occasionally there may be some nausea or vomiting but that is not seen as often. Flu like symptoms seem to begin with general malaise and then develop over the next 12 – 24 hours and you just feel miserable. Some of the confusion now is about sore throats and the difference between a sore throat with the flu, which is due to a viral infection, and strep throat, which is a bacterial infection. As for most things in life, nothing is 100 percent and the same goes for viral and bacterial sore throats. But, with that being said, there are certain things that might make a parent think more about a viral sore throat than strep throat and vice versa. Viral sore throats, which we are seeing a ton of with the flu right now, are typically associated with other viral symptoms which include cough, and upper respiratory symptoms like congestion or runny nose. A viral sore throat may or may not be accompanied by a fever. In the case of flu, there is usually a fever over 100 degrees. With a viral sore throat you often do not see swollen lymph nodes in the neck (feel along the jaw line) and it doesn’t hurt to palpate the neck. If you can get your child to open their mouth and say “AHHH” you can see the back of their throat and their tonsils, and despite your child having pain, the tonsils do not really look red, inflamed or “pussy”. Even though it hurts every time you swallow, to look at the throat really is not very impressive. Strep throat on the other hand, typically occurs in winter and spring (that is when we see widespread strep), but there are always some strep throats lurking in the community, so it is not unusual to hear that “so and so” has strep, but you don’t hear a lot of that right now. As we get into winter there will be a lot more strep throat. Strep throat most often affects the school-aged child from five to 15 years. Children get a sudden sore throat, usually have fever, and do not typically have other upper respiratory symptoms (cough, congestion). This is another opportunity to feel your child’s neck and see if their lymph nodes are swollen, as strep usually gives you large tender nodes along the jaw line. When you look at the throats of kids with strep they usually have big, red, beefy tonsils (looks like raw meat) and may have red dots (called petechia) on the roof of the mouth. The throat just looks “angry”. Sometimes a child will complain of headache and abdominal pain with strep throat. Some children vomit with strep throat. The only way to confirm strep throat, again, a bacterial infection, is to do a swab of the back of the throat to detect the presence of the bacteria. There are both rapid strep tests and overnight cultures for strep. Most doctors use the rapid strep test in their offices. If your child is found to have strep throat they will be treated with an antibiotic that they will take for 10 days. Again, antibiotics are not useful for a viral sore throat and that is why strep tests are performed. I’m sure we’ll talk more about sore throats as we get into winter. But in the meantime, get those flashlights out and start looking at throats. That’s your daily dose, we’ll chat again tomorrow.

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!

 

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