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Daily Dose

Swollen Lymph Nodes

1:30 to read

A parent’s concern over finding a swollen lymph node, which is known as lymphadenopathy, is quite common during childhood.  The most common place to notice your child’s lymph nodes are in the head and neck area.

Lymph nodes are easy to feel  around the jaw line, behind the ears and also at the base of the neck, and parents will often feel them when they are bathing their children.  Because young children get frequent viral upper respiratory infections (especially in the fall and winter months), the lymph nodes in the neck often enlarge as they send out white cells to help fight the infection. In most cases these nodes are the size of nickels, dimes or quarters and are freely mobile. The skin overlying the nodes should not appear to be red or warm to the touch. There are often several nodes of various sizes that may be noticed at the same time on either side of the neck.   It is not uncommon for the node to be more visible when a child turns their head to one side which makes the node “stick out” even more.

Besides the nodes in the head and neck area there are many other areas where a parent might notice lymph nodes.  They are sometimes noticed beneath the armpit (axilla) and also in the groin area.  It your child has a bug bite on their arm or a rash on their leg or even acne on their face the lymph nodes in that area might become slightly swollen as they provide an inflammatory response. In most cases if the lymph nodes are not growing in size and are not warm and red and your child does not appear to be ill you can watch the node or nodes for awhile.  The most typical scenario is that the node will decrease in size as your child gets over their cold or their bug bite.  If the node is getting larger or more tender you should see your pediatrician. 

Any node that continues to increase in size, or becomes more firm and fixed needs to be examined. As Adrienne noted in her iPhone App email, her child has had a prominent node for 7 months. Some children, especially if they are thin, have prominent and easily visible nodes.  They may remain that way for years and should not be of concern if your doctor has felt it before and it continues to remain the same size and is freely mobile.  Thankfully, benign lymphadenopathy is a frequent reason for an office visit to the pediatrician, and a parent can be easily reassured.

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

Your Baby

Teething May Make Your Baby Fussy, But Not Sick

2:00

Parents sometimes have trouble distinguishing between whether their cranky baby is actually ill or is just getting his or her first teeth. Because a baby’s gums may be tender and swollen as their teeth come in, a slight rise in temperature can occur.  Other changes may happen as well such as fussiness and increased drooling. All- in –all, babies can be pretty miserable till those first teeth break through.

That said, teething does not cause a full-fledged fever above 100.4 degrees Fahrenheit or any other signs of illness according to a new review led by Dr. Michele Bolan, of the Federal University of Santa Catarina, Brazil.

Certain symptoms can be confusing for parents says Dr. Minu George, interim chief of general pediatrics at Cohen Children's Medical Center, in New Hyde Park, N.Y.

"I get questions about this on a daily basis," said George, who was not involved in the study.

When a baby’s temperature reaches 100.4 degrees F or higher, it becomes an actual fever, not just a slight increase in temperature.

"Fevers are not a bad thing," she pointed out. "They're part of the body's response to infection." But, George added, parents should be aware that a fever is likely related to an illness.

Of course, new parents are going to be somewhat edgy when it comes to caring for their infant. It’s a new world of responsibility that can seem overwhelming at times. 

Pediatricians and family doctors regularly answer questions about this topic with an explanation of how a typical teething experience presents.

Over the ages, other symptoms have been linked to teething that should never apply. They include sores or blisters around the mouth, appetite loss and diarrhea that does not go away quickly. Any of these symptoms warrant a call to your pediatrician.

Babies differ in age as to when their teeth begin to come in.  Typically, the fist tooth begins to erupt around 6 months of age. It can also be as early as 3 months and as late as 1 year of age. There really isn’t a set age for teething to begin, just an average.

Baby’s teeth usually erupt through the gums in a certain order:

·      The two bottom front teeth (central incisors)

·      The four upper front teeth (central and lateral incisors)

·      The two lower lateral incisors

·      The first molars

·      The four canines (located on either side next to the upper and lower lateral incisors)

·      The remaining molars on either side of the existing line of teeth

By age 3, most children have all 20 of their primary teeth.

As for helping babies get through the misery of teething, George advised against medication, including topical gels and products that are labeled "natural" or "homeopathic."

Instead, she said, babies can find relief by chewing on a cooled teething ring or wet washcloth, or eating cool foods.

The analysis was published in the February online edition of the journal Pediatrics.

Sources: Amy Norton, http://www.webmd.com/parenting/baby/news/20160218/teething-makes-babies-cranky-but-not-sick-review

http://www.webmd.com/parenting/baby/tc/teething-topic-overview

Daily Dose

Constipation

1:30 to read

Constipation is a topic that every pediatrician discusses….at least weekly and sometimes daily. It is estimated that up to 3% of all visits to the pediatrician may be due to constipation. Constipation is most common in children between the ages of 2 and 6 years. I have been reading an article on updated recommendations for diagnosing and treating common constipation. The most important take home message is “ most children with constipation do not have an underlying organic disorder. Diagnosis should be based on a good history and physical exam for most cases of functional constipation”.

 

Like many things in medicine….the evaluation and treatment of constipation has also changed a bit since the last guidelines were published in 2006. It is now appropriate to define constipation with a shorter duration of symptoms (one month vs two) and some of the most common diagnostic criteria (Rome IV Diagnostic Criteria) include the child having less than 2 stools/week, painful or hard bowel movements, history of large diameter stools (parents will tell me their 3 year olds “poops” clog the toilet), and some may have a history of soiling their underpants. 

 

By taking a good history you can avoid unnecessary tests..including X-rays which are not routinely recommended when evaluating a child with possible constipation.  In most cases physical findings on the abdominal exam will confirm the diagnosis in combination with the history. I often can feel hard stool in a child’s left lower quadrant and when asked the last time they “pooped”, no one can really recall. 

 

The preferred treatment is now polyethylene glycol (PEG) therapy. PEG is now used to help “disimpact a child” as well as to maintenance therapy.  Where as enemas were often previously prescribed, PEG therapy has been shown to be equally effective in most cases, is given orally and is much less traumatic (for parent and child!). PEG works by drawing more water into the stool, causing more stool frequency. There are many brands of PEG including Miralax and GoLytely among others. Miralax works well for children as it is tasteless and odorless and can easily be mixed in many liquids without your child knowing it is there. 

 

The guidelines now state that for children with functional constipation maintenance therapy with PEG should continue for as least 2 months with a gradual tapering of treatment only after a full month after the constipation symptoms have been resolved. I usually tell parents that this is equivalent to about how long it takes for them to forget that they have been dealing with constipation….and then begin tapering.

 

Lastly, there is no evidence that adding additional fluid or fiber to a child’s diet is of benefit to alleviate constipation….although it may “just be good for them in general”.

 

 

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

Helping a Child With Croup

With all of the illness going around that seems to be flu and RSV I was surprised to see a toddler today with symptoms more suggestive of viral croup. Croup is another one of those pesky viruses. Most children will experience croup at least once in their toddler years. Croup causes that "seal like" barking cough, and is very alarming when it awakens both you and your child in the middle of the night.

Croup causes swelling of the upper airway, which causes the voice to be hoarse and the airway to swell (not the lungs) and makes your child have that pronounced seal like cough. Children often seem perfectly well when they go to bed and then awaken coughing. The best treatment is to grab a book and your child and make a beeline to the bathroom and turn the shower on hot to fill the room with steam. Sit in the steam and read a book to calm your child down and help quiet the cough. If the steam treatment does not seem to be helping (and you are now out of hot water) try taking your child outside into the cool night air. Both the humidity from the steamy shower and the change in temperature from hot to cold will help reduce the airway swelling and calm your child's cough. Make sure that you look at your child's chest to how they are breathing. Despite the loud sound, they should look fairly comfortable and should not show signs of respiratory distress or stridor (a distinct sound made when you child breathes in). If they are having any respiratory distress, call the doctor as they may need to be seen and are sometimes given steroids to help with the upper airway swelling. Because this is a viral infection antibiotics won't help. Most children have the croupy cough for a night or two and then improve and will then have a little cold. When older children and adults get this virus they are usually only hoarse and develop a cold. That's your daily dose, we'll chat again tomorrow.

Daily Dose

Sick Child? Have Patience

1:30 to read

I just got off the phone from texting with the mother of a 3 year old patient of mine. It was late in the afternoon and her son had just started crying that his mouth hurt.  I was texting her from the back of a car en route to the airport..the wonders of technology!

She was concerned because the pain had come on so abruptly, but she text me that he did not have a fever, had not had a fall or trauma to hurt his mouth, and that when he opened his mouth she could not see anything that would cause “obvious pain”.  

I asked her a few more questions via text and recommended that she might try giving him a dose of ibuprofen and see if he calmed down and felt better, but I did not hear back from her for awhile.

It was then that I realized that pediatrics and parenting have quite a bit in common…one of the similarities being patience.  

While she was concerned that her child had suddenly started crying due to some sort of pain, much of pediatrics is about watching and waiting.  We parents all want to keep our children pain free, but sometimes things will hurt both physically, and as your child gets older, emotionally (which may be even worse to watch).  A parents first instinct is to find the cause of the pain and “fix it”.  Whether that means a band aid, a kiss on a boo-boo, or medicine.. “just make it better”.

But in many cases in pediatrics and actually all of medicine, it is about watching, following, and waiting, which is not as easy as it may sound. Doctors, parents and patients often have to “be patient” and see what evolves.  Not all tummy aches are cases of appendicitis, not all falls cause a concussion and not all boo-boos result in broken bones (thank goodness!).

But for a parent to hear “let’s see what happens in an hour or so” may sound like a lifetime and waiting just seems crazy when there is a “doc in the box” on every corner.  You may see where I am going with this.

So, by the time I heard back from this concerned mother, she was already at the nearby “doc in the box” waiting for a doctor to see her son, who by now had stopped crying.  She had already put him in the carseat for the drive to the clinic before she read my text, so he had not even had any ibuprofen.

According to the clinic doctor (or nurse), the child “had an ear infection causing his pain” and she was given a prescription for antibiotics.  Once the mother was home and I could talk to her I asked if they had prescribed medication for pain relief, such as ear drops and/or ibuprofen. She said she only had the antibiotic prescription which she had filled, but her child had stopped complaining of pain.

So, I was not there, and did not see her child, but I wonder if ibuprofen might have done the trick and alleviated his pain..and also kept him off of an antibiotic until he could be seen the following day in the office?

But in this age of “quick” medicine and a clinic on every corner,  a patient/parent may not need to wait and see what evolves. I wonder if this “quick” medicine may be one reason we see antibiotic overuse . I’m just saying….  

Daily Dose

Swollen Lymph Nodes

1.45 to read

A parent’s concern over finding a swollen lymph node, which is known as lymphadenopathy, is quite common during childhood.  The most common place to notice your child’s lymph nodes are in the head and neck area.

Lymph nodes are easy to feel  around the jaw line, behind the ears and also at the base of the neck, and parents will often feel them when they are bathing their children.  Because young children get frequent viral upper respiratory infections (especially in the fall and winter months), the lymph nodes in the neck often enlarge as they send out white cells to help fight the infection. In most cases these nodes are the size of nickels, dimes or quarters and are freely mobile.

The skin overlying the nodes should not appear to be red or warm to the touch. There are often several nodes of various sizes that may be noticed at the same time on either side of the neck.   It is not uncommon for the node to be more visible when a child turns their head to one side which makes the node “stick out” even more.

Besides the nodes in the head and neck area there are many other areas where a parent might notice lymph nodes.  They are sometimes noticed beneath the armpit (axilla) and also in the groin area.  It your child has a bug bite on their arm or a rash on their leg or even acne on their face the lymph nodes in that area might become slightly swollen as they provide an inflammatory response.

In most cases if the lymph nodes are not growing in size and are not warm and red and your child does not appear to be ill you can watch the node or nodes for awhile.  The most typical scenario is that the node will decrease in size as your child gets over their cold or their bug bite.  If the node is getting larger or more tender you should see your pediatrician.  Any node that continues to increase in size, or becomes more firm and fixed needs to be examined.

As Adrienne noted in her iPhone App email, her child has had a prominent node for 7 months. Some children, especially if they are thin, have prominent and easily visible nodes.  They may remain that way for years and should not be of concern if your doctor has felt it before and it continues to remain the same size and is freely mobile.  Thankfully, benign lymphadenopathy is a frequent reason for an office visit to the pediatrician, and a parent can be easily reassured.

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

Daily Dose

Dealing With Winter Nosebleeds

1:15 to read

It is not uncommon for children to get occasional nosebleeds, and noses albeit small, may really seem to bleed a lot.

With winter in full swing, cold temperatures and heat running in the house the air is really dry. Not only does this cause lots of dry skin and chapped lips, it may also cause nosebleeds. It is not uncommon for children to get occasional nosebleeds, and noses albeit small, may really seem to bleed a lot. If your child experiences a nosebleed in the middle of the night, which is not unusual, you will be convinced that some horrible trauma has occurred during the night, by virtue of the blood stains on the sheets. Once you check out your child you will realize that all of that blood came from the nose, and your child is perfectly comfortable, happy and there are no obvious injuries. Off they go to play while you get the job of changing the bloody sheets.

Once a child experiences a nosebleed it is not uncommon for it to re-occur, as there is a scab or clot in the nose and if the nostril is rubbed or picked on again, the clot dislodges and the nose will re-bleed. The nose is just like a scab on the knee, if you keep bumping or bothering that scab it will continue to bleed and seem to never get better. Parents may also notice a small amount of blood from the nostril of a newborn or infant who has a cold after you have used a bulb suction to irrigate the nose. Again, it is just due to a small amount of nasal trauma and not to worry.

To help prevent nosebleeds during the dry, winter months, use a lubricant in your child's nose. There are several nasal sprays that help and good old Vaseline seems to do the trick at our house. The jar comes out in November and goes up in March but helps keep dry noses a little less likely to bleed. That's your daily dose, we'll chat again tomorrow.

Daily Dose

Lice is Going Around!

1.30 to read

It only took a month of school being in session for the lice (pediculus capitis) problem to “rear its angry head”! I have had phone calls, emails and even frantic texts from many parents who are fighting head lice in their homes. This causes a lot head scratching in kids but even more anxiety in their parents (a few of whom have also gotten lice). 

The first line treatment for lice is NOT to shave your child’s head (as one mother threatened), but to buy one of the over-the-counter products for the treatment of head lice. These products contain either permethrin or pyrethrin. 

It is important that a parent follow the directions: using a hair conditioner before the use of the OTC product can diminish the effectiveness, and many products recommend not washing the hair for several days after finishing the application. It is also important to follow the directions for re-applying the product in order to treat hatching lice and lice not killed by the first application. In other words, you must read the package insert! 

But with that being said even with parents following the directions to a “T”, there are cases where the lice continue to thrive. This may be due to the fact that the lice have become resistant to the OTC products, and different geographic areas do seem to have different rates of resistant head lice. 

There are now four fairly new prescription products that have been approved by the FDA for use when OTC products have not worked. These products are Sklice, Natroba, Ovide and Ulesfia. Each of these products contains a different product that has proven to work against the human louse. These prescription products do differ by application time, FDA labeled age guidelines, precautions for use and cost. There is not one product that is currently preferred for use. 

Lastly, there has been a study that looked at oral Ivermectin as a therapy for head lice in children over the age of 2. The drug is not FDA labeled for this use. There are guidelines for its use when both OTC and prescription topical agents have failed to eradicate lice.

There is no need to try all of the crazy stuff like mayonnaise on the head, or using Cetaphil on the hair with the blow dryer. There are several areas of the country where there are businesses that will “nit pick” your child’s heads, but one of my patients spent $500 dollars on this (for real), but continued to have problems with lice. 

So, if the lice won’t go, call your doctor before resorting to alternative, unproven therapies.

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