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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

Shingles in Childhood?

1:30 to read

Is it possible for children to come down with shingles? I recently saw a 2 year old with a most interesting history who then developed a weird rash.   Funny thing, I read an article shortly after seeing this child that described his case perfectly, only wish I had seen this the week before.

So, this 2 year old complained that his leg hurt. Enough pain that he limped and woke up at night crying that his thigh hurt. He had no history of trauma and also was otherwise well, in other words no fever, vomiting, cold symptoms etc.

After several days of watching him without resolution of his pain the mother noticed 3 little spots on his thigh, which she thought might be a bite. The little boy was seen and the diagnosis of herpes zoster (shingles) was considered.  In children the differential diagnosis of localized leg pain in the absence of a rash would not normally include shingles.

According to the pedi dermatologist (that I consulted) shingles in children occurs more frequently on their lower extremities (not for adults) and may involve the back on the same side.   Unlike adults, most cases of zoster in children are only mildly painful and resolve fairly quickly.

Well, this little boy didn’t read the book and his rash continued to get worse and spread, and was quite painful for days. Prior to this, he was a perfectly healthy little boy and had received his first varicella vaccine when he was 1.  

Since the widespread use of the varicella vaccine (chickenpox vaccine, see old post), the incidence of chickenpox has decreased dramatically, and vaccination should also reduce the risk of developing shingles later in life. In otherwise healthy children shingles (zoster) tends to develop at a younger age among vaccinated children than in those who have had a “natural” chickenpox infection.  When shingles occurs after vaccination it represents either a new infection with wild-type virus (an exposure to chickenpox or shingles) or reactivation of the vaccine virus.

Once a child has received 2 doses of varicella vaccine as recommended, the immunity is “boosted” and should further reduce the risk of developing shingles. Varicella–zoster virus can be transmitted via contact with skin lesions of those who have either chickenpox or shingles.  Infection is less likely after exposure to shingles. Transmission of the virus occurs until all lesions have crusted over. In this case, the little boy was ultimately started on an oral anti-viral therapy with slow resolution of his rash and pain and a return to normal around his house.

Note to self: “weird” pain may precede the rash in herpes zoster by several days.  Even though unusual, herpes zoster may occur in a healthy child who no history of varicella exposure and who has received all or part of their chickenpox vaccine.

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

Daily Dose

Why Babies Get "Goop" In Their Eyes

1:15 to read

If you have recently had a baby you may already know about “clogged tear ducts”. This is also named nasal lacrimal duct obstruction and is fairly common in newborn infants in the first weeks to months of life.

A baby’ s tear duct, the tiny little hole in the inner corner of the eye, is very small and narrow and may often get obstructed. If that is the case the tears that an infant makes gets backed up and may form a thickened “goopy” discharge in the eye. At times when this occurs the baby’s eye will seem to be “glued” shut as the goop gets in the eyelashes and almost seems to cement those little eyes shut. Occasionally the eye will look a little puffy due to the debris in the eye. The best thing to do for this problem is to use a warm compress or cotton ball dampened with warm water to wipe the eyelashes and remove the discharge from the eye.

Once the “goop” is removed and your baby opens their eye, look at the whites (conjuctiva) of the eye. The conjunctiva should not appear to be red or inflamed. The goop will re-accumulate over time, but the eye itself should continue to look clear. Babies with clogged tear ducts do not appear to be ill and continue to eat well. The only problem should be the goopy eye. In order to help open the clogged duct you can try to massage the inner lower corner of the baby’s eye (beneath the tear duct itself), several times a day. Gently apply pressure to the area and do this several times a day. The eye “goop” always seems to be worse after the baby has been sleeping. It is also not uncommon for one eye to clear up only to have the other eye develop “goop”.  Most of these obstructions resolve on its own by four to six months of age. If the tear duct continues to be obstructed, talk to your pediatrician about a possible referral to the pediatric ophthalmologist.

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

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

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

Urgent Care Testing

1:30 to read

How quickly the holidays pass and the office is back to “regular” hours and “sick” season is in full throttle. I have noticed that when our office is really busy, or it has been a holiday or on a weekend many patients will sometimes find themselves using a convenient “urgent care” facility. In our area there seems to be one on every other block and inside the pharmacy chains as well...you can’t miss them.  Not all are geared for children.

Most of the patients being seen are complaining of fever, cough, sore throat and body aches. A few have other symptoms as well. Unfortunately, I sometimes find myself questioning why a patient needs both a flu test and a strep test, as in most cases the history is a bit different and the physical exam points to one illness over another.  Not 100% of the time, but most.  But, when reviewing the “short chart notes” that are usually sent to me from the “urgent care” I find over 50% of my patients were tested for both.  At the same time I sometimes see results that say, “positive for flu A, B and strep”?  Are you kidding me?  

I realize that everyone wants to get well quickly...especially in the midst of the holidays. But, is it really necessary to go to an “urgent care” facility rather than waiting a day to see your regular doctor?  I still submit to the idea that your doctor is going to know you and your child’s history. A few more questions during the exam may point to one illness over another, and save you not only the discomfort of several tests, but also the cost. It is easy to order tests, doesn’t take much thought and also makes money.

I know it is hard when you are the patient or parent and don’t understand why the “provider” is ordering numerous tests, giving you confusing results and prescribing both antiviral and antibiotic medications.... is that a matter of too little information or TMI?? Many parents tell me they left feeling confused and unsure of what “illness their child even had”.  Unnecessary antibiotics are not benign either.

If your child has a fever, cough, congestion and sore throat and no signs of respiratory distress or dehydration then wait until you can call your own doctor. In the meantime treat the symptoms with fluids, fever reducing medications and some tender loving care.  I still think the waiting is worth it to get “better” medical care.  

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

Parental Anxiety Continues Over Swine Flu

As the H1N1 virus (swine flu) continues to cause flu throughout the country, with 26 states reporting widespread illness, parental anxiety continues to be prevalent in our office.

Tragically, there have been recent deaths in the pediatric population, and it seems that the H1N1 virus is infecting many children between the ages of two to 24 years. Fortunately, the vast majority of children who have developed “swine flu” really are not any sicker than with other influenza viruses we see each year. It is unusual to see influenza in the summer and early fall, and that is one reason we are expecting a longer flu season with greater numbers of sick people than in previous years. The issue continues to be that the media reports the tragedies rather than the reassurance that MOST children, including my own, are handling this virus with a three to seven day stay at home, in bed with plenty of parental TLC, fluids, and fever reducing medications. It is definitely tragic, and certainly scary for parents to hear about a pediatric death secondary to H1N1 illness, but we all must be reminded of the fact that there have been pediatric deaths secondary to flu each year. There has just not been as much publicity. For perspective, I decided to look back at the statistics from the Centers for Disease Control and Prevent (CDC) for the last several flu seasons. For the 2006- 2007 flu season there were 78 pediatric deaths in the U.S., 2007 – 2008 flu season, 88 pediatric deaths, and for the 2008-2009 flu season through Sept 19, 2009 there were 117 pediatric deaths, with 49 of the deaths in children with H1N1 illness (recorded since April, 2009). The difference is that the flu season this year is longer so there are more people being affected. Remember math facts, the denominator is bigger, so while the numerator (deaths) may seem higher, the actual ratio is no different from year to year. I guess the point of all of this is that panic and fear is not going to help anyone get through the flu season. It is better to be educated about H1N1 and to know when to call the doctor, visit the pediatrician or go to the ER, than be one of the thousands of worried parents who are seeking medical care for their children simply out of fear. For physicians and hospitals to be able to care for the sickest patients it is imperative that parents try to remain calm. The majority of kids I have seen would rather be at home in their bed watching TV and playing games than sitting in my office, only to be told to go back home to bed, drink lots of fluids, to cover their mouths when coughing and to wash their hands. REST is still the best medicine for most of us when sick (the mother in me comes out a lot). The CDC, state and local health departments are no longer recommending routine testing for influenza, as the in office test is often inaccurate anyway. The in office test also only tells you that you have Influenza A or B, it does not tell you the subtype. It will not tell you if it is H1N1, so think of it as just flu. Clinical symptoms are really the best diagnostic clue to the “flu” and the more patients doctors see with the same symptoms of fever, sore throat, headache, and cough the more you “know” how epidemic this flu is. There is no need to test ever patient, but testing for the sickest patients or those with an underlying chronic medical condition is appropriate. Your doctor will decide if it is necessary. As I have written before, routine use of anti-viral medication is NOT being recommended, so don’t expect your otherwise healthy child to be placed on antiviral medications. Tamiflu and Relenza are good drugs when used appropriately, and overuse of these medications could lead to resistance in their effectiveness when they are really needed. I understand that there are school tests, field trips, homecoming dances, birthday parties, and sporting events that all of our children “need to attend”, but these are not really reasons to begin antiviral medications. If you look at the data, these drugs typically only shorten the course of the illness by one day, and Tamiflu may even cause side effects of nausea and vomiting, which could be worse than the fever and body aches! Is there ever a “convenient” time to be sick? So, I am hopeful that these posts are helpful in providing information and education to alleviate some of the anxiety and panic during this “swine flu” outbreak. Stay abreast of the latest information and get your seasonal flu vaccines and when available (hopefully in the next month) get the “Swine flu” vaccine.  I will continue to be in my office otherwise known as the “swine zoo” to see those children who need us. That’s your daily dose, we’ll chat again soon.

Daily Dose

Enterovirus Continues to Spread

1.15 to read

Enterovirus infections are in the news and are causing a lot of parental anxiety. While enterovirus D-68 has caused some serious illness in children, especially in the midwest and now spreading to the northeastern states, you have to remember that there are many other children who handle this virus just like a bad cold.

Enteroviruses have been around for a long time...in fact polio is an enterovirus. But thankfully there is a vaccine for polio.  The hundreds of other enteroviral infections continue to cause upper respiratory symptoms, viral meningitis, as well as vomiting and diarrhea.  In most cases when you have many of these symptoms you don’t even think to “name the virus”.

Enterovirus D-68 was first reported in 1968 (so the name) but it was in 2008-2012 when it again began to be identified and was reported in the literature.  Enteroviruses typically peak in late summer and early fall, so this is the time of year that we expect to see a peak in these infections.

The typical symptoms with a  D-68 infection are upper respiratory with sore throat, runny nose, and a cough. Only about 25% of patients are even reporting a fever. In some cases, especially in children who have an underlying history of asthma or wheezing, there have been more severe symptoms with difficulty breathing, wheezing, and respiratory distress. In these instances the children have been admitted to the hospital for supportive care, which includes IV hydration, bronchodilator therapy, and supplemental oxygen.  In some cases a child may require intensive care. Fortunately, there have not been any deaths associated with enterovirus D-68. 

The bottom line? This is yet another respiratory illness that may cause more severe symptoms in some children. We also see this with other viruses such as RSV and flu which will be circulating later this fall and winter.  What parents do need to know is that if your child is sick and seems to be having ANY difficulty breathing you need to call your doctor or go to the ER. 

If your child is sick, keep them home from school. If you are sick don’t go to work or volunteer in the school cafeteria. To stay healthy over the ensuing “sick” season promote good hand washing and cough hygiene. Lastly, everyone over the age of 6 months needs a flu vaccine.

 

 

 

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