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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

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

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

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.

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.

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

How to Treat Hyperventilation

It is not uncommon for someone to hyperventilate when they are in pain.I saw a child today who had been injured in a soccer match when he was accidentally kicked in the chest. He had shortness of breath and then became uncomfortable and started to breath rapidly and get upset about "feeling light headed" and anxious. Because he had a history of asthma his Mom brought him straight to the office for fear that he was having an asthma attack.

But he was not having any real respiratory distress and his oxygen levels were normal and his lungs were clear. The problem was that he was hyperventilating. It is not uncommon for someone to hyperventilate when they are in pain. When you hyperventilate and disturb your CO2 and O2 levels, you will have a feeling of lightheadedness, and often tingling in your arms and hands. That seems even scarier, so you then breathe faster and faster and the cycle continues. The best thing to do if you think someone is hyper-ventilating, have them re- breathe into a paper bag. By re-breathing your CO2 it will slow down your breathing and within several minutes they will be feeling much better, less anxious and light headed. If you don't happen to have a paper bag, have them follow your lead as you slow their breathing down and reassure them that their symptoms are going to improve as they take slow deep breathes. A bit of TLC for the little guy today, slow breathing exercises, a Sprite and a note for school sent him on his way! That's your daily dose, we'll chat again soon!

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Daily Dose

What is a Fever?

1:30 to read

A child with a fever is one of the most frequent reasons a parent either calls their pediatrician or brings them to the office to be seen.  When I was a resident the term “fever phobia” came into use, and it referred to parents concerns about fever and its harmful consequences.  I must say, some 30 years later, fever phobia still persists and there is still a lot of inaccurate information floating around and even on the internet.

In fact, looking back at studies done in the 1980’s, 52% of parents thought that a fever of 104 degrees could cause serious neurological damage...and 20-30 years later 21% of parents still believe that brain damage is the primary harmful effect of fever and 14% even thought that fever alone could cause death.

So, here we go a fever update for all, especially for new parents to keep them from worrying unnecessarily.  Fever is just a symptom of an inflammatory response in the body, and may be due to many things including a viral infection, which is the most common reason for a child over 2 -3 months of age to develop a fever. Fever occurs when something in our bodies called “cytokines” are released and these increase the level of prostaglandins in the hypothalamus; and the hypothalamus is the body’s temperature regulator.  When this occurs the body’s thermostat elevates and raises the body’s internal temperature. There you go...lots of science...but trying to explain this in the middle of the night to an anxious parent....they really don’t care about cytokines!

Fever in and of itself does NOT cause brain damage and in fact may be beneficial to a child with a viral infection.  The most important thing for parents to watch is not the number on the thermometer (and many worried parents will take a temperature every 30 minutes to an hour), but rather how your child is behaving.  While your child may have 103.6 degree temperature are they still smiling on occasion and making good eye contact, are they still eating and drinking ( again maybe less than usual as they are sick), will they play with a toy off an on, or wake up from a nap and watch some TV?  (yes, you can still let your child watch TV when they are sick!). This is the hardest thing for me to help teach new parents....behavior is always far more important than any reading on a thermometer.

Parents of course want to do something to help their child’s fever. Treating your child’s fever with some acetaminophen or ibuprofen might make them more comfortable and therefore a bit happier as well. Make sure to use the appropriate dosages for weight and age and the correct dosing device as well when giving these medicines.

Getting through a few episodes of fever will also help...remember, “fever is your friend” and shows that your body is working to fight off that nasty virus....but if you are worried, always call your doctor!

Your Child

Measles Vaccine May Help Prevent Other Diseases

2:00

The measles vaccine may provide additional benefits beyond protecting children from the highly contagious and sometimes fatal disease.

According to a new study, by blocking the measles infection the vaccine may also prevent measles-induced immune system damage that makes children much more vulnerable to other infectious diseases for two to three years after immunization.

The immune system has the advantage of having “cellular memory” for previous infections to help fight invading microbes.

The study focused on a phenomenon called "immune amnesia" in which the measles infection destroys cells in the immune system that remembers previously encountered pathogens.

Prior research had suggested that “immune amnesia” typically lasted a month or two. The new study, based on decades of childhood health data from the United States, Denmark, England and Wales, showed the measles-induced immune damage persisted on average for 28 months.

Because of the long-term damage to the immune system by the measles infection, children that were not vaccinated and got the measles were more likely to die from other infections.

"The work demonstrates that measles may have long-term insidious immunologic effects on the immune system that place children at risk for years following infection," said Princeton University infectious disease immunologist and epidemiologist Michael Mina, whose study appears in the journal Science.

"The work also demonstrates that, in these highly developed countries prior to the introduction of measles vaccine, measles may have been implicated in over 50 percent of all childhood infectious disease deaths."

Measles was declared eliminated in the United States in 2000, but increasing numbers of cases have been reported in recent years, as more people remain unvaccinated. Last year's 668 U.S. measles cases were the most since 1994, the Centers for Disease Control and Prevention said.

"Our work reiterates the true importance of preserving high levels of measles vaccine coverage as the consequences of measles infections may be much more devastating than is readily observable," Mina said.

The study provided data showing that measles prevention through vaccination lowered childhood deaths from the pathogens that cause conditions such as pneumonia, sepsis, bronchitis, bronchiolitis and diarrheal diseases.

The study comes as many parents opt out of the measles, mumps and rubella (MMR) vaccine for their children based on discredited claims about the vaccine's safety or for religious and other reasons.

The MMR vaccine has been thoroughly studied by scientists around the world and has been found safe for children. This new study shows that its benefits may last much longer than previously thought.

Source: Will Dunham, http://www.reuters.com/article/2015/05/07/us-health-measles-idUSKBN0NS23N20150507

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