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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 Tubes

1:00 to read

I had been seeing a 3 year old VERY verbal patient for several months as he would intermittently complain to his mother that his “ears were ON?”.  He would tell her this off and on but could not explain what he meant by this statement. He did not say his ears hurt, he did not have a fever, he was sleeping well….but he seemed to be bothered enough to talk about it from time to time.

 

His mother brought him in to see me a few times and his exam was normal…but one day when she brought him in I noticed that he had clear fluid behind his ear drum(serous otitis). His eardrum was not inflamed and his exam was otherwise normal.  When a child has fluid behind their ear drums it is not always a sign of infection, and in this case you watch and see if the fluid goes away on its own. 

 

Well, he continued to talk to his mother about his “ears being ON”, and he even told his teachers a few times.  Because he continued to talk about it ( over about 3 months) I sent him to see a pediatric ENT.

 

When the ENT saw him he also noted that he had some fluid behind one of his ear drums. Because he had had persistent fluid it was decided to place ear tubes….

 

And guess what? Once he had ears tubes placed he told me his “ears had turned off”!!  I guess he sometimes felt funny or heard sounds differently and that was his way to express his ear issue - on and off! What took me so long?

Children continue to amaze me. 

Daily Dose

Your Chid's Fever

1:30 to read

Now that you have taken your child’s temperature, what do you do with the information? As discussed previously, a fever is defined as a body temperature above 100.4 degrees. If you take your own temperature all day long it will be quite variable as will your child’s, and body temperature often goes up as the day goes on.

If your child has 100 degree temperature in the morning, the mother and pediatrician in me thinks that by the end of the day they may be running 101 degrees or higher. I would keep that child home that day to see what happens with the temperature. If you’re wrong and their temperature stays down, back to school or day care the next day. If it goes up you have not exposed everyone else throughout the day. All infant’s under two months of age with a documented temperature (preferably rectally) above 100.4, should be seen by their doctor. That is a phone call day or night, to find out if your doctor wants to see you in the office or go to ER etc. Do not give this age infant any acetaminophen, before talking to your doctor. Many times this age child will be admitted to the hospital, so be prepared for that discussion with your doctor.

Once your child is over two months of age but still younger than six months, it is important to discuss your child’s fever with the nurse or doctor. There are certain things they will ask you that will help determine if your child needs to be seen that day or night. After six months of age it is easier to judge a child’s degree of illness by not only the reading on the thermometer, but by how they are acting. The hardest thing to teach any parent (me included) is that the height of the fever does not necessarily correlate with degree of illness.

During flu and viral season, it is not uncommon to see temperatures in the 103 - 104 degree range. Try not to react to the number on the thermometer, but rather look at your child. Go ahead and treat the fever with either acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) and then watch your child over the next 30 – 40 minutes. Reducing their fever will often improve how sick they look. Whenever a pediatrician walks into a room the first thing we do is look at how the child is interacting with the parent. Whether that is a toddler in a lap, or a big kid on the table, a quick look at a child is really worth a thousand words. If your child will smile (okay just briefly), make good eye contact, responds to the pediatrician by kicking and screaming (a toddler for sure), can play on the Nintendo DS, eat cheerios or candy or chips (I know, they won’t eat well when sick, do you?) and tell you just how crummy they feel, they are probably okay. I describe this as pitiful, and pathetic, but not critically ill. That is what we are trying to distinguish on a busy day in the office, and that is the same thing you want to look for in your own child.

It takes practice, but as a parent, you will be dealing with children and fevers for the next 21 years and you too will get better at dealing with fever. It is always scary the first time you see your child sick, but fever is not the enemy. It actually means that your child’s body is fighting the infection. So remember the mantra: Fever is your friend. I think we will be saying this a lot this winter. More fever topics later.

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

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

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.

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!

Daily Dose

Baby's First Cold

I find myself in the office each day amid a host of babies who are finally succumbing to their first colds. I walk into the room and see their little runny noses, their red rimmed eyes and hear their frequent coughs, while simultaneously see them sitting on their mom or dad's laps, playing with a toy and making good eye contact with the parent.

The parents of course are "worried sick" but I am immediately reassured as I watch their bright-eyed, runny nosed your-baby interact with me. So it goes in the winter.... No one is immune to those nasty cold viruses and many of these babies have managed to ward off illness for months, but are finally battling their first cold. The babies actually are fairing pretty well, but the parents are both worried about the cold and sleep deprived, because one thing about most kids with colds whether they are four months or 15 months, they just don't sleep as well. Colds are an unfortunate fact of life and each cold that a your-baby suffers through actually makes them a little stronger. Their bodies are making antibodies to that virus and helping to shore up their immune system. Small victories amid the myriad of viral infections they get in those six to 24-month period. There is still no real treatment or cure for the common cold. The recommendations for a your-baby are fairly similar to the rest of us. Hydration (milk is okay), fever control if they need it, and TLC and tincture of time. The first cold is the hardest, at least for the parent. You can try putting a humidifier in their room and irrigating their noses with saline to help clear the mucous and make it easier for them to breathe. Tylenol for fever, which is common in the first several days, may also make them more comfortable. After several days, the worst of the cold is over and they should feel a little better. Watch for fever that re-occurs or worsening of their sleep habits or mood which my signal an ear infection. Most ear infections don't occur on the first day of the cold, so give it a little time and if they are not improving it warrants a trip to the pediatrician. Best news, I saw very few ear infections today, but lots of colds. That's your daily dose, we'll chat again tomorrow.

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

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! 

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