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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

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

A Germ-free Office?

To keep the germs at bay, it has been suggested to remove all toys & magazines from a doctor's office. Really? Aren't there germs on magazines in a lawyer, dentist or school office?I was just reading an interesting newspaper column in one of the advice columns carried in my daily newspaper. I just had to comment!  The writer had written in to suggest that doctor’s offices needed to change their practice of having magazines and toys for those in the waiting room.

Her feeling was that if doctors would discontinue having magazines in their offices, then patients would bring their own periodicals and that this would then reduce the spread of germs. The columnist also thought this sounded like a good idea and thanked the writer for such a great suggestion. I had to re-read the column as I really could not believe that someone would suggest that doctors should have empty waiting rooms!!!   Have we just gone overboard with “germ fears”?  I understand the need to wash your hands, and to try and keep your hands away from your face, to cover your mouth when coughing etc.  But taking magazines, newspapers, toys and books out of a waiting room seems a little extreme. There are also similar items in the waiting room of my dentist, lawyer, accountant, hairdresser etc.  I guess there could also be germs in those offices too, but no one is suggesting that these professions “sterilize” their waiting rooms and common areas. While I agree it is important to try and keep waiting rooms clean, especially in a doctors’ office (where not everyone is even sick), there is no way to keep any common area totally germ free. The magazines and books are not the only objects that may harbor germs. What about the chairs, the door knobs, the table tops, the counter tops, the fish tank glass, even the floor?  There is just not any way to keep the area entirely germ free, even with good cleaning. In my office we are very conscious about trying to keep the office clean to reduce the spread of germs. Our housekeeping staff that mop the floors and wipe the surfaces between morning and afternoon patients. To try and make an office germ free is as impossible as making a grocery store, a department store, a library or even a school germ free. It is just a fact of life that we will all be exposed to germs. To suggest that discontinuing the long standing tradition of having reading material in the waiting room of a doctor’s office in order to decrease the spread of germs just doesn’t seem to make common sense to me. If you (as a patient) are “afraid” to read a magazine at your physician’s office, then by all means bring your own. But to take away the books and magazines from everyone is just a bit too much. For many parents a trip to the pediatrician’s office is difficult enough without having to lug your own stash of toys and books. I have sweet moms who don’t even remember to bring diapers or wipes as they are just trying to get to their appointment.  Arriving to an empty waiting room to try and entertain 3 children waiting on their doctor seems like torture to me. Schools are full of germs too, but we send our kids there to learn (and occasionally get sick too). Getting sick is never fun, but germs are ubiquitous.  Don’t sweat the small stuff; remember there is a bigger picture. What do you think? I would love to hear from you! Feel free to leave your comments below.

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

RSV is Still Lingering

1.30 to read

I can’t believe that I am writing another post on RSV! After another long day in the office with tons of wheezing and coughing, I decided to take a look at the national RSV statistics. Guess what, most of the country is still in the throes of RSV season (Florida is lucky as their rates are on the decline). So I know that everyone is still dealing with RSV (respiratory synctial virus) and we may still be several more weeks away from declining viral rates and the end of the RSV season. 

I am still seeing many parents who are “fearful” of RSV, as their day care or schools have sent home notices that there are cases of RSV. I am still confused by the need to send out notices which may only scare parents, as at this time of year, RSV is virtually everywhere. 

RSV is a virus that occurs every fall, winter and often into early spring. It causes cold symptoms for most of us, and most of the population (both child and adult) can never name the virus that caused their terrible runny nose and cough.  By the time a child is 2 years old the majority of them (upwards of 90%) have had at least one RSV infection. Again, most parents never need to know the name of the virus that is causing their child to have that terrible cough and runny nose. It is just another bad cold! 

But, with that being said there are children, especially those under the age of 2 who will have more problems with RSV. In some cases, especially young infants, the virus will cause not only a runny nose, congestion and coughing, but wheezing as well, and in a few, respiratory distress. It is in those cases that we “name that tune” and test to confirm that the baby has RSV. 

Our office does not routinely test every child with a cough, runny nose or even all of the kids that are wheezing to see if they have RSV. (If we did we would be testing almost every child!) We only do the tests on the sickest children that end up needing to be hospitalized. The real reason behind the testing is to confirm our suspicions and to follow the epidemiology of the disease during RSV season. 

The treatment of the symptoms does not really change based upon the confirmation of RSV. Other respiratory viruses such as rhinovirus and metapneumovirus are also lurking out their wrecking havoc with coughs, colds and wheezing as well. 

So once again, don’t worry about “naming the virus” or rush to the doctor because your next door neighbor’s child or a friend in day care has been diagnosed with RSV. Rather, pay attention to your child’s symptoms and how they are breathing and handling the virus. RSV is still around will hopefully move out of the country in the next 6 weeks. But guess what, it will surely return next year too.  Keep covering those coughs and washing hands!  

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

Daily Dose

The Luxury of House Calls

A quick visit to a family down the street made me realize the luxury of "the olden days" of house calls.I went down the street today to see a family of mine who had just had their second your-baby. I saw the stork sign in her front yard, announcing the birth of their second son, and thought I would "pop" in to take a peek at the your-baby and see how things were going.

It was such a delight to get the opportunity to see the family (now four rather than three), at home with their newborn and almost 2-year-old son, relaxed and happy. What a difference to have the chance to visit with them and do a cursory exam on the four-day-old, in the comfort of their home, rather than the chaos of a busy pediatricians office in the winter. It was easier for them I am sure, rather than having to bundle the your-baby up, drive to the office, sit in a waiting room etc. We sat together while I had the pleasure of holding their precious newborn and talked about bringing home a new your-baby and questions or concerns that they had. We had the time to talk about breastfeeding, jaundice and newborn stools, all the while watching the toddler show me his puzzles and new toys. It was a wonderful visit. This 20-minute visit made me realize the luxury of "the olden days" of house calls, when you had the chance to see a family in their surroundings. I am sure that a doctor could gain a lot of insight into family dynamics by making house calls, as there are many times I think, "I wish I was a fly on the wall to watch this family at home". That may be my next life, pediatrician on call, only going to a few houses a day to do home visits. In the meantime, back to the office tomorrow, but one less patient to see as I have already taken him off my schedule! That's your daily dose, we'll chat again tomorrow.

Daily Dose

Treating Altitude Sickness

1.30 to read

What can you do if your child suffers with altitude sickness.With winter breaks in full swing, many families are traveling. Some families are heading to the mountains to ski and encounter higher altitudes.

I seem to get several calls each year about “acute mountain sickness” which may occur when traveling to altitudes above 5,000 feet (1,500 meters),  but is typically associated when travelling to altitudes of 8,000 – 14,000 feet (2,440 – 4,270 meters).  To give you a frame of reference, Denver, Colorado is 5,280 feet above sea level, while Vail, CO is 8,200 feet. Fortunately, most people will not have serious problems when traveling to higher altitudes.  The human body acclimatizes to higher altitudes by allowing your body to function with less oxygen without having distressing or debilitating symptoms.  Despite that, the body is not functioning as well as it does at sea level, as the air is less dense at higher altitudes and consequently there is less oxygen available for breathing. The first thing you may notice is a slight increase in respiratory rate, which will help to increase oxygen delivery to the lungs but at the same time results in the loss of extra CO2.  Some people may also notice an increase in heart rate. I think that most children without underlying medical problems (chronic pulmonary or cardiac problems), seem to actually acclimate better than adults. But in some cases you may notice that your child has non-specific symptoms such as irritability (I must admit hard to tell if altitude, traveling or just having a bad day), decreased appetite, headaches, disrupted sleep (always seems to happen when travelling with children) and occasionally vomiting. All of these symptoms usually resolve after several days and may be minimized by planning a gradual ascent to higher altitudes.  So, driving may be better than flying, but…..I can remember several days while driving to Colorado with cranky children and we were not even out of Texas! I also think one of the boys vomited due to the driving and not altitude. Oh well, fond memories nonetheless. For some children and teens who have experienced repetitive episodes of altitude sickness I have used a prescription medication called Diamox to minimize symptoms.  I would not recommend this for young children.  You should speak with your doctor about the use of this medication, as it aids in acclimatization by increasing the excretion of bicarbonate in the kidney, which will stimulate the respiratory rate and improves oxygenation.  Some families who are frequently sick when skiing or hiking also have portable oxygen to use to help alleviate symptoms for the first several days they are at higher altitudes. For most of us, just maintaining hydration and taking the first few days of exercise a little slower is enough for our bodies to acclimate and enjoy the trip! That's your daily dose.  We'll chat again tomorrow. Send your question to Dr. Sue right now!

Daily Dose

The Dangers of Diagnosing Online

The hazards of using the Internet as your own medical textbook can be great.Here I am on the internet writing about the dangers of diagnosing yourself or your children via information on the web. The internet is a valuable resource, and I cannot remember what I used to do before I could “Google” something to get a quick answer. You don’t need a phone book anymore or zip code directory or even a map, as it is all available online.

But, when it comes to medicine there is still nothing as effective and reliable as seeing a doctor in person and having a physical exam. The hazards of using the Internet as your own medical textbook can be great. The Internet is a resource, and not a doctor. Just like Sir William Osler taught when he published The Principles and Practice of Medicine in 1892, the physician must examine the patient. The best doctors still take a complete history and do a good physical exam!! I often tell parents and patients to use the Internet as an adjunct once the diagnosis has been made. The Internet may be a great resource to provide further information about a specific problem or disease. But when searching online you want to make sure that you are using a resource that has good research and is reputable and reliable. Many postings on the web may be anecdotal rather than factual and there are no requirements on the web to post information. In other words, you don’t have to go to medical school and get a degree to “publish” on the Internet. I sometimes see a worried parent in my office, whose child may have awakened during the night with a “tummy ache”. Despite the fact that the child had already gone back to sleep, the parents stayed up searching the Internet for “abdominal pain”. Due to their Internet “research” the parents have convinced themselves that their child must have appendicitis, and by morning they are convinced that testing is warranted (of course they read every blog about “missed appendicitis”). The child may have had no other symptoms than that “tummy ache”, slept the rest of the night, and awakened feeling just fine, ate breakfast and are ready for their day. But, they appear in my office, many times 8 – 12 hours later and want to run for further tests and are planning for imminent surgery. All of this anxiety provoked by Internet research. Somehow, the most common symptoms have been overlooked during the parent’s panic. The child feels fine now, looks great and is ready to go back to playing! But the poor parents have scared themselves into wanting CAT scans and ultrasounds to “make sure” nothing is missed. A good review of the history and physical exam is often all that is needed in the case of the “mystery midnight tummy ache”. The only thing that came of that internet research is that the parent had 12 hours of a tummy ache worrying about obscure diagnoses rather than heading back to bed themselves. So, beware of using the Internet for research without knowing what you are researching. Always use reputable web sites and check out the credentials of those who are giving information. Beware of people or companies that provide information that are not in the mainstream and who do not provide valid scientific research to back their claims for a “cure”. When in doubt, ask your own doctor, I am sure they have an opinion about the pros and cons of online diagnosing. That’s your daily dose, we’ll chat again tomorrow. How much do you use the internet when it comes to a diagnosis? Let me know and leave your comment below.

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