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Daily Dose

Summer Viruses

1:30 to read

June….now seems like officially summer, although there are still some schools around the country in session, and even a couple in Dallas.  So, with summer here it is check up time in my pediatric office.  That means most days I am seeing very few sick patients, and most of the patients who come in for a visit other than a check up have a rash, a bug bite or maybe a swimmer’s ear.


But, with that being said there are also always some of those pesky summer viruses hanging around and many of them appear with just a fever. Many of the “sick” children I am seeing only have a fever, some of whom have a temperature as high as 103-104 degrees, with very few other symptoms.  Although these kids have a significant fever, once they are given an over the counter product like acetaminophen or ibuprofen they feel pretty well and even play for awhile. 


Fever is often just a symptom of a viral infection and these summer viruses have names…enterovirus, adenovirus, and even some left over parainfluenza virus.  We are definitely out of flu season….at least till next year.


Some of these summer viruses may have associated rashes which are more common with summer viral infections than winter viruses.


I have seen some kids with these summer viruses with prolonged fever, even 5-7 days which is a bit longer than a pediatrician and a parent want to see. But, with that being said, when I have seen these children they appear to look well and have not had any other physical findings.  I have often seen them again after having 5 or more days of fever, and it seems that many of them have adenoviral infections.  Adenovirus may also cause a myriad of other symptoms than just fever, including pink eye, sore throat, abdominal pain and vomiting and diarrhea and tummy cramps.  Rarely, some children will develop blood in their urine without having a urinary tract infection. 


Parents often ask me….where did they catch this? Remember that these are just viral infections and that there is not a vaccine for adenovirus. Once we see one virus in the community I know I will continue to see more and more children as it is “passed around”.  Best thing to do is to keep up good hand washing and keep your child home from the pool or summer activities if they have a fever.  


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 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.




Daily Dose

Summer Viruses Are Gearing Up


Is it hot enough for you? Summer is here for a bit! Winter viruses are a distant memory (good bye flu and RSV), summer viruses which have been laying dormant are once again rearing their angry heads.

My office has been overflowing with really hot feverish kids of all ages.   I think the most likely culprit for much of the illness we are seeing right now is an enteroviral infection.  For some reason, it makes us parents feel better if we can “name that virus”, seems to help validate the illness.  

Enteroviral infections typically cause a non-specific febrile illness and with that you can see fairly high fever. In other words, just like the thermometer as summer heat arrives , 101-104 degrees of fever is not uncommon in these patients.  Remember the mantra, “fever is our friend”. I think it is almost worse to have a high fever in the summer as you are even more uncomfortable because it is already hot!

With that being said, if your child has a fever, don’t bundle them up with layers of clothes and blankets.  It is perfectly acceptable to have your younger child in a diaper and t-shirt, and older children can be in sundress or shorts rather than long sleeves and pants.  Bundling may increase the body temperature, even while you are driving to the doctor’s office. I often come into a room with a precious baby who is running a fever and they are wrapped in blankets, let them out! That hot body needs to breathe.

These summer enteroviruses may cause other symptoms as well as fever, so many kids right now seem to have sore throats and are also vomiting and having diarrhea. With this type of virus you also hear complaints of headaches and body aches (myalgias).  The kids I am seeing don’t look especially sick, but they do feel pretty yucky!  Just kind of wiped out, especially when their temps are up.

Besides treating their fevers, treat their other symptoms to make them comfortable.   If they are vomiting do not give them anything to eat and start giving them frequent sips of liquids such as Pedialyte (for the younger ones) and Gatorade or even Sprite or Ginger Ale. Small volumes are the key. 

I often use pieces of Popsicle or spoonfuls of a Slurpee to get fluids in kids. I always tried to pick drink colors for my own kids that were easier to clean up, in case they were going to vomit again, so no bright red!  The cold fluids may also help to soothe a sore throat. Once the vomiting has stopped, and it is usually no more than 12-24 hours, you can start feeding small amounts of food, but I would steer away from any dairy for a day or two. Again, nothing worse than thinking your child is over vomiting, fixing them I nice milkshake (comfort food) and seeing that thrown up!  Many a mother has come into my office wanting to strip after being vomited on, in a hot car no less.   I don’t think there is a car wash around that can fully get rid of that smell!

Most enteroviral infection last anywhere from 2-5 days. There are many different enteroviruses too, so you can get more than one infection during the season. This is not just a virus you see in children, so watch out parents you may succumb as well. Keep up good hand washing and your child should stay home from school, the pool, camp, day care etc. until they have been fever free for 24 hours. 

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

Daily Dose

More Zika News

1:30 to read

There continues to be more and more information being published about Zika and the continued concerns over side effects of the viral infection. So there are several new key facts that every parent needs to know.

Based on more research the CDC and WHO have now confirmed the link between Zika virus infection and birth defects. Two interesting studies were just published further substantiating the link. The first was in the journal Stem Cell in which researchers found that the Zika virus selectively infects cells in the brain’s outer layer which makes “ those cells more likely to die and less likely to divide normally and make new brain cells.” In other words, Zika preferentially affects tissues in the brain and brain stem of the fetus.  While this does not prove that Zika causes microcephaly it certainly points to the fact that brain cells are very susceptible to the virus and if the cells don’t divide to make new cells….one would think the brain would be smaller as would the head (microcephaly).

Another article in the New England Journal of Medicine reported on research that had been done on 88 pregnant women in Rio. The article stated, “infection during pregnancy has grave outcomes including fetal death, placental insufficiency, fetal growth restriction and central nervous system involvement.”  They also stated that “major fetal abnormalities were found in nearly a third of the women who had been infected and had undergone ultrasounds.” This virus seems to act like some other viruses (rubella) that have caused congenital infections and brith defects as well. The study also showed that the Zika virus may affect the placenta as well, which could cause miscarriages and/or still births.

While much of the Zika virus news has focused on pregnant women and associated birth defects, countries with high rates of Zika infections have also seen an increase in the number of cases of Guillian Barre Syndrome (GBS), a neurological disorder which causes muscle weakness and varying degrees of paralysis.  A study published in The Lancet reviewed results of blood tests from patients who had Zika and GBS in French Polynesia, which was the site of an earlier Zika outbreak. Of the 42 patients that had been diagnosed with GBS, 41 had antibodies to Zika, which is more evidence that Zika may be the cause of the serious neurological condition. While GBS has been seen in children and adolescents post Zika, it tends to be seen more frequently in older adults and is actually a bit more common in men.

Although it seems that the virus affects pregnant women and older adults in different ways, the severe side effects of Zika are in both cases related to the nervous system. There is still much research to be done to elucidate the how and the why, before any type of cure or vaccine is available, but all of these studies are getting scientists one step closer.

Another issue that scientists continue to work on is how to best test for Zika virus.  It is still not clear how long the incubation period is after being exposed to Zika virus, and remember about 80% of people will not even realize they were infected. With that being said, one of the tests ( called a PCR test)  requires that the patient’s blood be drawn within 4 - 7 days after being bitten by the infected mosquito. Another test ( Zika MAC-ELISA) , may be the better test as it may be used for a longer period of time after being bitten. Both of these tests are being used for diagnosis and are now being sent to qualified labs to help speed up the diagnosis of Zika. 

In the meantime as warmer, humid weather is approaching the United States, we all need to be pro-active about using insect repellant, reduce standing water (it has been raining in TX for days), and wear long sleeved clothes and pants when possible. Stay tuned for further updates as the CDC expects to see cases of Zika in the U.S. over the coming months. To date all of the Zika cases that have been diagnosed in the U.S. have been imported and not acquired here.  

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Daily Dose

Dealing with Warts

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Warts are one of the most common skin lesions seen in pediatric practices. Warts also drive parents and some kids crazy!  According to one study up to about 1/3 of school children have warts.  

Warts are viral infections of the skin which are caused by human papilloma viruses (HPV).  There are more than 100 types of HPV and different types of HPV cause different types of warts. The most common warts on hands and knees are caused by HPV types 1,4, 27, 57.  These are not the HPV types that cause sexually transmitted infections 

Some people seem to be more prone to getting warts than others, and it is not uncommon to see several children in one family dealing with warts. The HPV virus is spread through skin to skin contact or through contaminated objects or surfaces. In other words, they are hard to prevent.  HPV can also have a long incubation period, so when parents ask, “Where and when did my child get this wart virus?”, my answer is typically, “not even the CIA will be able to tell you that”.  

I many cases if the warts are left alone they may resolve on their own in months to years (one study showed two thirds remission in 2 years) ......but with that being said, most teens (especially girls) want those warts to “be gone!” 

There are several different ways to treat warts and one of the most effective is with over the counter (OTC) products that contain salicylic acid.  Salicylic acid acts as an irritant that activates an immune response against HPV.  There are tons of different OTC products and in many studies there was not one product that proved superiority over another, so I would buy an “on sale” salicylic acid for starters. I know from using these on my own children that you have to be consistent and persistent in their use....but it did work. 

If OTC products don’t seem to be working the next step for those who are determined to try and get rid of the wart,  is to head to the doctor who may try freezing the wart with liquid nitrogen or using cantharidin.  Unfortunately, there is typically a little pain involved with these products. 

Like so many other things, sometimes it may pay to just to wait it out and see if the virus just gives up and goes away!

Daily Dose

Fever Blisters & Cold Sores

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Fever blisters are fairly common and are also often called cold sores, but have nothing to do with a cold. These sores typically appear on the outside of the mouth, on the lips. The majority (about 95%) of  fever blisters are due to a virus, typically herpes type 1.  Because the fever blister  is due to a virus,  they are contagious and most people will be exposed to the virus during their lifetime. Children are typically exposed via contact from an adult, a sibling or a relative who has a fever blister, or by other children who have mouthed toys etc that may have been contaminated with the virus. In many cases the exposure may be asymptomatic while others will develop painful  vesicles appearing both inside the mouth,  on the tongue and gums,  as well as  on the lips about 3 -5 days after their exposure. This initial illness is called herpetic gingivostomatitis.  The initial infection tends to be more uncomfortable and may take up to two weeks for the lesions to resolve. The most difficult problem is due to oral discomfort so it is important to make sure that these young children stay hydrated.  Popsicles are often helpful for this. Once you have been exposed to the herpes virus the virus remains in nerve endings where it may be dormant and asymptomatic for years. About 60% of children are positive for HSV -1 by adolescence. At other times the virus may become active (times of stress, sun exposure, fever, menstrual periods) and result in a fever blister. If a child develops a fever blister, they too are contagious and may spread the virus to others by touching or picking at the lesion and then touching other people or objects with their mouths. Fever blisters may be treated in most cases by using a topical antiviral that may be applied to the lesion. These are prescription medications that may shorten the duration of the fever blister by a day or two, especially if started early and applied frequently.  If children experience recurrent fever blisters speak with your pediatrician about the use of oral antiviral medications. Remember, if you have a fever blister don’t kiss your baby.  Although the most viral shedding occurs after the initial HSV infection, you remain contagious with each fever blister so it is better to take precautions for a few days. That's your daily dose for today.  We'll chat again tomorrow.

Daily Dose

Ebola Fear Running High

1:30 to read

As the weekend passes and there are thankfully no further cases of Ebola disease in any of the people who had the earliest contact with Thomas Eric Duncan (the first patient to be diagnosed with Ebola),  I hope people may be reassured that we are not in the throes of an Ebola epidemic in the United States and that the people who are at greatest risk of contracting the disease are unfortunately those health care workers who are treating the infected patient. 

Despite every precaution possible, and all of the personal protective equipment available, I am well aware that nothing is ever 100% .  But, with that being said, we (all health care professionals) continue to learn from mistakes as well as victories and I am sure that as we go forward combatting Ebola or other emerging viral infections, there will be new recommendations and procedures to learn, which is not a new concept in medicine.  That is how progress is made.

Unfortunately, the media (of which I must include myself) has once again managed to try to frighten the public and has done a good job of putting the three cases of Ebola out of 318 million Americans (unfortunately including 1 death) at the top of the news 24 hours a day.  The cameras continue to focus on the hospital in which I go in and out of every day.  This continued media presence has also affected the doctors who practice in the hospital as well as the professional buildings on the same campus. These doctors are my colleagues and friends and are great doctors.  

People have been canceling their dermatology visit in a professional building not even attached to the hospital and postponing a mammogram in another building.  Some patients will not come to my practice across the street from the hospital and would prefer to drive 20 minutes north to another office?   

There are parents keeping a child home from school because their classmate’s father is one of the doctors (heroes) taking care of the Ebola patients.  What are they thinking? How is this idea of catching Ebola from walking into an office or down a hallway or being in the same school being sustained?  Basically due to unsubstantiated fear and not fact. Fact is this illness is not airborne you must come into contact with body fluids of the sick patient.

Emotions are running wild in my hometown of Dallas. But emotions will not treat or eradicate Ebola, only good science will. Thankfully we have that available to us in our country. 

So listen to those who are knowledgable about infectious disease not lay people who expose their own ideas based on “what if’s”. Don’t listen to the pundits who are arguing with some of the best scientists and doctors that we have because if they themselves get sick one day, they will be seeking out these very same physicians and nurses to care for them. 

But one thing I am sure of, we will have influenza this winter and you can try to protect yourself and your family with flu vaccine.  There has never been a more important year to get vaccinated. Run, don’t walk and get vaccinated!

Daily Dose

Homemade Cure for Coxsackie?

1:30 to read

Desperate times call for desperate measures…or so it seems according to several of my patient’s mothers who have resorted to all sorts of “cra-cra” stuff to “treat” their child’s “HFM” - hand foot and mouth infection.  Remember, HFM is a viral infection that most children get in the first several years of life. It may cause all sorts of symptoms but in a classic case the child develops a macular-papular (flat and/or raised) vesicular rash on the palms, soles and buttocks. In some children the rash is fairly mild and in others it can look pretty disgusting and uncomfortable…but it has to fade away on its own…with time.


There has been a lot of HFM in our area and much anxiety among parents about this infection….fueled a lot by social media identifying who has HFM and where they go to school and how many cases there are. (too much information!!). Parents are even posting…places to “stay away from”. So, some of my patient’s parents are scouring their child looking to see if there might be a bump..and could this be HFM and if so, what do I do to “stop” it!  That would be “nothing” besides good hand this is a viral infection and you may be exposed to it almost anywhere.


Since coxsackie virus has been around for years, this means that most adults had the virus when they were young.  But, several moms and dads whose children have HFM have also shown me a rash on their palms and soles, that I presume may be HFM? They are kind of freaked out and may be uncomfortable too…but this is not life threatening.  Even so,  several parents are resorting to THE GOOGLE to get their medical information… and one young mother kindly brought me all of the stuff that she had gotten to treat her son’s HFM as well as hers.  She was earnest in hoping that this was the “cure”…and did I know about all of these remedies?


Here we go, her potions!  Epsom salts for baths as this is an “antiviral”, turmeric and ginger in veggie juice, crushed garlic which she was mixing with small amounts of orange juice and squirting into her toddlers mouth with a syringe, lavender essential oil and lastly “virgin” coconut oil massages.   


I was most impressed that her sweet toddler was eating, drinking and bathing in all of this!!! Unfortunately, despite her best efforts it took about 2 weeks for his rash to totally disappear and she kept him under house arrest for most of that time!!  He really could have gone out long before that as he was over his acute illness, but she wanted every “mark” to have faded. She was most chagrined to hear that he might get HFM again. I am not sure the her “voo-doo” did any good, except in her mind. 


Lastly, if you do resort to “internet medicine” remember the oath, “first do no harm” and check with your pediatrician about some of the advice you might find online, not everything may be safe.



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Which viruses are gearing up for summer?

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