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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

Treating Late Season Colds

Even though the temperatures are really warming up and we are approaching the end of the "sick'" seasons, there are still a few children with lingering colds. The most frequently asked question is "how long does a cold last?" and everyone is disheartened to hear that a typical cold lasts anywhere from 7 - 14 days. (UGH, in unison).

Despite all of the medical science we have, a common cold due to a virus, still causes symptoms of congestion and or runny nose, sore throat, and cough. A cold usually begins two to four days after exposure to the offending virus. It often starts with a scratchy or sore throat and then is followed by the runny nose, congestion and cough. The nasal mucous usually begins as a clear discharge that is then followed by color change to green or yellow mucous, which then thins out and becomes less cloudy as the cold improves over the requisite 7 -10 day period. In children it is not necessary for them to see their pediatrician for a common cold if they are fairly comfortable, do not show any signs of respiratory distress and do not have persistent fever of more than 48 - 72 hours. I am often more concerned about a child who has had a cold for a week and then develops a fever, which may signal a secondary infection, like an ear infection later into the course of a cold. Coughs often linger the longest but again should not be getting worse after a week, instead of improving, and your child should not have any respiratory distress or wheezing. Children can manage horrible sounding coughs, but look totally well and have no breathing problems, as they are quite comfortable in coughing very productively which is actually beneficial in keeping their chests clear. For children whose cold seems more persistent or who seem to be getting worse instead of a little better each day (after the first 5 - 7 days), my rule of thumb is that they are seen in the office. Only by looking at their nose, throat, and ears and listening to their chest am I able to see if they are developing any secondary infections. That's your daily dose, we'll chat again tomorrow.

Daily Dose

More Zika Virus Cases

1:15 to read

I have been receiving a lot of phone calls from patient families, especially from mothers who are either pregnant or thinking about becoming pregnant, with their concerns and confusion over the Zika virus.  Several of these women have trips scheduled to Mexico and the Caribbean in the coming weeks, and called to ask what they should do?

While I don’t want to be an alarmist, I do think there is real concern that this virus seems ia spreading amid new reports of countries who have identified the Zika virus and associated microcephaly in newborns.  The list of countries grows daily, and in fact, the CDC website has being updated with a new map showing the distribution of the virus.  

The Zika virus is transmitted to humans by the bite of an Aedes mosquito that has been infected by the virus.  There is no human to human transmission, but a mosquito could bite an infected person and then become infected itself and go on to bite another human.  It is a cycle.  Travelers to Zika-affected countries will ultimately bring the virus back to the United States where it is expected to spread to states with warmer and humid climates (such as TX, FL, MS, LA and HA) as summer approaches.

The CDC has already issued a warning for pregnant women and those who are planning to become pregnant to avoid travel to the 20 countries ( and growing) who have known Zika virus. As I told my patients, is it worth it to go on vacation or to attend a wedding and risk ( even the slightest risk) becoming infected with this virus and having a child who is born with microcephaly (small head) and abnormal brain growth??? Short of wearing mosquito netting to cover yourself from head to toe, copious amounts of DEET insect repellent and staying inside (which is not foolproof) …I  just think it may be time to re-think plans to travel to these areas while more research and data is being gathered.  The World Health Organization and the CDC have researchers investigating all aspects of Zika virus, including trying to develop a vaccine, but all of this takes time. 

While for most people the Zika virus causes a mild illness with headache, fever, pink eye and joint aches, the effects on the unborn baby may be devastating. The CDC has also just issued guidelines for OB/Gyns who may see women who are pregnant that have returned from a trip to one of these areas with Zika and show signs of a “viral infection” with symptoms as above. In this case, the recommendation is that a blood test is done to confirm Zika virus and if the mother is positive she should have serial ultrasounds (every 3-4 weeks)  performed to monitor the baby’s head growth. Unfortunately, not all pregnant women who may be infected with the virus will have symptoms ( p to 80% of people may not feel ill ), and their babies could possibly be affected as well.  While it seems that the virus may be more likely to affect a fetus during the first trimester, it is difficult to pick up microcephaly on ultrasound before the second trimester.

So….this story continues to evolve and new recommendations should be expected as more information is gathered. But my advice continues to be…”why risk it?” . To have any concern, doubt,  or worry about exposure is enough for me to advise my patients to change their plans!

Stay tuned. This story is not going away…..

Daily Dose

Dealing with Warts

1.30 to read

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!

Your Teen

HPV Vaccine Safety

1.15 to read

Do you have a teenager?  If so, have they received their HPV vaccine?

HPV stands for Human Papilloma Virus, which may cause cervical and penile cancer, oral cancers and genital warts.  There has been a vaccine available since 2007.

A recent study in the journal Pediatrics looked at vaccination rates for teens and the HPV vaccine. While 80% of teens are receiving their Tdap booster, and 63% of teens are current on their meningococcal meningitis vaccine, only 32% of teens have received all 3 doses of HPV vaccine.

Parents whose teenagers had not received a first HPV vaccine or completed the series often said that the vaccine was “not needed or necessary”.  

Other parents whose children had not received the HPV vaccine and who did not intend to vaccinate their children stated that they “were worried about the safety or side effects of the vaccine”.

The HPV vaccine has had a good safety record and has been shown to be very effective in preventing HPV infections.  The vaccine has been studied in the United States for amost 7 years, and in Europe and Australia for almost 10 years.  

The vaccine does not treat HPV disease, but rather prevents it, so the vaccine needs to be given to adolescents prior to any exposure to the virus.   While many parents feel comfortable discussing sexuality with their children, other parents are uncomfortable with vaccinating their children for a sexually transmitted disease.  

Getting parents to complete the series (which is given over a 6 month period) has also been a hurdle and  the vaccine is not effective until all 3 shots in the series has been completed.

If you have questions about the HPV vaccine, talk to your doctor in order that all of your questions can be answered. I know I have given my 3 children the vaccine and encourage all of my patients age 11 and older to receive the HPV vaccine series. 

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

Strep Throat Continues

1.30 to read

Still in the sick season and I’m counting the weeks that are left. Probably at least 6-8 more weeks before it will really slow down. The good news is that flu does seem to be waning, but there are still plenty of coughs, colds, and sore throats.  

So many children have sore throats at this time of year and I find myself explaining to parents what we pediatricians are looking for during the physical exam to determine if a child might have strep throat. Although parents often “want a throat culture” regardless of their child’s age or symptoms, their pediatrician is using clinical judgement before performing a “rapid strep test”, which is the most common method for detecting streptococcal pharyngitis (strep throat).

Strep throat is a bacterial infection and is treated with antibiotics, while most other causes of a sore throat (pharyngitis) are due to viral infections and are therefore self limited and do not require antibiotics. In fact in a recent study of a general pediatric office practice about 20-30% of sore throats seen throughout the year were due to strep.  The other 70-80% were viral.

The “typical” child with strep throat will have some notable symptoms and physical findings. Strep is most commonly seen in children between the ages of 2-13 years.  Most children will NOT have concomitant upper respiratory symptoms (cough, runny nose) but will complain of a sore throat, difficulty swallowing and may also have a stomach ache or even vomiting. On physical exam they will have fever, a “beefy” red throat and enlarged tonsils and tender lymph nodes in their neck. These are the symptoms and physical findings your doctor is using when deciding to swab your child’s throat.  

So, why not culture everyone with a sore throat?  There are several reasons, one of which is the cost of the test, but also there are false positives for those children (and adults) who might be strep carriers.  The medical literature suggests that somewhere between 5-25% of asymptomatic school aged children harbored group A strep. While hard for a parent to initially comprehend, the strep carrier does not need antibiotics. No one wants their child to be on antibiotics unnecessarily. 

So.....don’t run off to have all sore throats swabbed at first mention of pain, wait 12-24 hours to see if there are other symptoms as well. I also see entire families come in for a “strep test” because one of the children is ill or their child rode in carpool with a child with strep. There is No need to  swab contacts unless they are symptomatic.  Hopefully this will save you an unnecessary trip to your pediatrician too.  

 

 

 

Daily Dose

E. coli Outbreak Continues

E. coli bateria is spreading across Europe with more deaths reported. What you need to know about this deadly bacteria.I was on the treadmill this morning simultaneously watching a plethora of channels on the flat screens TV’s at the gym. One of the headlines at the bottom of the MSNBC screen caught my eye as it read, “deadly virus spreading across Europe”, while the next headline read, “e. coli continues to spread in Europe.”

Unfortunately, there does continue to be concern over the deadly BACTERIA that has been spreading across Germany and has caused illness in at least 10 other European countries as well as several cases in the United States. But the concern is not due to a virus, but a bacterial infection!  Viruses and bacteria essentially have nothing to do with one another except that they can both cause illness. The bacteria, a new strain of Escherichia coli (E.coli), have caused an outbreak of diarrheal disease with over 2,900 people being infected. Of these, over 500 have suffered life-threatening complications, and there have been 30 deaths reported. The sickest patients have developed hemolytic uremic syndrome, a kidney disease which may result in renal failure. It seems that this “new” bacteria has caused the most serious illness among previously healthy women, including those that are pregnant. This is unusual as it is typically thought that children and elderly have more serious complications from hemorrhagic E.coli strains. Several of the cases of this specific type of E.coli have been reported in the U.S., with all persons except one having had recent travel to Germany. E. coli is a bacteria that had long been known to cause food borne gastroenteritis (vomiting and diarrhea). The bacteria may be found in fecal material and then may be spread via food that has been contaminated.  It was just announced that the most likely source of this E.coli infection is not cucumbers as was previously suspected, but rather by contaminated bean sprouts. The initial source of infection looks to be from a farm worker who has tested positive for E.coli and is thought to have spread the bacteria while working. The mainstay for preventing any food-borne illness is HANDWASHING!!  It is also important to thoroughly wash fruits and vegetables, especially those that are eaten without being cooked.  Peeling the produce is also a way of helping to prevent disease. The WHO and also the CDC have put U.S. doctors on alert for this disease. If you or your children develop bloody diarrhea it is important that you seek medical care, and if possible have a stool specimen available for your doctor. In the meantime, have your children practice good hand washing, especially after using the bathroom!  Remember, this is a bacterial rather than a viral infection. There is a difference. That’s your daily dose for today. We’ll chat again tomorrow.

Daily Dose

Recurrent Ear Infections

1:30 to read

It is winter and fortunately while there is not much flu to date, there are certainly colds and coughs throughout the country.  It seems that every child I see has a runny nose.  Remember, a toddler will get anywhere from 5-10 colds a year for a couple of years as they start to have playmates and pass those pesky viral upper respiratory infections back and forth.  But for some young children, (especially those in daycare) those frequent colds may lead to recurrent ear infections (otitis).

Otitis media is an infection of the middle ear. In children,  an ear infection typically follows a common cold, which may be caused by a plethora of viral illnesses. It seems that the virus changes how the middle ear “functions” lots of complicated science about cilia, and mucous and eustachian tube function) which then leads to secondary bacterial infection and an acute ear infection.  It typically takes a few days to weeks of a cold, before developing an ear infection. I tell my patients, “you don’t usually see an ear infection in a young child on day 1 or 2 of a cold”.  If everything else seems okay, you might want to watch your child for a few days before having their ears checked.

The guidelines for treating acute otitis media (AOM) changed several years ago after studies showed that not all ear infections were caused by bacteria, especially in older children, and that with “watchful waiting” many ear infections would improve on their own.  So, for children between the ages of 6-23 months of age with bilateral or unilateral ear infections and signs and symptoms of pain (tugging on the ear, rubbing the ear, irritability and sleep interruption) and fever the recommendation is to treat the infection with antibiotics.  The recommendations get a bit trickier for children who do not have bilateral infections and who are considered to have “non-severe” AOM, in which case the doctor and parent may discuss the pros and cons of antibiotic therapy and in some cases may decide to defer the use of antibiotics for 48-72 hours and observe the child for worsening of symptoms or failure to improve at which time an antibiotic may be started.  “Watchful waiting” has helped to decrease the number of antibiotics prescribed for children.

For the younger children 6-23 months who are more likely to be “sicker” than an older child with AOM, the first line antibiotic to be prescribed is still Amoxicillin (unless the child is known to be penicillin allergic). Amoxicillin is the gold standard, “pink medicine” that many parents remember from their childhood…..tastes like bubble gum and needs to be refrigerated.  For children who have had recurrent ear infections other antibiotics know as “second line” drugs may be used.  Again, there are pros and cons to many antibiotics as well in terms of taste, how often they need to be given and side effects….so discuss this with your own pediatrician. 

For children 2 and older I am a big believer in “watchful waiting” and pain control.  So many of these children will do well with over the counter acetaminophen and ibuprofen as well as topical ear drops for analgesia.  I would guess that in my practice (not a valid scientific study) about 80% of my older patients do not fill a prescription for antibiotics….which as you know is a good thing (no one wants to be on an unnecessary antibiotic).

Unfortunately, there seems to be a “group” of children (typically the younger ones) who get recurrent AOM and spend many of their winter months in the pediatricians office.  More about those infections in another post.  

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