Daily Dose

Moles On A Child's Skin

1:30 to read

Everybody gets moles, even people who use sunscreen routinely. Moles can occur on any area of the body from the scalp, to the face, chest, arms, legs, groin and even between fingers and toes and the bottom of the feet.  So, not all moles are related to sun exposure.

Many people inherit the tendency to have moles and may have a family history of melanoma (cancer), so it is important to know your family history. People with certain skins types, especially fair skin, as well as those people who spend a great deal of time outside whether for work or pleasure may be more likely to develop dangerous moles. Children may be born with a mole (congenital) or often develop a mole in early childhood. It is common for children to continue to get moles throughout their childhood and adolescence and even into adulthood.

The most important issue surrounding moles is to be observant for changes in the shape, color, or size of your mole. Look especially at moles that have irregular shapes, jagged borders, uneven color within the same mole, and redness in a mole. I begin checking children’s moles at their early check ups and look for any moles that I want parents to continue to be watching and to be aware of. I note all moles on my chart so I know each year which ones I want to pay attention to, especially moles in the scalp, on fingers and toes and in areas that are not routinely examined. A parent may even check their child’s moles every several months too and pay particular attention to any of the more unusual moles. Be aware that a malignant mole may often be flat, rather than the raised larger mole. Freckles are also common in children and are usually found on the face and nose, the chest, upper back and arms. Freckles tend to be lighter than moles, and cluster. If you are not sure ask your doctor.

Sun exposure plays a role in the development of melanoma and skin cancer, so it is imperative that your child is sun smart. That includes wearing a hat and sunscreen, as well as the newer protective clothing that is available at many stores. I would also have your child avoid the midday sun and wear a hat. Early awareness of sun protection will hopefully establish good habits and continue throughout your child’s life.

That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Ear Infections Can Develop Quickly

1:15 to read

One of the things that I sometimes see in my practice, which is interesting to me as a pediatrician, and was equally interesting when I had young kids, is how quickly a child's ear exam can change.

You are taught that in medical school, but when you really see it happen it with your patients or your own child you become a real believer. As the saying goes, seeing is believing. I can remember checking one of my boy's ears for an ear infection early in the morning before heading out to work, and declaring, "his ears are perfectly clear". How could it be, my husband would inquire, "that they seem worse after we have been at work all day" and lo and behold, I would re-check their ears and a normal morning ear is an abnormal evening ear. What a difference 12 hours can make! Not a very good warranty on ears and infections.

I was reminded of this yesterday when a patient called and said that her little boy had developed "disgusting" eye drainage which was worsening since I had seen them in the office a few days ago. They had just returned from taking both of their young children to Disney World, and she "couldn't believe they came home sick!" That's a whole 'nother column. At any rate, seeing that they lived fairly close I told them to swing on by and let me look at him again. I think she was just hoping I would call in eye drops. The two precious boys arrived at my doorstep on Saturday night and lo and behold after looking in the youngest child's ears, both of his ears were so infected. So, once again I was a believer in ears changing, and he did not need eye drops he needed to have oral antibiotics to clear up his ears (and subsequently his eyes). There are several lessons from all of this. Ears can change quickly, eye drainage in a toddler with a cold may often really indicate that their ears are infected, and house calls are a good thing.

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

Daily Dose

No Oreos in Lunch?

1:15 to read

I have been interested in the recent news article about a mother who had packed Oreo cookies in her child’s lunchbox. It seems that although she had also packed other lunch items, the school her child attended deemed the lunch “unhealthy” and not only did not allow her to eat the cookies, they  sent her mother a note encouraging her to “pack a nutritious lunch”.

WHAT?  Are schools and daycare centers now deciding what a parent may put in a child’s lunchbox?  I understand the need for nutritious lunches for our children. I talk about this everyday in my practice. But are there not bigger issues facing our schools than policing every child’s lunch. This mother did not “just” pack Oreos, her child had a sandwich and string cheese as well. Her mother stated that, “she was out of fruits and vegetables that day”, so added some cookies.  

Schools are in the throes of changing menus in an effort to help our children make good choices at lunch. But, even without serving fried foods or soft drinks, they do still offer dessert during school lunch.  They have ice cream, frozen yogurt, pies, cookies....and unfortunately many children probably eat more than one.  

I once headed a committee at our sons’ school to change the school cafeteria’s policy to have a “soda fountain”.   I realized that even if I talked to my children about nutrition and health, and did not have soft drinks in our home , if they were offered a choice between soft drinks and milk I knew  that they would sometimes choose a soft drink (with free refills I might add). 

After about a year of discussions and some very unhappy parents and students our school did stop serving soft drinks. As I pointed out even then, this was for children who were buying school lunch and drinks....we were not telling parents what they could and could not send or have in their own homes.

At the minimum I think this poor 4 year old should not have been put in the middle of this discussion. Would it not have been more appropriate to send the mother a note asking her not to send cookies for lunch again?  Was there a notice of acceptable lunch items that had been posted at the beginning of school?  Is there a “zero tolerance” for cookies rule?

I guess schools will be sending sandwiches home that have white bread or bologna, or who knows what else. While I am a huge advocate for healthy eating habits and making changes in all of our homes...let’s not take it out on a 4 year old.

Daily Dose

Bug Spray & Bug Bites!

1:15 to read

 It’s that time of year again when the bugs start to return from their “off season vacations” and pediatricians start to see children who are suffering from uncomfortable bug bites.

The best way to prevent bites from the myriad of insects including mosquitoes, mites, chiggers, flies and fleas is by using an insect repellent. Insect repellents do not prevent bites from stinging insects such as bees, hornets and wasps. The AAP recommends using bug sprays in children who are older than 2 months of age when necessary for preventing insect bites during outdoor activities. The most common insect repellent is DEET, a chemical that has been studied for over 50 years. Most of the OTC bug sprays contain DEET in different strengths. The higher the concentration of DEET, which typically ranges from 5 – 30 %, the greater the protection and length of effectiveness. I usually recommend starting with the lowest concentration of DEET, which typically provides protection for 1-2 hours, and use a higher concentration as needed for longer protection.

The number of bites a child receives and their reaction to bites are different in all children, so each child may need a different concentration of DEET to be effective. With concentrations of DEET above 50% (not recommended for children), the effectiveness and duration of protection actually plateaus, so there is really no benefit from higher concentrations.

Another product approved for use in the U.S. about 5 years ago is picardin. Picardin provides similar protection in both duration and effect to DEET. Cutter, Skin So Soft and Off all have some products containing 7-10% picardin. The advantage to picardin containing products is that they are odorless (unlike DEET) and do not feel as greasy on the skin and are less likely to cause skin irritation and damage to fabrics . With all products you must read the labels to see what you are getting. There has been some recent data on the use of natural products such as oil of eucalyptus which the CDC has found to be comparable in its duration of effectiveness in preventing mosquito bites, to lower concentrations of DEET. It may also work well against ticks (Repel).

Eucalyptus oil may be poisonous if ingested in large quantities and should not be used in children younger than 3 years of age. Other studies have found that 2% soybean oil (Bite Blocker for Kids) has similar levels of protection to products containing 5-15% DEET, and may provide up to 90 minutes of protection from mosquitoes. This may be a useful product for short term exposures. Chemical repellents containing permethrin kill ticks on contact but should never be applied to the skin, but may be applied to clothing. Insect repellents should not be reapplied throughout the day, as is sunscreen. Parents should be instructed to spray the insect repellent on their hands first and then apply to their child and do not apply to the areas around the nose and mouth. 

It is a good idea to wash the repellents off with soap and water at the end of the day. That’s your daily dose for today. We’ll chat again tomorrow.

Daily Dose

Swollen Lymph Nodes

1:30 to read

A parent’s concern over finding a swollen lymph node, which is known as lymphadenopathy, is quite common during childhood.  The most common place to notice your child’s lymph nodes are in the head and neck area.

Lymph nodes are easy to feel  around the jaw line, behind the ears and also at the base of the neck, and parents will often feel them when they are bathing their children.  Because young children get frequent viral upper respiratory infections (especially in the fall and winter months), the lymph nodes in the neck often enlarge as they send out white cells to help fight the infection. In most cases these nodes are the size of nickels, dimes or quarters and are freely mobile. The skin overlying the nodes should not appear to be red or warm to the touch. There are often several nodes of various sizes that may be noticed at the same time on either side of the neck.   It is not uncommon for the node to be more visible when a child turns their head to one side which makes the node “stick out” even more.

Besides the nodes in the head and neck area there are many other areas where a parent might notice lymph nodes.  They are sometimes noticed beneath the armpit (axilla) and also in the groin area.  It your child has a bug bite on their arm or a rash on their leg or even acne on their face the lymph nodes in that area might become slightly swollen as they provide an inflammatory response. In most cases if the lymph nodes are not growing in size and are not warm and red and your child does not appear to be ill you can watch the node or nodes for awhile.  The most typical scenario is that the node will decrease in size as your child gets over their cold or their bug bite.  If the node is getting larger or more tender you should see your pediatrician. 

Any node that continues to increase in size, or becomes more firm and fixed needs to be examined. As Adrienne noted in her iPhone App email, her child has had a prominent node for 7 months. Some children, especially if they are thin, have prominent and easily visible nodes.  They may remain that way for years and should not be of concern if your doctor has felt it before and it continues to remain the same size and is freely mobile.  Thankfully, benign lymphadenopathy is a frequent reason for an office visit to the pediatrician, and a parent can be easily reassured.

That's your daily dose.  We'll chat again tomorrow.

Daily Dose

Uber & Teens

1:30 to read

Do you have Uber cars in your area?  I first found out about Uber (and I am only using them as an example) when my son lived in NYC and often used the car service. Later on I heard about college kids using Uber as well.  In that case, many college kids did not have cars and/or they were being “responsible” after being at a party.

But recently, in conversations with my adolescent patients, I have heard that high school kids are using Uber to come home after a party, or other social activities. In otherwords, their parents are not picking them up from the dance, concert, or party but are letting their children (often young girls) call Uber.  Where are their parents and what are they thinking?

I realize that once your child heads off to college you hope and pray that they are making good choices and are being safe. You don’t really plan on picking them up after an event or talk to them that same night about what they have been doing and with whom.  But when we had high school age children, my expectations were that we, the parents, were responsible for taking our teens to the party and to pick them up. Once they were driving the “rules” changed a bit in that they were then often driving themselves to an event and then would drive home and we would be up waiting for them to get home.  They always knew that we would be there when they got home and also that if there were any “issues” we were also available to pick them up. We talked a lot about underage drinking as well as driving and responsibility.  Never did I think they would call a cab or car service, nor was that idea ever broached, they were to call their parents.

So now that these “app” car services are available around the clock, are parents abrogating their responsibilities for parenting teens?  By allowing their teens to call a car service for their ride home, are parents seemingly not interested in where their child has been or who they have been with or what they have been doing before they get home?  You certainly can drop your child at a concert or party and tell them to text Uber to get a ride home, but does this parental non-participation quietly help to condone inappropriate, risky, teen behavior?

Although picking your child up at the end of the evening or checking on them when they pull in the driveway will never ensure that your teen does not get into trouble, I think it does help them think a bit more about having to interact with their parents at curfew time. This “worry” might help lead them to make a better decision about drugs, alcohol or whom they are hanging out with. Putting teens into the “hands” (cars) of strangers as their ride home just seems wrong. Parents be aware. 

Daily Dose

White Patches on the Skin

1:30 to read

I saw a 10 year old patient last week for her routine physical. One of her mother’s concerns was that her daughter had “white patches” under both of her arms.  Once I examined her I told her mother that the “white patches” were actually due to Vitiligo, which is an acquired disorder of pigment loss. 

Vitiligo is caused by a reduction in functional melanocytes, the cells that cause pigmentation in the skin. Vitiligo often develops before the age of 20 and there is no difference in predilection for male over female cases.  In children the hypopigmented areas are often first noted on sun exposed areas like the face (around the eyes and mouth) and well as on the hands.  The underarm area (axilla) is often involved, as are areas around the genitalia. In many cases the depigmentation is symmetrical (both arm pits, or hands or knees). 

Although the exact cause of Vitiligo is not clear, it is known that it has an immunogenetic basis, as there is a positive family history of others with vitiligo in 30 -40 % of patients. There are numerous theories as to different reasons that the melanocytes (pigment cells) are not working. The genetics of vitiligo is also being studied with changes seen on certain chromosomes. 

So why doctors are not clear as to how and why Vitiligo occurs, in most cases it does seem to be slowly progressive. There is spontaneous repigmentation in 10-20% of patients, especially in sun exposed areas of young patients. 

The problem with Vitiligo is that treatment is often lengthy and is frequently unrewarding. There is not “one way” to treat Vitiligo that will ensure repigmentation and resolution. Dermatologists have used phototherapy for treatment, but facial areas and small patches seem to be most responsive. A recent study showed that narrow band UVB therapy was superior to UVA therapy, but studies continue. 

Potent topical corticosteroids are also used to help promote re-pigmentation.  Topical immune modulators such as Tacrolimus have also been tried. 

With all of this being said, a referral to a dermatologist that is familiar with treating Vitiligo is of upmost importance. The sooner the treatment for these “white patches” the better. 

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

Daily Dose

Kids Who Snore

1.30 to read

Does your child snore?  If so, have you discussed their snoring with your pediatrician.  A recent study published in Pediatrics supported the routine screening and tracking of snoring among preschoolers.  Pediatricians should routinely be inquiring about your child’s sleep habits, as well as any snoring that occurs on a regular basis, during your child’s routine visits.  

Snoring may be a sign of obstructive sleep apnea and/or sleep disordered breathing (SDB), and habitual snoring has been associated with both learning and behavioral problems in older children. But this study was the first to look at preschool children between the ages of 2-3 years.

The study looked at 249 children from birth until 3 years of age, and parents were asked report how often their child snored on a weekly basis at both 2 and 3 years of age.  Persistent snorers were defined as those children who snored more than 2x/week at both ages 2 and 3.  Persistent loud snoring occurred in 9% of the children who were studied.

The study then looked at behavior and as had been expected persistent snorers had significantly worse overall behavioral scores.  This was noted as hyperactivity, depression and attentional difficulties.  Motor development did not seem to be impacted by snoring.

So, intermittent snoring is  common in the 2 to 3 year old set and does not seem to be associated with any long term behavioral issues. It is quite common for a young child to snore during an upper respiratory illness as well .  But persistent snoring needs to be evaluated and may need to be treated with the removal of a child’s adenoids and tonsils.

If you are worried about snoring, talk to your doctor. More studies are being done on this subject as well, so stay tuned.

Daily Dose

Is it Appendicitis?

1.15 to read

Last night, a patient called me and wondered if their daughter had appendicitis. I always thought it would be the easiest diagnosis, and that we would call the surgeon and whisk the patient off to the operating room for an appendectomy, just like Madeline (one of my favorite books as a child). Well, over the years have I been taught a few things. At times the diagnosis is easy. The patient has the classic symptoms of a "tummy ache" that starts around the belly button, they may vomit a few times and have a fever and the parent in all of us thinks, "yuk, another one of those tummy viruses". But over several hours the tummy aches worsens, and moves from around the belly button (peri-umbilical) to the right lower quadrant and the nausea and vomiting persist and your child just looks SICKER. At the same time you may notice that they have a funny walk, and won't stand up straight, as they try to get to the bathroom and when possible, they move very little at all, as any movement makes the pain worse. This is classic appendicitis. For a parent, that means a phone call to the pediatrician, day or night, as that child needs to be examined. On the other hand some children just forgot to read Nelson's text book of pediatrics. They don't vomit, they may not have a fever, they are a little nauseated, but when pressed could still eat, and it only hurts in their right lower quadrant, everything else is just okay. These are the difficult cases to diagnose. These children require a lot more history, repeat exams and lab tests and may even need a CAT scan to look at their appendix. But, you don't want to miss an appendicitis, as a perforated appendix is serious and requires a lengthy hospitalization. So as a parent and a doctor, if your child's tummy ache seems to be getting worse, it may be worth a trip to the doctor to feel that tummy, run a few tests and decide how to proceed. It is not always as easy as in a book or on TV. That's your daily dose, we'll chat tomorrow!

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