Daily Dose

Migraines in Children

1:30 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

Spring Sports Injuries

1.30 to read

With the advent of spring the sport season heralds in baseball, softball, track and field.  This also means that kids need to be prepared to play.   

Professional ball players spend 4-6 weeks in spring training, preparing for the season, but for many kids the spring ball season starts without any real spring training.  Some kids have been less active during the winter, others may have been playing indoor sports, but with spring kids of all ages head outside to “play ball”.  Their bodies may not be quite ready for “full steam ahead” play.  

I am already starting to see both boys and girls coming in complaining of early muscle strains and sprains.  Kids need to get into shape with throwing, hitting, pitching and fielding increasing over time. But no one seems to understand “gradual” these days.  

Kids want to play ball and they may want to impress their coaches as well.  They are being watched to determine who plays which position, batting line up etc. which may make some athletes try to throw too much or too hard as they first start back. 

Parents (and coaches) need to encourage daily pre-activity warm up and stretching followed by light throwing to prepare the body to increase the activity and intensity over several weeks rather than days.  

Kids need to learn proper throwing mechanics which will not only improve efficiency but will control stress on the body.  The shoulder joint is held together almost entirely by muscles. Developing strength and endurance in the key muscle groups that keep the shoulder stable will help to prevent fatigue. 

The same goes for pitching.  Strict adherence to pitch counts, and well as following the recommended rest period between pitching will help to prevent overuse injuries as well. I have already seen a high school baseball player with elbow pain who admitted to me that he was pitching curve balls and fast balls, far over the number that he is supposed to. He does not realize the stress that he is placing on his body, and it is still very early in the season.  He was not thrilled that I told him he need a week off to rest before he started back and then much less aggressively. He has a few more years of high school ball before he even thinks about college baseball and needs to stay healthy. 

Remember to use ice as an anti-inflammatory as well as ibuprofen. And if shoulder or elbows already hurting, try a slower spring re-entry into throwing and pitching. 

There is an American Academy of Pediatrics policy statement on Baseball and Softball with some practical information for parents and coaches and officials.  Check it out at: http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2011-3593

Daily Dose

Get Your Baby to Sleep!

1:30 to read

How many times can you discuss newborns and getting them to sleep? It doesn’t matter how many babies you have, the biggest issue for new parents is ”when is my baby going to sleep through the night?”.  This statement is often followed by, “I have read every book and none of it seems to be working”. “What’s the trick?”  

Over the years I have realized that there is “NOT” one way or method that makes that newborn sleep through the night.  While some babies seem to lull themselves to sleep fairly easily and are sleeping in the first 4-6 weeks, most infants still awaken during the night for the first 8-12 weeks. There are also the “difficult” infants who don’t sleep through the night until 4- 6 months. But all in all...it just takes time, patience and a bit of prayer.

So, with all of this knowledge and remembering how I longed for my own babies to sleep 8-10 hours at night, I found a new article in The Archives of Diseases and Children quite interesting and thought provoking.  

Physicians have long known that it takes some time for circadian rhythm (biological sleep patterns distinguishing day and night) to develop in babies and a study done in the UK actually looked at infant’s sleep patterns between 6-18 weeks of age. They analyzed data including the infants’ body temperature throughout the night,  length of sleep a d urine samples collected am and pm to look at cortisol and melatonin levels. They also looked at the babies’ cheek swabs for circadian gene expression.  All in all a lot of data.

The findings were interesting showing that increasing cortisol secretion at night occurred around 8.2 weeks of age, followed in the next week or two by increased melatonin at night....both integral to establishing circadian rhythm.

When they analyzed body temperature, a drop in core temperature at the beginning of sleep (again maturational) they found that this occurred around 10-11 weeks.  Lastly, mature circadian gene expression was found at about 11 weeks.

So, no matter what book you read, or what your pediatrician, best friend or your own mother tells you, it is all about those hormones starting to “wake up” and regulate sleep. 

At least you know your baby is “normal”, even when everyone on Facebook “SWEARS” that their baby slept all night in the first 2 weeks. They probably either have totally forgotten or just made it up...it is all about science after all.

Daily Dose

Dealing with Pink Eye

1.15 to read

I have been seeing a lot of “gooey” red eyes which means bacterial conjunctivitis is going around.

Conjunctivitis is defined as reddening of the outermost layer of the eye, it is also called pink eye. I have to laugh when I tell a patient that their child has conjunctivitis, and the parent replies, “at least they don’t have pink eye”.  If your eye is pink then it is called pink eye, but the question arises, what is causing the pink eye?

There are several common causes for conjunctivitis in children.  Like many other illnesses, pink eye may be caused by a viral infection, a bacterial infection or allergies. There are certain physical findings that may point to the type of infection that is causing pink eye.

Bacterial conjunctivitis is more common in infants, toddlers and preschool children. Did you know that 1:8 children has an episode of conjunctivitis each year and there are 5 million cases in the U.S every year? Those little “germy” toddlers are good at touching their eyes, toys and each other and can readily spread pink eye.

Bacterial conjunctivitis typically causes a “gooey” discharge as well as matting of the eyelids. Children awaken with an eye that is “glued” shut with gunk.  It is usually present in both eyes and may be associated with an infected ear as well, so if your toddler has gooey eyes they should be examined. If they have both otitis (ear infection) and conjunctivitis they will need an oral antibiotic and not just eye drops.  

Viral conjunctivitis is more common in older children (and adults), than in the preschool set. It is also very contagious but the discharge is usually more watery. The most common cause of a viral pink eye is adenovirus (see another post) and this may cause one really red eye.

Viral pink eye is more often one sided than a bacterial infection. It is also not uncommon to have a sore throat to go along with a viral pink eye. Viral conjunctivitis does not improve with antibacterial eye drops, so if you have a pink eye and it is not getting better with antibiotic eye drops it is most likely viral in origin. I often just use over the counter artificial tears for a viral pink eye, just to help soothe the eye if the child/adolescent is “bugged” by it. No contact lenses either.

Allergic conjunctivitis is more commonly seen during allergy season. The symptoms of the allergic pink eye seem to come and go and may include itchy red eyes, watery or gooey discharge, swelling of the eye lids and area beneath the eye (allergic shiners) and a runny nose.  Sometimes the conjunctiva becomes so affected that there are even blebs present.

So if you have a child with draining pink eyes, keep up that hand washing in hopes that you are not going to catch pink eye! We can always tell which doctors/nurses and staff have succumbed to pink eye as they show up in their glasses!

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

Daily Dose

Head Flattening on the Rise!

1:30 to read

A recent study published in the online edition of Pediatrics confirms what I see in my practice. According to this study the  incidence of positional plagiocephaly (head flattening) has increased and is now estimated to occur in about 47% of babies between the ages of 7 and 12 weeks.  

The recommendation to have babies change from the tummy sleeping position to back sleeping was made in 1992. Since that time there has been a greater than a 50% decline in the incidence of SIDS. (see old posts).  But both doctors and parents have noticed that infants have sometimes developed flattened or misshapen heads from spending so much time being on their backs during those first few months of life.

This study was conducted in Canada among 440 healthy infants.  In 1999, Canada, like the U.S., began recommending  back sleeping for babies. Canadian doctors had also reported that they were seeing more plagiocephaly among infants.  

The authors found that 205 infants in the study had some form of plagiocephaly, with 78% being classsified as mild, 19% moderate and 3% severe.  Interestingly, there was a greater incidence (63%) of a baby having flattening on the right side of their heads.  

Flattening of the head, either on the back or sides is most often due to the fact that a baby is not getting enough “tummy time”.  Although ALL babies should sleep on their back, there are many opportunities throughout a day for a baby to be prone on a blanket while awake, or to spend time being snuggled upright over a parent’s shoulder or in their arms.  Limiting time spent in a car seat or a bouncy chair will also help prevent flattening.

Most importantly, I tell parents before discharging their baby from the hospital that tummy time needs to begin right away. It does seem that some babies have “in utero” positional preference for head turning and this needs to be addressed early on. Think of a baby being just like us, don’t you like to sleep on one side or another?  By rotating the direction the baby lies in the crib you can help promote head turning and prevent flattening.  

Lastly, most cases of plagiocephaly are reversible. Just put tummy time on your daily new parent  “to do list”.   

Daily Dose

Sledding Accidents

Over 20,000 children were seen in the emergency room for sledding accidents. how to keep your kids safe while still having fun.With another major snowstorm hitting most of the East Coast and blanketing the south in ice, it seems like there will be several more “snow days” with children (and their parents) home from school.

I have such fond memories of growing up in Washington, D.C. and the idyllic “snow days” spent outside with our Radio Flyer sleds.  My brother and I would head out the door for the big hill right outside of our house which would become a mecca for the sledders. The street was fairly steep and for that reason was often closed (guess they didn’t make 4 wheel drive vehicles then?), and the hill was perfect for a fast ride that was probably ¼ mile long. The ride down was glorious, the trek back up seemed VERY long.  Those were the days!  We could spend hours out there, only coming in long enough to change out of wet gloves, grab a hot chocolate, and back out we went. I must say, most of the time there was very little adult supervision, and thankfully there were no “major” injuries that I recall. With those memories in mind I decided to do a little research on sledding safety and accidents. An article in the September 2010 issue of Pediatrics reviewed sled related injuries.   Did you realize that there were over 230,000 sledding injuries reported over a 10 year retrospective period, in other words more than 20,000/year and those were only those that were seen in emergency rooms. There were probably many more that went unreported as the child was seen in an urgent care, or private practice rather than ER. Children 10 – 14 years of age were in involved in 42.5% of sledding related injuries and boys represented about 60% of all cases.  WOW! Sleds can reach speeds of up to 20-25 mph and head trauma is one of the biggest concerns.  It is reported that the head was the most commonly injured body part (I feel lucky that I survived those sled races) and that injuries to the head were twice as likely to following a collision. Children 4 years of age and younger were 4 times more likely to sustain a head injury. Other injuries reported from sled related accidents included fractures, contusions and abrasions.  In this study about 4% of cases required hospitalization and of this number nearly half were due to fractures while about ¼ were due to traumatic brain injuries. The injuries were more common when toboggans, snow tubes or discs were used than with traditional sleds that have a steering mechanism. Another interesting finding was that many of the injuries occurred due to the fact that the sled was being pulled by a motorized vehicle which resulted in more collisions. As you well know, the advent of helmets has really helped to prevent injuries from biking, and helmets are now recommended for sledding, skiing and snowboarding.    A report from the consumer product safety commission showed a 58% reduction in head injuries among children less than 15 years of age after helmets were used for skiing and snowboarding. As more and more people wear helmets for these activities one would hope to see a decrease in injuries reported from sledding. To ensure safety while sledding make sure that there is parental/adult supervision at all times. Sledding on streets should be discouraged and never sled where a hill meets a pond which may not yet be frozen. Sledding slopes should be free of tress and other obstacles that might cause collisions.  Children should sit up and face forward and never sled head first. Sleds should never be pulled by a motorized vehicle, which includes a snow mobile.  Sleds with the potential to rotate like discs (I guess that is the flying saucer of old) and snow tubes may carry significant risks, and should be discouraged. With 49 of 50 states currently reporting have snow “somewhere” on the ground make the winter sledding safety a priority and go buy a helmet and have fun. That’s your daily dose for today.  We’ll chat again tomorrow. Send your question or comments to me. I would love to hear from you.

Daily Dose

Amber Beads for Teething?

1:30 to read

What is the deal with these amber teething beads?? Suddenly so many of “my” babies are wearing these little necklaces, which are “supposed” to help with teething. I worry they are a choking hazard and I have no clue why they would help a baby get their teeth?

I have previously written about teething and the many thoughts and/or “myths” surrounding babies and tooth eruption. A baby typically gets their first tooth around 6 months of age, and they are usually the lower 2 central incisors.  But, some babies will get teeth a bit earlier and some babies will not get a tooth until 15-18 months of age. The latest age that I have seen for a first tooth to come in was 22 months, and yes that child is totally normal and has all of their teeth!

Teething gets a bad rap for causing any fussiness in an infant once the baby reaches 4 months of age.  Whether the baby is fussy day or night, it is often attributed to teeth ( prior to this age it is “gas”). But, while many babies are drooling and putting their hands in their mouth and chewing on toys, it is probably actually due to development of hand to mouth coordination rather than tooth eruption.  A baby becomes really fixated orally around this age...and this stage last until they are about 24 months...you will see, everything goes straight to their mouth!

I am sure I remember my first child’s “teething” but I am also sure I could not begin to tell you when the 3rd son got his first tooth.  My middle son was the “crankiest baby/toddler” on the planet (he is a gem now) and he did not get a tooth until he was about 15 months old, and promptly knocked out his upper middle tooth around 2!   Don’t remember pain with teeth coming in or out?!?

So, back to the amber beads...I think they are a bit like essential oils...not sure what they really do. I also worry that a baby might get tangles up in the necklace and get asphyxiated...even though they are supposed to break apart. I would NOT take the risk. 

Lastly, you don’t see 5-6 year olds wearing amber beads as they lose their teeth and get their first permanent teeth. You also don’t hear a parent make excuses for a cranky/tired elementary school aged child....”she is just behaving like this because she is teething”, sounds a bit crazy right?

We parents like to have reasons for everything...and I don’t care if you blame teeth for making a baby fussy...I am just not sure there really is a correlation and certainly not for month after month...as a child gets 20 teeth in the first 2-3 years of life.   

Daily Dose

Ear Infections: Take A Look Inside

Ear infection: make sure your doctor takes a lookMore coughs and colds today in the office and a lot of emails with questions about ears infections.

There is really not a way to diagnose an ear infection without your doctor looking in your child’s ears. With that being said, once your child reaches about the age of 9 -12 months, and they have had several colds, you get an idea if your child seems to be ‘otitis prone’. In other words, do they get an ear infection with each cold or runny nose, or have you taken them in to the doctor and they always have clear ears. Despite what ‘many mothers say’ not everyone gets an ear infection with a cold, and in fact, most children don’t.  Parents also want to ‘prevent’ an ear infection and studies continue to show that antihistamines and/or decongestants do not seem to have a role in preventing the development of an ear infection or in the treatment of otitis.  Antihistamines and decongestants also have side effects and are not recommended to use in children younger than 5-7 years. Once your child is older and they may now be able to tell you that their ear hurts (typically 2 and older), they still need to have their ears looked at. Ear pain (otalgia) is not always due to an infection of the middle ear.  There are many times that a child (or adult) will complain about their ears hurting, but they may have referred pain from a sore throat, or they may have fluid behind the ear drum (serous otitis) and feel as if their ears are full, but they are not infected.  I also see teens who complain of ear pain and may be grinding their teeth. All ears that HURT are NOT due to an infection. A new approach to treating ear infections in a child over 2, who is not ‘otitis prone’ and does not appear to be terribly sick is to treat the painful ear with pain relieving ear drops and oral Tylenol or Motrin.  This is termed “watchful waiting”. There have been several studies, in older children, to compare immediate versus delayed antibiotic treatment.  The studies to date have shown little difference in symptoms by watchful waiting and may indeed limit unnecessary antibiotics.  There is still the need for further research in this area, but I  must say, I have used this approach in a lot of children. I will write the antibiotic prescription as well as a pain relieving ear drop and instruct a parent to wait a few days before filling the antibiotic. If their child is improving they will not need to even take an antibiotic. I really have had a lot of success with this approach, but only in older children, who do not seem to be very ill.  More to come on this issue. One last point, I do not recommend that parent’s buy an otoscope to try and diagnose an ear infection at home.  Looking in ears (otoscopy) is one of the hardest things to learn during residency. It takes thousands of ears to be seen to become really proficient in examining an ear drum. It really is practice, practice, just like many other professions. If you really think that your child’s ears are infected, you must let your pediatrician take a look. Surely we will have a better method someday?? That’s your daily dose. We’ll chat again soon.

Daily Dose

Ear Tugging & Your Child

1.15 to read

I see a lot of parents who bring their baby/toddler/child in to the pediatrician with concerns that their child might have an ear infection. One of the reasons for their concern is often that their baby is tugging on their ears.  

Babies find their ears, just like their hands and feet, around 4 -6 months of age.  I guess a baby must think “this ear tugging is fun and feels good” as maybe babies have “itchy” ears just like adults. It also seems to be a self soothing habit for other children who seem to pull on their ears when they get tired and cranky.  Maybe it is related to new molars coming in at the back of the jaw line?   

Whatever the cause, it often concerns parents who are told by their friends or relatives, “I am worried, this ear pulling probably means the child has an ear infection”.  So, being a good parent off you go to your pediatrician only to find out that the ears a beautiful and clear! 

Most babies and children do not get an ear infection without ANY other symptoms besides ear pulling.  In most cases infants and toddlers will get a secondary ear infection during cold and flu season. The multitudes of viral respiratory infections that children get in the first 3 years of life, often cause continuous runny noses and congestion. This congestion causes fluid to build up in the middle ear space which connects to the nasal passages via a small canal called the eustachian tube.   

Infants and children have so called “immature” eustachian tubes that are soft, and don’t drain well and the tube gets inflamed and swollen from the viral infection as well.  At times this fluid gets secondarily infected from bacteria that find their way to the middle ear.  Voila....an ear infection ensues. 

So, if a parent brings their child in for “pulling on their ears” and they are otherwise well (no cough, congestion, runny nose and sleeping well) I usually ask if they want to “wager” if their child has an ear infection.  That is really not fair, as this sweet parent is only concerned because typically someone else told them they should be.  But, in this case a quarter bet is usually made and I end up with a lot of quarters.  (they are good for all of the other bets I do lose with parents and kids about all sorts of things). Friendly betting at the pediatrician’s office, wonder if I am going to be investigated! 

Don’t worry about simple ear pulling especially when you see it happening all of the time.   

Lastly, with the new guidelines for prescribing antibiotics for an ear infection parent’s don’t need to worry as much about a prescription for antibiotics and a few days of waiting will not hurt.  


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Why you should never use a kitchen spoon to measure medicine.