Daily Dose

What Are Breast Buds?

1.15 to read

I received a phone call today from a mother who was worried about the “bump” beneath her 12 year old daughter’s nipple. I do get this phone call quite often and even see mothers and daughters in the office who are concerned about this lump?  First thought is often, “is this breast cancer?”  The answer is a resounding “NO” but rather a breast bud.  While all mothers developed their own breast buds in years past, many have either forgotten or suppressed the memory of early puberty and breast budding.

Breast buds are small lumps the size of a blueberry or marble that “erupt” directly beneath a young girl’s areola and nipple. Most girls experience breast budding somewhere around 10-12 years of age although it may happen a bit sooner or even later. It is one of the early signs of puberty and estrogen effects.

Many girls will complain that the nipple area is sore and tender and that they are lopsided!! It is not unusual for one side to “sprout” before the other. Sometimes one breast will bud and the other is months behind. All of this is normal. 

While a lump in the breast is concerning in women reassure your daughter that this is not breast cancer (happy that they are so aware) but a normal part of body changes that happen to all girls as they enter adolescence.   Breast budding does not mean that their period is around the corner either, and periods usually start at least 2 years after breast budding (often longer).

Breast buds have also been known to come and go, again not to worry. But at some point the budding will actually progress to breast development and the continuing changes of the breast during puberty.

Reassurance is really all you need and if your daughter is self-conscious this is a good time to start them wearing a light camisole of “sports bra.”  

Daily Dose

Sore Throat or Strep?

1.30 to read

Fall weather is finally here across most of the country and with the new season, and school back in session, the first fall colds have hit.  I am already seeing a lot of runny noses and coughs, many of which are in the toddler and preschool set who still haven’t learned to cover their mouths when coughing (don’t worry, not yet age appropriate behavior, it takes some time to learn). 

With the common cold, or upper respiratory infection it is also not uncommon to have a sore throat.  Many parents worry that every sore throat is strep throat which is a bacterial infection.   A new article in the journal Clinical Infectious Disease published guidelines for doctors to help determine when it is appropriate to test for strep throat and use antibiotics when strep is confirmed. 

Studies have shown that up to 70% of patients who complained of a sore throat received antibiotics which are not necessary when the sore throat is due to a viral upper respiratory infection.  Strep throat is most common in children, where it accounts for between 20-30% of sore throats (and only 5-15% of adult sore throats). Strep is less common in children under the age of 3 years, and is most common during the elementary school years. 

Most viral upper respiratory infections cause runny nose, coughs, sore throat, hoarse voices and the symptoms develop over several days. In the case of strep, there is usually a rapid onset with a fever and cough and runny nose are not present. The child typically has very swollen and tender nodes in their neck as well. 

If a child is suspected of having strep throat a quick throat swab should be taken and a rapid strep test should be performed. These tests are performed in almost every doctors office. If the swab is negative for strep it may be sent for overnight culture as well.  Even the most seasoned doctor is not always correct in assuming a beefy red throat is strep.  If strep is confirmed an antibiotic, typically Amoxicillin is prescribed (unless the child is penicillin allergic). 

Antibiotic overuse for viral sore throats can lead to more drug resistance which continues to be a problem across the country.  With few new antibiotics in the pediatric pharmaceutical pipeline, it is important that doctors screen for strep only when the symptoms and physical exam point towards a bacterial cause for the sore throat.  It will be important to educate the parent and child as well, as not every sore throat requires a throat swab, and popsicles and Slurpees may soothe a sore throat and taste better than an unnecessary antibiotic. 


Daily Dose

How to Treat A Vomiting Child

We are definitely in the throes of "sick season" in our office and with that comes a lot of kids with vomiting. I remember the first time that one of my own children vomited.

We were in Target, he was about two and he had said he "was sick". Now, seeing that he was not very specific and did not elaborate, I just went on shopping. Several minutes later, as he sat in the cart (with seat belt fastened), he just looked at me wide eyed and suddenly vomited. This is the moment as a parent that you understand the difference between babies that "spit up", and true, projectile vomiting! Now what do you do once your child has vomited (besides rush out of Target as fast as you can)? Once a child has vomited it is important not to give them anything else to eat or drink, for at least 30 to 45 minutes. That means even if they are "begging" for a drink, as you will probably see it come right back at you if you do. After waiting, you want to begin re-hydrating with clear liquids. Not a good idea to pull out the milk or food yet. In an infant you can use Pedialyte, which is an oral electrolyte solution, and instead of breast milk or formula you can try feeding your infant about an ounce of Pedialyte every 10 to 15 minutes and see if they can keep Pedialyte down. In toddlers and older children I use Gatorade, as it is not quite as "salty" and kids seem to take it better. Again, frequent small sips of Gatorade while you wait to see if the vomiting is persistent. Don't go too quickly on giving them larger volumes. The key is small amounts, frequently, which are easier to handle. As your child keeps down the Pedialyte or Gatorade you can increase the volume that they are taking and decrease the frequency. The main thing you are trying to do with a child of any age is to keep them from getting dehydrated and their vomiting is typically due to a viral illness affecting their GI tract. Because it is typically a virus that is the culprit for nasty vomiting, it just takes time to get through the illness. There is no "miracle" cure, and watching your child vomit, or cleaning up the vomit that invariably is usually not in the toilet, is one of the worst parenting jobs. That being said, there are very few children who will not experience vomiting at least once or twice during their childhood, so you need to keep "clear liquids" on hand in the pantry. Having powdered Gatorade around is a lifesaver at 2 a.m when your four-year-old wakes up and throws up. If you are giving the clear liquids, and your child tolerates larger volumes, but then vomits again later on, you just back up and start all over with smaller amounts more frequently. It is somewhat like a "balancing act" to give enough that they are hydrated, but at the same time to not give too much at one time that they vomit again. Slow and steady is the mantra. You should always be looking for your child to have tears, a wet and moist mouth (put your finger in there, it should come out with some saliva on it), and urine. It is often hard to tell if a child in diapers has had a wet diaper as they will not be "soaking" the diaper and smaller amounts of urine are "wicked" with the new super absorbent diapers. Children will also be pitiful after vomiting and may seem "lethargic" to you, but if they are an infant and can smile and make good eye contact or they are an older child who can tell you they feel terribly and don't want to drink Gatorade or play with their blocks they are probably not dehydrated. If in doubt, give your doctor a call to discuss what is going on. After using Pedialyte and Gatorade, and your child has not vomited for six to eight hours you can try adding some formula or breast milk, or other liquids such as chicken soup or a Popsicle. I still would not start solid food until the child has kept down other liquids. We parents all worry if our children don't "eat" but the fluids are the important part, and as we all know, a day without out chicken nuggets or peanut butter will be okay. Keep up the fluids!! If your child continues to vomit despite your best efforts with "slow and steady" fluids you need to call the doctor. We have plenty of patients that we see everyday to make sure they are hydrated, and to even watch them while they take fluids in our office. Occasionally, when all else fails we will have to hospitalize a child for IV hydration. Oh yes, remember to wash your hands frequently as these nasty viruses are contagious and parents will often find themselves getting sick after their children. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Diagnosing Diabetes

1:30 to read

After just wrapping up National Diabetes month, it seems a good time to review the fact that type 1 diabetes, formerly known as juvenile onset diabetes (JODM) is diagnosed in about 13,000 children every year. In type 1 diabetes the pancreas stops producing insulin, which is the hormone that is necessary to take glucose (sugar) from the bloodstream into the cells, which then provides the body energy.  Without insulin a person’s blood sugar continues to rise, which causes a myriad of effects.  In children the symptoms are increased thirst, weight loss (despite an increased appetite), new onset bedwetting, fatigue, and lethargy.  It is myth that children who eat a lot of sugar are at risk of developing diabetes, but it is known that there seems to be a genetic pre-disposition to developing diabetes, and there may also be a viral trigger involved.  Interestingly, type 1 diabetes is more commonly diagnosed during winter months when there are more circulating viruses.  

Type 1 diabetes, a lifelong disease, is treated with insulin. It was not uncommon to have children giving themselves 2 -3 shots of insulin a day. With improved delivery and monitoring systems many children with type 1 diabetes are now using insulin pumps which provide different amounts of insulin which can be programmed throughout the day.  There are also ongoing studies with pancreas and islet cell transplants as well as stem cell transplants, so stay tuned for new developments in the fight to cure type 1 diabetes.

Type 2 diabetes was previously thought to occur only in adults, but over the last decade there has been an increase in cases among children and notably adolescents. This is thought to be due to the increased incidence of obesity in children, which is a contributing factor to developing type 2 diabetes. In this case, while the pancreas continues to make insulin, it seems that body cannot use the insulin efficiently and the pancreas cannot keep up. This again causes the blood sugar to rise.   In this case many people do not realize that they are slowly developing diabetes and do not have the same symptoms as a child with type 1 diabetes.  One of the early signs may be a rash (acanthosis nigracans) which appears as thickened darkened skin along the nape of the neck or under the arms. 

For many children with type 2 diabetes losing weight and having a regular exercise routine will help to improve blood sugar levels and they may never require insulin.  But, this requires a commitment to lifetime lifestyle changes. 

Lastly, the days of totally restrictive diets for diabetics is “old news” as researches have found that a well balanced diet including some carbohydrates and fats, as well as portion control, are the key to maintaining healthy blood sugars.  This sounds like a healthy meal plan for everyone!

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.  

Daily Dose

Middle Ear Issues

1:30 to read

I just read a really intriguing study on children who have persistent middle ear fluid (otitis media with effusion) in The Canadian Medical Association Journal. Persistent middle ear fluid is fairly common and is often a reason that children will undergo a day surgical procedure to insert tympanostomy tubes (ear tubes).  In fact, my 11 month old granddaughter just had tubes placed.

The treatment for middle ear fluid is often to just “watch and wait” and in many cases the fluid will resorb on its own and the problem is solved. But for persistent fluid surgery was often recommended. For older children I often would see if they could learn the “valsalva maneuver” which would increase the pressure in the nasopharynx and help open the eustachian tube. This is the same maneuver you use to “pop” your ears after an airplane flight.  The only problem is that some children don’t seem to be able to understand how to do this as there is not a way to really let them know how it feels when performed correctly.

In this study, 300 children aged 4 -11 years who had had recent ear symptoms and persistent fluid in one of both ears were randomized to “usual care” or were taught to use a nasal balloon.  The nasal balloon with auto inflation is a device which is inserted into one nostril while occluding the opposite nostril and the child blows up the balloon through their nose. By doing this they increase the pressure in their nasopharynx and open up the eustachian tubes and clear the fluid.  Genius…. the child can see that they are doing the maneuver properly as the balloon blows up….and it is both painless and fun!!

In the study the children, used the nasal balloon 3 times a day for up to 3 months and they were more likely to “achieve normal middle ear pressure” than the children who did not use the auto inflation balloon.  

This is certainly low cost and can be taught in the pediatrician’s office with minimal time and effort for both parent and child. Who wouldn’t want to try this rather than have a surgical procedure?

I am now going to look into where to purchase this product (wish I had thought this up) and try this on some of my own patients. I am sure there are plenty of kids that would love to blow up a balloon with their nose…perfect for a show and tell demonstration as well!

Daily Dose

Start the New Year Stress Free

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With the start of another New Year and a long weekend ahead we have an extra few days of relaxation and reflection before "really" beginning 2016. The "down time" after the holidays is important for everyone and the best way to start the New Year is being well rested and less stressed. I envision 2009 starting off stressful enough due to the economy, job loss or salary cuts for many parents and all of the ensuing issues that brings. So this is a year to commit to ways to reduce stress, before it even starts. There are certain things we cannot control, but we can all improve our stress levels by doing things that have been proven to be stress reducers. This includes healthy eating, good bedtime routines and exercise.

For some people, these things are already their routine, but for most of us we can improve in any one, or maybe all of these areas. This is not only for parents but also for kids, as stress in children is also on the rise. Ask any pediatrician and they will probably agree that they see more kids today with anxiety manifesting as headaches, sleep disturbances, stomach aches, and adolescents who complain of chronic fatigue. The best medicine for this is teaching relaxation and stress reduction as a routine part of family life. Less medication and more meditation may be the best prescription that a doctor can give you. A new routine in the day may be family morning meditation or evening yoga and deep breathing exercises. Be creative and start the year with a plan.

As we all begin 2016 let's commit to time spent on family stress reduction. That's your daily dose, we'll chat again soon.

Daily Dose

Zika Virus

1:30 to read

If you are pregnant or planning on becoming pregnant in the near future you need to be aware of the Zika virus.  This virus is spread via the Aedes mosquito (as is West Nile Virus, Dengue fever and Chikunguyna), and has been found in Africa, Southeast Asia, the Pacific Islands , South America and Mexico.  The Zika virus was also just confirmed in Puerto Rico and the Caribbean in December.  There are new countries confirming cases of Zika virus almost every day, as the Aedes mosquito is found throughout the world.  

When bitten by a mosquito that has the Zika virus, only about 1 in 5 people actually become ill.  The most common symptoms are similar to many other viral infections including fever, rash, joint pain and conjunctivitis.  For most people the illness is usually mild and lasts for several days to a week and their life returns to normal.  Many people may not even realize that they are infected. 

Unfortunately, if a pregnant mother is infected with the Zika virus, the virus may be transmitted to the baby.  It seems that babies who have been born to mothers who have been infected with the Zika virus may have serious birth defects including microcephaly (small head) and abnormal brain development. There have been more than 3,500 babies born with microcephaly in Brazil alone…and just recently a baby was born in Hawaii with microcephaly and confirmed Zika virus. In this case the mother had previously lived in Brazil and had relocated to Hawaii during her pregnancy.  The virus to date has not been confirmed in mosquitos in the United States.

Because of the association of the Zika virus and the possibility of serious birth defects, the CDC has announced a travel advisory stating, “until more is known and out of an abundance of caution, pregnant women in any trimester, or women trying to become pregnant, should consider postponing travel to the areas where Zika virus transmission is ongoing”.  

Should pregnant women have to travel to these area they should follow steps to prevent getting mosquito bites during their trip. This includes wearing long sleeves, staying indoors as much as possible, and using insect repellents that contain DEET.

Researchers are continuing to study the link between Zika virus and birth defects in hopes of understanding the full spectrum of outcomes that might be associated with infection during pregnancy. There will be more data forthcoming.

At this point the safest way to avoid being bitten is to stay away from the countries who have had confirmed cases of the Zika virus.  But as the weather warms up in the United States and mosquitos become more abundant there is concern for Zika virus to be found here.  It only takes one infected mosquito to bite one person who then contracts the virus….should that person be bitten by another mosquito, that mosquito may acquire the infection and so it spreads.  There is not known to be human to human transmission of the virus.

Daily Dose

Treating Motion Sickness

With spring break under way, I seem to be getting some phone calls from patients of mine who have been on the road travelling and dealing with a child with motion sickness.Many areas around the country are enjoying spring break. What's interesting this time of year and during the summer months, is the amount of calls I receive from patients of mine who have been on the road travelling and dealing with a child with motion sickness. Whenever I get calls like this it brings back memories of my own children and episodes of throwing up in many different locales, YUCK!  

So, maybe this will help you be better prepared than I was when this first happened to our family while riding in the infamous minivan. The most common cause of motion sickness is car sickness, but children may get sick while on airplanes or boats too. It seems that about 58% of children between the ages of four and 10 experience the symptoms of car sickness. Younger children are also affected, but may not be able to verbalize the sensations of motion sickness. It seems to be due to an increased sensitivity to the brain’s response to motions. The brain receives signals from the motion-sensing parts of the body (the eyes, the inner ear, and the nerves in the extremities), and in most situations all three areas respond to any motion. When the signals the brain sends and receives are in conflict, (typically between the ear which senses movement, while the eye does not), the symptoms of motion sickness occur. The signs of motion sickness usually start with a slight feeling of queasiness: “I have a stomachache” is heard from the backseat of the car. Dreaded words to any parent. In some cases children can be sick before you have even gotten out of town and on the highway. The initial nausea is then followed by a cold sweat, fatigue and loss of appetite. A younger non- verbal child may just become restless, pale, sweaty and cries. At some point these symptoms are usually followed by vomiting. By then you have figured it out! The best treatment for motion sickness is like many things: prevention! If you have already experienced motion sickness with your child plan ahead for trips. If your child is over the age of two, place them in their carseat in the middle of the backseat and face them forward. Provide a small nutritious snack prior to the trip rather than a big meal, and avoid dairy (there is nothing worse I can assure you from personal experience). Open the windows to provide fresh air. Do not let your child play video games or read while the car is in motion, Try to distract them by singing or talking. Sleeping may also be helpful, so at times you may plan your trip around naps and bedtime. Frequent stops for a child who is feeling sick are a necessity. Letting them lay flat for a few minutes while the car is stopped and even applying a cool rag may make them feel better. Try small sips of carbonated beverages or crackers to help the nausea. Some children who have a tendency to get sick may do well if they are pre-medicated for a trip with either Dramamine or Benadryl. Although these medications typically cause drowsiness, some children may have the opposite reaction and become agitated. You might want to try them prior to a trip. Check with your doctor about dosages. Lastly, be prepared and have zip lock bags and hand wipes available in case of emergency. This will make everyone in the car a little happier. That’s your daily dose, we’ll chat again tomorrow. Send your question or comment to Dr. Sue!



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