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Daily Dose

Hand, Foot & Mouth Disease is Back

I have been seeing a lot of cases of "hand, foot and mouth disease" (HFM) in the office. This illness is usually caused by a Coxsackie virus A-16, a member of the enteroviral family. These viruses are typically seen in the summer and early fall. Don't worry, this illness is not related to "hoof and mouth" disease seen in animals.

Hand, foot and mouth disease is most common in younger children and often is seen in the toddler crowd. You can see "hand, foot and mouth" in older children, but most children have had it at younger ages and are immune as they get older. It is not unusual to have outbreaks of HFM in child-care centers or pre-schools. How is Coxsachie virus transmitted?  Person-to person contact as well as from contact with contaminated surfaces. The incubation period from time of exposure is about three to seven days. The typical child with HFM will present with fever, which is often fairly high. If seen early in the illness they may not have any other physical findings but over several days they will develop a sore throat with painful sores on the tongue and throat. Several days later they may develop the classic small, red, blister like lesions on their palms, soles of feet and often in the diaper area. When they have all of the symptoms it is an easy diagnosis, but not everyone who gets Coxsackie virus will have every symptom. Sometimes you see a child with the classic rash on palms and soles, but they have never had fever or even felt badly, lucky for them! One of the most common complaints may be drooling and irritability in a child with fever as the mouth and throat are sore, even before the classic lesions appear. Because this is yet ANOTHER viral infection, there is no specific treatment and antibiotics won't help. Keeping your child comfortable with Tylenol or Motrin/Advil will help with both fever and pain. This is a good time to try things that would help soothe a sore throat, things like ice cream, popsicles, pudding, Jell-O and even a Slurpee, especially in a child who is refusing fluids. The main concern is keeping your child hydrated during the illness. Once your child is fever free for 24 hours and feeling better they may return to child-care or school. The small lesions on the palms and soles will clear over the next five to seven days. The best way to prevent others from getting sick is with good old hand washing. That's your daily dose, we'll chat again soon.

Daily Dose

Summer Skin Infections

1:30 to read

I have been seeing a lot of skin infections and many of these are due to community acquired methicillin resistant staph areus (caMRSA). The typical patient may be a teen involved in sports, but I also see this infection in young children in day care, or summer camp. The typical history is “I think I have a spider bite” and that makes your ears perk up because that is one of the most common complaints with a staph infection, which is typically not due to a bite at all.

The poor spider keeps getting blamed, and how many spiders have you seen lurking around your house waiting to pounce? The caMRSA bacteria is ubiquitous and penetrates small micro abrasions in the skin without any of us every knowing it. The typical caMRSA infection presents with a boil or pustule that grows rapidly and is very tender, red and warm to the touch. The patient will often say that they “thought it was a bite” but the lesion gets angry and red and tender very quickly and typically has a pustular center.

For most of us pediatricians, you can see a lesion and you know that it is staph. It is most common to see these lesions in athletes on exposed skin surfaces such as arms and legs, but lesions are also common on the buttocks of children who are in diapers in day care. The area is angry looking and tender and the teenage boy I saw the other day would not sit on the chair, but laid on the table on his side as he was so uncomfortable. If the lesion is pustular the doctor should obtain a culture to determine which bacteria is causing the infection, but in most cases in my office the culture of these lesions comes back as caMRSA or in the jargon Mersa. When I say Mersa, I often cause widespread panic among my patients, but in most cases to date these infections may still be treated with an oral antibiotic that covers caMRSA, such as clindamycin or trimethoprim-sulfa. Many of the lesions improve dramatically once the site is drained and cultured. I will reiterate that if possible you want your doctor to obtain a culture to identify the bacteria that is causing the infection.

To prevent caMRSA remind your student athlete not to share towels, clothing or other items. Make sure that common areas are disinfected and once again encourage good hand washing. The closure of schools or disinfecting an entire football field or area with turf is not recommended. Lastly, this is a good reminder that you only want to take an antibiotic for a bacterial infection and that overuse of antibiotics leads to resistance. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Swim Lessons Can Reduce Risk of Drowning

1:15 to read

Now that hot weather is with all of us, the issue of childhood drowning is an ever-present concern. The American Academy of Pediatrics recommends that after the age of five years, all children be taught to swim. The AAP does not recommend for or against swimming lessons as a measure to prevent drowning in children younger than five years. Between 2000 and 2005, 6,900 children died from non-boating accidental drowning. The rate of drowning was almost four times higher for children one to two years of age, and twice as high for those younger than five.

An article in Archives of Pediatric and Adolescent Medicine looked at the association between swimming lessons and risk of drowning specifically in the one to four year old age groups. Previous concerns had been raised about the potential for swimming lessons to increase the risk for drowning in younger children. This study provided good news that kids aged one to four who have taken formal swimming lessons have an 88% less risk of drowning. Researchers found that only three percent of the children who had drowned had taken swimming lessons. So with this news, it might be prudent to start swimming lessons at a younger age than previously thought.

But swimming lessons alone will not prevent drowning and even in this study, many of the older children who drowned were noted to have been proficient swimmers. It is still important to have other drowning prevention strategies in place including pool fencing (some parents with pools feel like their child will not be able to unlock a door and head to the pool and do not have a fence in place, and I totally disagree with that argument), constant and age appropriate adult supervision and training in CPR. Children are amazing at finding ways to unlock doors, and windows that lead outside and no parent can know where their child is for every minute of the day. If you have a pool and a child is missing always check the pool first, as a child can quietly slip into the water and lose consciousness in as little as two minutes and drown in five minutes.

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

Daily Dose

College Students & Drugs

1:30 to read

It is the end of the school year and therefore there seems to be a great deal of stress among students of all ages. I am especially seeing this in some of my college students…..who seem to be making some rather dangerous choices in order to “help them cram for finals” and “stay awake”.

In the past few weeks I have had several students who have purchased or somehow procured a variety of drugs that were “purported” to aid in their studying for finals.  While there has been a great deal in the news about opiod addiction in young adult males, some of my patients have preferred other drugs that are seemingly available and acquiring them illegally.  

The on line drug scene, as well as the drug dealing among students, seems to be a growing problem among some college students.  While I have known that there was a great deal of alcohol and weed being used and abused, I suddenly feel as if I am getting more calls about patients, typically male, being taken to the ER after trying a combination of drugs, which were purportedly being taken to help them study, stay awake, curb anxiety and “succeed in school”.

So, what to do when you realize you have a test in a few days, or a paper that is due and you are “freaking out” as you are not prepared?!?!  Your roommate, or friend in the dorm, or even a complete stranger on line offers you an option - why not take a “stimulant”,  the preferred drug seems to be Adderall  (which was not prescribed for you) and chase it with an anti-anxiety drug   (Xanax, Valium or Ativan) then add in some alcohol when you need to chill or get some sleep. Some have even bought an unknown drug that is also supposed to curb anxiety and relax you (on line fake quaaludes)? This same scenario may occur over a few days or even weeks. While these patients thought they were “fine” and ready for class the next morning they were not!  In several cases these “crazy, stupid boys” suffered a grand mal seizure..never making it to class. Truly they are lucky to be alive the way they combined all of these medications.

Neither of my patients had ever had a history of seizures and were otherwise healthy.  Thankfully, they both recovered without problems.  But, they both admitted to me that they were just one of many who were doing the same thing.  Why they asked, did they have “adverse effects” from this lifestyle, when lots of their friends seemed to be fine….really??? I don’t even have words to try and answer this.

When I probed about how they “acquired” these drugs they said they are for sale in the dorms or on line and basically all over their campuses…..and these students attended what would be called “good” colleges. I have asked several kids who were already home from school about this and they too had heard some similar stories….and were aware of drugs being readily available, but had not partaken.

So, when your college student gets home you might take the opportunity to ask some questions about their college experience and if they are aware of these drugs …and remind them of the fact that taking ANY drug which is not prescribed for them is dangerous.  I have discussed binge drinking before and warn all of my student/patients that drinking excessive alcohol to “get drunk and pass out” can kill you from alcohol poisoning. But after hearing these stories and dealing with my own patients and their visits to the ER I am adding more information to my check ups with college students.  Mixing alcohol  and drugs has always been risky….but now the availability of these drugs is nothing but scary…..BE WARNED.  

Daily Dose

Keeping A Good Bedtime Routine

As I wrap up sleep week, another common question I get from parents is how to have a consistent bedtime for children when your own schedule is not consistent. I think it is best for kids to maintain some sort of schedule as they do well with knowing expectations and consistency, and that goes for bedtime routines too.

That being said, if your schedule is inconsistent does that have to mean that your child’s is too? Not knowing the age of your child makes it a little harder. For a younger child bedtime can be at the same time but may have to be with a different caregiver, like a your-babysitter, spouse, or even having an older sibling help with the bedtime routine. I often got home later than I would have liked, and missed the bedtime routine with my kids when they were young, but felt it important enough that they went to bed on time that I would only get a goodnight hug and kiss long after they were asleep. On other days I made it a point to be able to be home for bedtime so that we had that experience together, even if only one night a week and weekends. With older kids, even if your schedule is inconsistent, I would let them know the expectations of bedtime and lights out, even if that meant that I was going to have to call them to check in that this was happening. I also utilized a college student to come over in the evening to supervise the evenings and bedtime when necessary in order that my crazy schedule or my husband’s travel schedule did not disrupt most bedtimes. There are so many studies that re-iterate the importance of bedtimes and good sleep to promote school readiness, attention in class, academic performance and success in kids that I tried to make their schedules as consistent as possible. That wraps up a special week focusing on sleep. We’ll chat again soon.

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Daily Dose

Your Child's Sitter

1:30 to read

Do you ever leave your child with a babysitter or caregiver? Weird question right? But some parents never want to leave their child with someone else....and I am not sure that is healthy for either parent or child.   

I recently had this discussion with parents of a 3 year old child who was having a terrible time with separation anxiety. While many children go through stages of separation anxiety, by the time a child is 3-4 years they are typically past this stage. When I was talking with this family they told me their child had never been left with anyone.  

I guess as a working mother I was incredulous. What? Had the parents never gone out to dinner or to a party, a concert, lecture  or even on a night away for some much needed “couple” time?  They told me that they would occasionally call in grandparents but typically took their child everywhere with them.  (I think there are many places such as movies, adult restaurants, and other venues that might not want the 2 year old in tow).   I suppose some would say the child was fortunate, but I really believe that as a child reaches age 2ish they need to begin learning to separate from their parent. Not for days or weeks, but for either a play group, a pre school program, the gym nursery or something where the child is learning a bit of independence.   

While some parents are quite fortunate that they don’t have to leave their child to go to work every day, the concept of leaving your child for any hour or two with a trusted babysitter should not cause anxiety for the parent and ultimately not the child. Separation is an important milestone, as your child learns that while you may leave for an hour or two, you always return. There is security in that knowledge. They will also learn how to interact with  other adults and children, which is often different than they do with their own parents.  (Ask any teacher about that phenomena). 

Autonomy and independence are typically traits that parents desire for their children.  Parents also need to have some autonomy as well.....I think this makes for a better parent child relationship in the long run.  Little steps in separating become bigger steps as a child grows older....starting with a babysitter or nursery for an hour or two on occasion is often the beginning. 

Daily Dose

Wheezing & Respiratory Distress

2.00 to read

What is that hissing noise in the air? Plenty of wheezing and coughing ushering in upper respiratory season.  With all this noise, I’m on the lookout for respiratory distress. As I start to see more and more sick kids, my office becomes a cacophony of coughing.  While many of the coughs sound horrible, fortunately most of the children I will see do not have any real respiratory distress.

I will spend a lot of time this respiratory season talking to parents about respiratory distress and what to watch for. Just like so many things in parenting, observation is the key. Watching your child’s breathing when they are coughing or even wheezing is the most important thing you can do. But knowing what is “distress” or “shortness of breath” really often means you need to know what to look for.  

I just saw a precious little girl in the office, my first patient of the morning. She had a history of a few episodes of wheezing, and did have a nebulizer and medications at home. She had been well all summer and the mother hadn’t thought about wheezing, but noted that her daughter started to cough over the weekend and had then gotten worse and had coughed all night, which made her come to the office bright and early the following am.

When I walked into the room I immediately could see that the little girl was in a bit of respiratory distress. Not only was she coughing (which every other patient seems to be doing), she was also retracting or “pulling”.  She was still happy and playing but you could see that she was “working” to breath. Her tummy was moving in and out and you could see her ribs pulling in and out a bit. She was still well oxygenated and pink.  

Her mother had not looked at her chest and had forgotten about her daughter’s nebulizer (you know, out of sight out of mind), as she had not used it for 6 months and was not “clued” back into coughs and respiratory season.

A quick review and she remembered what we had discussed last winter and realized that she should have pulled out the nebulizer over the weekend. It is repetition that makes you remember “the home wheezing action plan” and if you only do it once a year it is easy to forget.

Any time your child is coughing, whether they are 2 days or 20 years old, you want to look at their color (pink, not blue) and at their chest. You want to see if they are using their ribs or tummy to breathe. The sound of the cough is not as important as LOOKING at their chests. Whether it is during the day or the middle of the night, take off their shirts, (turn on a light) and look. That is what your pediatrician is doing throughout the season.

Any type of retractions, pulling, or respiratory distress means a phone call and visit to the doctor or ER.  Coughs are usually okay, but never respiratory distress.

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

Daily Dose

Have Your Child's Blood Pressure Checked

1:00 to read

When you take your child in to the pediatrician for a check-up do they check their blood pressure? The American Academy of Pediatrics (AAP) recommends that children, beginning at the age of three years, should routinely have their blood pressure checked.  

In certain circumstances a younger child should have their blood pressure checked too. With the growing epidemic in obesity, pediatricians are seeing more children with abnormal blood pressure readings. It is important that the right sized blood pressure cuff is used for measuring a child’s blood pressure. There are standards for blood pressures for different age children. The standards are also based on a child’s height.

When a child’s blood pressure reading is greater than the 90th percentile for their age they are said to have pre-hypertension. The prevalence of childhood hypertension is thought to be between one and four percent and may even be as high as 10 percent in obese children. Obesity plays a role but, related to that is also inactivity among children, diet, and their genetic predisposition for developing high blood pressure. Then it is appropriate for further work up to be done to evaluate the reason for the elevation in blood pressure.

If I find a child with a high blood pressure reading during their physical exam, it is important to re-take their blood pressure in both arms. I also do not depend on automated blood pressure readings, as I find they are often inaccurate and I prefer to use the “old fashioned” cuff and stethoscope to listen for the blood pressure. If the blood pressure reading is abnormal, then I have the child/adolescent have their blood pressure taken over a week or two at different times of the day. They can have the school nurse take it and parents can also buy an inexpensive blood pressure machine to take it at home. I then look at the readings to confirm that they are consistently high. The “white coat” syndrome, when a doctor assumes that the elevated blood pressure is due to anxiety, may not actually be the case, so make sure that repeat blood pressures are taken. If your child does have elevated blood pressure readings it is important that further evaluation is undertaken, either by your pediatrician or by referral to a pediatric cardiologist.

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

Daily Dose

TV & Tragic Events

1:30 to watch

It was with much sadness and disbelief that I found myself watching the news of yet another senseless tragedy where 14 innocent victims in were “shot in cold blood” for no apparent reason except for being in the wrong place at the wrong time.  This shooting in San Bernadino is becoming all too common and how do you discuss these weekly or monthly shootings with your children. I have found myself discussing this issue all too frequently with families.

The statistics surrounding “random” shootings in the U.S.  in the last several years are staggering and it seems that we are becoming all to used to “breaking news” with yet another shooting in malls, movie theaters, workplaces, and schools.  The pictures from one disastrous event are barely off of the news and screens before another one occurs. 

How do you talk about your children about these events? How do you even begin to explain to them that these events should not keep them awake at night or cause them to have bad dreams or nightmares, when these attacks are causing so much concern and even nightmares for their parents? It is a difficult, but unfortunately necessary discussion for families.

Our children need to feel safe and secure and that is the primary role of parents.  We all want to protect our children but at the same time prepare them for the “real world”.  So, discussions surrounding these news events should be tailored to a child’s age.  If you are fortunate to have very young children my hope is that they are unaware of the recent events that have blanketed the news.  I am still convinced that having constant news replaying the horrific events of the day is not healthy for anyone. So….with that being said, turn off the TV.  Even if you think the news is  “only on in the background”, your children are aware of the pictures that replay of bloodied bodies, terrified adults and children, SWAT teams and sirens.

If your children are older then they have probably seen the breaking news and have watched the situations on their social media sites as they evolved. In this case, I think it is appropriate to have family discussions about violence, guns, politics, terrorism and the world we live in.  Tailor your conversations to your children’s ages. Let them ask questions, answer them honestly and succinctly and let them guide how much detail needs to be discussed.  

Talking to your children and teaching them to be aware of their surroundings and to have a plan in case of emergency is now a reality.  But at the same time, reassuring even a cynical teenager that they will be safe needs to be part of that discussion. We cannot allow the recent violent news to change our daily lives….we just need to be aware.

Remind your children that adults are all around to protect them.  This includes not only parents, but teachers, administrators, police and security ( that most schools now have).  It saddens me that schools now have “lock down drills”, but again this should be another reassurance that adults have plans to protect children in any number of circumstances.

Lastly, once you have had a discussion….let your child guide you if they have further concerns or questions. And I pray…we will not have to have these discussions again. 

 

 

 

 

 

 

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