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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

When To Worry About Stuttering

1.15 to read

I received an e-mail today from a mother who is concerned about her 2 1/2 year old daughter who has started stuttering in the last week. She asked ”is this something to be worried about or just watch it and see?”

This is a common question from parents with preschool aged children, and is typically most frequent between 18 months and five years of age. Stuttering at this age is called disfluency or pseudo stuttering and is quite common as children learn to speak and develop more complex speech patterns.

In many cases the stuttering occurs out of the blue, and may last for several weeks, and resolve, but may return off and on during the preschool years as a child is learning more and more language. In a preschooler who is stuttering the parents usually note that the child repeats an initial sound such as l-li-like or s-st-star or may have frequent pauses with “um” and “er”. It is not uncommon to see this happen when a child is excited, or anxious or tired.

They may stumble or words or sounds and after a good night’s rest you may see an improvement. They often don’t seem to realize that they are even stuttering as their brains and mouth try to keep up with one another. Remember they have a lot to say!

The best medicine for stuttering is for a parent to reassure their child that it is okay to slow down as sometimes it is hard to make the words correctly. A hug from Mom or Dad while they are reassuring their child is also helpful. Practice slow and relaxed speech when you are talking to your child and try not to rush them when they are talking, even if the stuttering is bothering you. When your child asks you a question, pause before answering to also model behaviors with speaking. Reading aloud with your child in a slow and normal manner is also beneficial (I remember nights of trying to rush through those early books to try and get everyone in bed!).

The best person to emulate is Mr. Rogers, think of how relaxed he always was when speaking. He never seemed as if he was hurrying for anything! In most cases a child’s stuttering will not last more than weeks to several months and will resolve on its own.

If you think the problem is increasing in severity or is causing stress and anxiety for your child it may be time for a discussion with your pediatrician.

Do you have any tips?  Feel free to share them with us!

Daily Dose

Flying with Your Baby

1:30 to read

Everyone has heard the adage, “never wake a sleeping baby”, correct? But there seems to be another adage, “a baby needs to be awake and eating for take off and landing to prevent ear pain” when traveling on an airplane.   These two statements at times seem to be in polar opposition. Wake up the baby to eat, or let the baby sleep?

So...I have never found any science that states that an infant’s ears are any different than older children's’ ears or for that matter even an adult ear. Why people think that an infant should always be “sucking” for take off and landing has never made much sense to me. When I was a parent with young children I can remember some wonderful flights when the baby slept for both take-off and landing, and actually probably did not even realize that we were in a different state. With that being said, I have some horrible memories of flights with a screaming baby, who would not eat, take a pacifier or quiet through out the flight....and many other passengers just staring at you!!  I certainly did not want them to ever know that I was not only a mother, but a pediatrician who had no idea how to stop the madness!! If there had been a parachute I swear I would have jumped.

But, I digress. I tell patients all of the time, “don’t wake up your baby if they are sleeping!”.  I swear, the baby will start to cry not from their ears but because they were awakened.  So...while traveling with my grandbaby, I had the opportunity to “practice what I preach” (which is humbling the second time around the parenting track).  As we boarded the plane for our flight the “sweet angel” was sleeping and her parents said, “we need to wake her” as we take off. I took a leap of faith and decided to offer my “two cents” (I really do often try to keep my lips sealed) and suggested that they let her sleep!

Guess what, we took off and she continued to sleep!! Thirty minutes later she woke up happily and played for a bit before taking her bottle.  No crying, no “obvious” discomfort from her ears.

So back to basics, “never wake a sleeping baby....even for flying”. I am sticking to that advice.

Daily Dose

Matching Underwear?

1.00 to read

More funny stories from work. 

I was on call yesterday.  In my practice, call days are pretty long. On a given call day, I might be responsible for making hospital rounds all morning (I may go to 3 or 4 different hospitals) and then work evening office hours as well. The evenings in the office are typically pretty busy and for some reason some of the sicker children seem to come at night.  Usually not a lot of time for chatting with the patients or their parents. 

The other night was a bit slower (maybe spring is finally here and all of those colds are going away!) and I was finishing up with a toddler who had been wheezing and was getting breathing treatments.  While waiting for her treatment to finish, her mother and I started talking and somehow got to the subject of funny things our mother’s had said to us.  (I think because her own mother had told her that her daughter was wheezing because she hadn’t been wearing a coat during the last cold snap. This is a myth).  

At any rate, I remember my own mother telling me during those teen years to always wear “matching undergarments” in case I got into an accident.  At the time it sounded a bit weird, but looking back now, it is kind of morose. I mean REALLY!!!   But I sometimes laugh out loud thinking about those words of wisdom. 

I saved the best line of this conversation for last.  This young mother, with her really cute 20 month old daughter in her lap, looks up at me and says, “I bet I tell this one to just make sure she has underwear on when she goes out, who cares about the color!”   

Talk about generations and the differences years can make! It continues to be all about perspective, right? 

The rest of the call night was easy as well......so funny!  

Daily Dose

Ice Burns!

1.00 to read

Many schools are in spring sports or playoff season which means I'm seeing a few strains and sprains in the office. 

The treatment recommendation for a sprain or strain is usually RICE which stands for rest, ice, compression, elevation.  I just saw an adolescent volleyball player who had started back to her volleyball work outs and “pulled a muscle”. So, she followed her coaches directions to “ice it”.  Unfortunately, she just put the ice pack directly onto her skin and she came in with an ice burn! OUCH!

Yes, ice can burn the skin and cause frostbite as well. When treating an injury with ice you need to make sure that you put a towel or sheeting between the ice and your skin.  In this patient’s case the ice burn looked similar to a sunburn, and did not blister or cause any severe damage. In fact, when she pulled up her pants to show me her leg she “quizzed me” to see if I could guess what had caused the redness.......guess what, knowing that she was an athlete helped me guess correctly!

The picture above shows her injury as well.

The treatment is similar to a thermal burn, apply a lubricant like Aquaphor or aloe vera, and let the skin slowly heal.  If it is blistered or has had severe damage to the skin you may need to see your doctor.

Remember, ice is good for injuries but cannot be applied directly to the skin.  

Daily Dose

Pool or Trampoline? The Safety Debate

1:15 to read

Do you have a pool or trampoline in your yard? Both pools and trampolines are fun for children, and both pose dangers as well. I saw a patient today who asked me my opinion of trampolines. It seems that she and a friend, both of whom have elementary school age children, are having a "discussion" about trampolines. My patient is totally against having a trampoline in her yard, although she has a pool. Her friend says that it is safer to have a trampoline than a pool. And so their debate continues.

Both pools and trampolines are fun for children, and both do pose dangers. But as my own children often told me "according to you Mom, everything that is really fun, is dangerous!" The biggest issue surrounding children playing in pools and jumping on trampolines is parental supervision. When children are taught safety and are given rules to follow that are then enforced, they may have fun and be safe at the same time. Pools are fenced, and gated. Parents watch their children swim. This is usually the party line. But trampolines also require the same amount of supervision and many parents don't realize this.

Most trampoline injuries occur when children are unsupervised. Many serious trampoline accidents occur when children of disproportionate weights are doubling jumping and the smaller child becomes a missile and is thrown from the trampoline when serious neck injuries may occur. Trampolines are also safest when they are buried in the ground or have safety nets on the side. Letting children jump unsupervised is as dangerous as swimming alone.

So, I can't resolve this friendly discussion, but I do know that both pools and trampolines require parental supervision and strict safety rules to ensure the safest possible experience. And yes, they are both fun! 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

No Need for Stitches?

1.45 to read

OUCH!! I was just heading out to grab some lunch when a patient of mine, who happens to have 3 young sons (brings back memories) walked in with her youngest son who had been jumping on the bed and bumped his head!

As you can see by the picture, there was a nice little laceration right in the middle of his forehead. This was the perfect wound that would have previously required a stitch or two, but can now be closed with a liquid adhesive called Dermabond.

Fortunately, this experienced mother of 3 boys had already become a fan of Dermabond and instead of going to the ER; she came by the office for a fairly easy procedure to close the wound.  Smart Mom!

When Dermabond was released in the early 2000’s it took me awhile to get used to how easy this made wound closure.  Dermabond is a liquid skin adhesive that holds wound edges together. The best thing is that it is painless and can be used on small superficial lacerations. Even for a wiggly toddler in most cases the laceration can be closed even while the parent is holding a child still. This is certainly not the case when having to suture!

Dermabond forms a polymer which causes adhesion of the wound edges so it is perfect for “clean, straight, small” lacerations that I often see among my patients.  The classic ones are on the edge of the eye, the chin, the forehead or even the scalp. In studies the cosmetic outcome was comparable to suturing, and in my opinion for those small lacerations it is preferable.

So, we cleaned the wound up, laid him right down (he was perfectly still too) and within 5 minutes the head wound was closed and a happy 2 year waltzed out of the office. Not a tear to be found, but I did have a little residual glue on my finger!

The Dermabond will wear off on its own in 5 – 10 days. Once the adhesive comes off I always remind parents to use sunscreen on the area, which also helps to prevent scarring.

Happily this little guy left while singing “Dr. Sue said, no more little boys jumping on the bed!”

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

Daily Dose

It's Allergy Season!

1:30 to read

WOW!  A busy week in the office and while I was on call in the evening,  the biggest problem right now seems to be allergies!  While some parts of the country may still be experiencing cold and a few snow flake, many states are warming up and the trees and grasses are starting to spread their pollens. In fact, my backyard is covered in yellow oak tree pollen, and some of it is so thick it looks like tumbleweeds. This cannot be good for anyone.

While I am finally seeing fewer and fewer children with the multitude of winter upper respiratory infections I see every year, the allergy season is looking “wicked” this year.  Seasonal allergies due to pollens from grasses and trees are typically not seen in children until they are over 24 months of age.  At times it is difficult to distinguish the last of the cold viruses from early allergy symptoms. But at this time of year, a good history is important (always) as well as a family history of allergies.

The good news is, there are a lot of medications available to help relieve the symptoms of itchy eyes, scratchy throat, cough, and drippy nose.  While the non-sedating antihistamines like Claritin, Zyrtec, and Allegra have been available over the counter for quite some time, intra-nasal steroids are now available as well. 

Intra-nasal steroids are one of the mainstays of allergy treatment, as they are a preventative medication. When used on a daily basis they help to prevent the “allergic cascade” that occurs when you inhale all of those pollens blowing in the wind.  They work best when used every day for the duration of allergy season which is really dependent on where you live. Allergy sufferers in the northeast will typically have symptoms later in the spring/summer than those in the “sunbelt”.

So you can now pick up Flonase and Nasacort over the counter and use them daily, even in children.  Make sure you try to aim the spray toward the outer side of the nostril and not toward the nasal septum (middle). This will allow the steroid spray more coverage as well as to try and help nosebleeds which may be a side effect of a nasal steroid spray. 

Lastly, with all of the kids playing outside in the “yellow mist” of pollen, make sure to bath/shower them and wash their hair when they come in.  This will help to reduce some of the itching and rubbing of their eyes and nose as well!

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