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Daily Dose

When Bug Bites Get Infected

1.00 to read

It is the season for bug bites and and I am seeing a lot of parents who are bringing their children in for me to look at all sorts of insect bites. I am not always sure if the bite is due to a mosquito, flea or biting flies, but some of them can cause fairly large reactions. 

The immediate reaction to an insect bite usually occurs in 10-15 minutes after bitten, with local swelling and itching and may disappear in an hour or less. A delayed reaction may appear in 12-24 hours with the development of an itchy red bump which may persist for days to weeks.  This is the reason that some people do not always remember being bitten while they were outside, but the following day may show up with bites all over their arms, legs or chest, depending on what part of the body had been exposed. 

Large local reactions to mosquito bites are very common in children. For some reason, it seems to me that “baby fat” reacts with larger reactions than those bites on older kids and adults. (no science, just anecdote). Toddlers often have itchy, red, warm swellings which occur within minutes of the bites. 

Some of these will go on to develop bruising and even spontaneous blistering 2-6 hours after being bitten. These bites may persist for days to weeks, so in theory, those little chubby legs may be affected for most of the summer. 

Severe local reactions are called “skeeter syndrome” and occur within hours of being bitten and may involve swelling of an entire body part such as the hand, face or an extremity. These are often misdiagnosed as cellulitis, but with a good history of the symptoms  (the rapidity with which the area developed redness, swelling, warmth to touch and tenderness) you can distinguish large local reactions from infection.

Systemic reactions to mosquito bites including generalized hives, swelling of the lips and mouth, nausea, vomiting and wheezing have been reported due to a true allergy to the mosquito salivary proteins, but are extremely rare. 

The treatment of local reactions to bites involves the use of topical anti-itching preparations like Calamine lotion, Sarna lotion and Dommeboro soaks.  This may be supplemented by topical steroid creams (either over the counter of prescription) to help with itching and discomfort. 

An oral antihistamine (Benadryl) may also reduce some of the swelling and itching. Do not use topical antihistamines. Try to prevent secondary infection (from scratching and picking) by using antibacterial soaps, trimming fingernails and applying an antibiotic cream (polysporin) to open bites. 

Due to an exceptionally warm winter throughout the country the mosquito population seems to be especially prolific. The best treatment is prevention!! Before going outside use a DEET preparation in children over the age of six months, and use the lowest concentration that is effective.  Mosquito netting may be used for infants in strollers.  Remember, do not reapply bug spray like you would sunscreen. 

Daily Dose

Bug Bite or Staph Infection?

I received another e-mail with an attached picture (you can take a look too) asking me my thoughts on what to do about this child’s bite. My first thoughts are, “is this really a bite, or is it an early staph infection?”I received another e-mail  asking me my thoughts on what to do about this child’s bite. My first thoughts are, “is this really a bite, or is it an early staph infection?”

This is often a common problem even in the office setting. A parent brings in a child and there is no history of a known bite, and at this time of year there really are not that many bugs creeping around biting our arms and legs. At the same time, the lesion looks fairly benign, it is not warm to the touch, or tender, and the patient or parents aren’t sure how long it has been there. When faced with this dilemma, I often take a “sharpie” marker and draw a circle around the area and instruct the parent to keep the area clean with an antibacterial soap (don’t worry, “sharpie” does not wash off that fast). I also have them give the child a dose of an antihistamine, like Benadryl (diphenhydramine), which might help if it is indeed a bite. Then we wait and watch. If it is a bite, in most cases it will look a little better by the following day, or at a minimum unchanged. In the case of a staph skin infection the area typically appears larger than the original “sharpie” mark. It is also usually hot, red and tender by now. It may have “declared” itself to be a bacterial infection as it has a purulent center that can be drained. When I say drained, I mean at the doctor’s office so it can be done in a sterile manner and also the purulent material may be sent for culture and sensitivity. DO NOT poke, squeeze, take a needle or anything to drain the lesion at home. Remember NO PICKING!! By doing this at home you may take a completely benign lesion that will go away on its own in several days, and actually break the skin and cause a secondary infection. This is hard for many to resist, but resist! If the said “bite” turns out to be an actual skin infection, then by culturing the drainage, the organism which is often staph, may be identified as a “staph” that is susceptible to many antibiotics, or it may indeed be the unfortunately more and more common MRSA. MRSA or methicillin resistant staph is causing frequent skin infections within the community rather what we previously thought of as a hospital infection. The most important thing is to pay attention to the “bite” and if is worsens make sure you go see the doctor. We should get up follow up in the next several days!! That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

"White Noise" and Babies

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I received an email from Meredith (via our iPhone app) because she had heard that “white noise” might cause a child to have speech/language delays. She used a sound machine in her children’s rooms at night, and was concerned about the possibility of “interfering with their speech”.

So, I did a little research and found an article from the journal Science in 2003.  A study from the University of CA at San Francisco (UCSF) actually looked at baby rats who listened to “white noise” for prolonged periods of time. The researchers found that the part of the auditory cortex (in rats) that is responsible for hearing, did not develop properly after listening to the “white noise”.   

Interestingly, when the “white noise” was taken away, the brain resumed normal development. Again, this study was in baby rats, and to my knowledge has not been duplicated.  But, these baby rats were exposed to hours on end of  "white noise” which may not be the same thing as sleeping with a “sound machine” at night. 

We might need to be more concerned about background “white noise”. We do know that babies learn language by listening and absorbing human speech. They need to hear their parent’s talking to them from the time they are born.  They listen to not only their parent’s speech, but also to siblings, grandparents etc. and from an early age respond to that language by making cooing sounds themselves, often imitating the sounds they have heard. They are also exposed to a great deal of “white noise” or background noise with the televisions being on, computers, telephones, vacuum cleaners, lawn mowers etc. going on all day.  The “white noise” that may be reduced by turning off televisions, videos, computers etc and replacing that background noise with human speech through reading, singing and just talking to your baby and child could only be beneficial. One might surmise that “white noise” in the form of a sound machine at night would not affect a child’s speech development, as this is not a time for language acquisition.

Having a good bedtime routine, reading to your child before bed, or singing them a lullaby will encourage language development, and the sound machine may ensure a good night’s sleep.  Just turn it off in the morning!

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

Daily Dose

Zika Warning in United States

1:30 to read

The Zika virus is now here….that is, in the continental United States and specifically Miami, Florida.  There are now 4 confirmed cases of Zika infections in Florida, all thought to have been contracted from the bite of mosquitoes in early July. The cases are clustered in a northern area of Miami.  Although there have not been any mosquitoes in Miami that have tested positive for the Zika virus, epidemiologists do not think that is unusual, as the mosquitoes that were presumably infected may have already died (they have a short life cycle). Large scale testing of trapped mosquitoes in Florida is continuing.

Because the Zika virus only causes symptoms in about 20% of those infected (80% of people will never show symptoms although being infected) the health department is working to see if there may be even more cases in the Miami area. They are doing door to door surveillance in some zip codes and obtaining screening urine specimens checking for the virus….there should be more information available in the near future. At the same time, due to the fact that the Zika virus may be spread from blood and body fluids, the donated blood supply in Miami is being screened for Zika prior to being used. 

So…many of the families I care for vacation in Florida in the summer, especially along the Gulf Coast. I have received a number of phone calls in the last week from expectant mothers, as well as some who are trying to conceive, asking if they should even go to Florida?  This is a tough question, but for the time being, seeing that Texas does not YET have any locally acquired Zika virus I told them that I would probably err on the side of caution and change my beach travel plans. (England has recommended that their pregnant citizens “delay or postpone” all non essential travel to Florida).  

Here is my rationale.  Why risk going to the beach, with your family and children (who are going to spend most of their time outside), in a state known to have the Aedes aegypti mosquito and now confirming the first cases of locally acquired Zika?  The anxiety that is associated with the possibility of getting a mosquito bite ( despite using insect repellent and trying to wear protective clothing - which is difficult at the beach??), is just not worth it. Worrying for weeks after returning from vacation and never truly knowing if you might have been exposed (remember most people will not become ill when infected), and wondering if you should not conceive? Or worrying at every OB appointment that your fetus is developing normally…..because you went to the beach in Florida a month ago….? I just can’t think of a reason to go through all of that…for a week at the beach.

With that being said, I now have 4 mothers who have decided to cancel their vacation plans at the beach, and to stay home and not “take any chances”. The effects of the Zika virus on a developing fetus are life long and a vacation is just a fun filled week - so why not make a few  memories this summer with a stay-cation?  No anxiety…right?  Let’s see what happens in Florida and other southern states over the next few weeks and months as this situation continues to evolve. 

In the meantime - get rid of standing water and use your insect repellent wherever you live!

Daily Dose

Concussions Are on the Rise

As our children become more and more involved in competitive athletics the incidence of concussions is also on the rise.

Not surprisingly, football still has one of the highest rates of concussions, with one in five high school or college players experiencing a concussion each year. Cheerleading has also seen a rise in number of concussions reported, as cheerleading stunts become more about athleticism and tumbling, putting cheerleaders at risk for a head injury from a fall. A concussion is defined as a trauma induced alteration in mental status that may or may not cause loss of consciousness. A concussion is a functional rather than a structural brain injury. The injury, typically arising from a direct or indirect blow to the head sets off a cascade of neuro-pathological events leading to a confusional state or memory dysfunction. Because a concussion is more of a metabolic crisis of the brain, neuroimaging studies with CT scans and MRI are rarely helpful. Concussions are typically diagnosed based upon symptoms including amnesia, confusion, impaired level of consciousness, poor concentration, headache, dizziness, fatigue, nausea or vomiting. Many symptoms may be non-specific in nature, but impaired mental status of any degree is the hallmark of a concussion. Because young athletes want to continue playing, even after a concussion is suspected, it is important to assess the athlete’s mental status immediately after the injury. There are several tests that may be performed even while the athlete is on the field, including orientation to person, place and time; attention; memory and higher cognitive functions. It is also important to assess the athlete’s judgment, and mood. Both coaches and parents should be aware of the hazards of returning a student to play after even a mild “ringing of the athlete’s bell”. Recent studies have shown that the still developing brains of adolescents and children are slower to heal from concussions. The younger you are the longer it takes to recover from a concussion; the brain is just more vulnerable. Allowing a teen to re-enter a soccer or football game, or cheerleading stunt immediately after a head injury puts them at risk of second – impact syndrome, a rapidly progressive brain injury that can lead to brain swelling and death. Concussions may lead to one fatality for every 300,000 children participating in sports. Current guidelines regarding return to activity and athletics are tending to be more conservative as studies have shown that the likelihood of long term and permanent impairment in cognitive function increases with each concussion. While a simple concussion typically resolves in seven to 10 days and requires no further intervention than rest, a more significant injury may take more than two to four weeks to reach full recovery. Once the athlete has rested, meaning no exercise or exertion for at least a week and all symptoms of headache, “feeling foggy” and fatigue have resolved, they may begin light exercise, such as walking or riding a stationary bicycle. If there are no recurrence of symptoms with light exercise then running, and resistance training may begin. With each increase in activity level the athlete should remain asymptomatic and may gradually move toward full activity and return to competitive play. Parents and coaches must remind student athletes that while missed games may feel like an unnecessary restriction, it is really only a minor inconvenience, which will help maintain long-term brain health. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Impetigo: Common Skin Infection

Summer can usher in a host of skin infections caused by bug bites and rashes. This makes your child more suspectible to infection. What can you ? Dr. Sue weighs in.One of the classic skin infections I see during the summer months is an infection called impetigo.  Impetigo (not infantigo as some parents say), is a bacterial skin infection characterized by tiny vesicles or blisters on the skin, that when open, leave a honey colored fluid that crusts on the inflamed skin.

Impetigo is caused by the bacteria, staph or strep, and methicilllin resistant staph may also cause impetigo. Why do we see more impetigo during the summer months?  The infection can be triggered by kids scratching their skin due to bug bites or rashes like poison ivy.  You've seen it...kids will scratch these areas and now they're more susectible to infection. The skin is broken and the bacteria from their hands (yes even when they have been washed), can enter through the breaks in the skin and set up an infection. Impetigo is most commonly seen on the face, arms, or legs, as well as in the diaper areas in infants. Impetigo is spread by touching one area that is infected and then touching another. This is called “auto-inoculation”. In other words it does seem to spread in front of your eyes, especially if you are a “picker/scratcher” and are picking at multiple bites. Suddenly, they all look infected. If you notice a bite that starts to look infected and it is only in one area, then the infection may often be treated by using a prescription antibiotic ointment. If the impetigo involves multiple areas, it may be necessary to use an oral antibiotic to treat the infection.  Your doctor will be able to decide whether an oral antibiotic is necessary. I also have parents make sure that the child’s nails are trimmed, which will help reduce breaking the skin while scratching.  I also have the child use an antibacterial soap for a few days for their baths and showers. Again, good hand washing is important to prevent spreading the infection, to different parts of the body. Impetigo has such a classic appearance that once you have seen it you will know it too! Just try to keep the itching, picking and scratching at bay and you will see much less impetigo. That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Transitioning to Whole Milk or Toddler Formula

Is it best to transition to whole milk or use toddler formula instead?I received a question from our iPhone App regarding the use of a toddler formula, such as Enfagrow. The mother wondered if this was preferred over switching to cow’s milk when a child reaches 12 months of age.

While there have been several products that have been brought to market in the last few years, so called toddler’s formulas, there is really no evidence to show that these are preferable to using cow’s milk you’re your child reaches 1 year of age. The toddler’s formula does contain more calcium and phosphorous than infant formulas, but beyond that there is really no advantage to using a toddler formula over milk.  It really seems to be an expensive marketing ploy directed to parents who are concerned about calories and vitamins. The American Academy of Pediatrics recommends that 1 year old children either continue breast feeding or make the transition to whole milk.  It is also recommended that child transitions from bottle to a cup (sippy cup is fine). At that time a toddler should reduce their milk intake to approximately 16 ounces a day, as they are getting the majority of their nutrition from eating a wide variety of solid foods, with less calories coming from breast milk or whole milk.  If a parent is offering their toddler a variety of healthy foods, you will be amazed at what they will and will not eat, but they do manage to gain weight and grow, which often surprises their parents. The most interesting thing about a toddler, is that they self-regulate, and unlike adults, they eat when they are hungry, rather than out of boredom or due to stress.  So, if you offer your toddler healthy meals and snacks accompanied by whole milk from a cup, they will meet their nutritional requirements and also get enough calcium and vitamin D. On the other hand, for parents that have a difficult time dealing with a child’s whims for eating, and will indulge their child’s  food preferences,while also allowing them to have juice instead of milk, the idea of a toddler formula seems to be just the ticket! Just let them drink their nutrition (somewhat like an adult who might need a nutritional supplement like Ensure while they are sick), but this may not be the answer as this really just reinforces poor eating habits. Like many things in parenting, the “perceived” easy solution, may not always be the best. So, at the end of the day there is little need for “follow up  formulas” for the otherwise healthy toddler.  Save the money, buy whole cow’s milk unless otherwise directed by your pediatrician.  Make sure that your child is getting about 16–18 ounces of milk a day and several other servings of dairy products.  If you are really concerned about calcium and vitamin D as well as other vitamins, then offer them an over the counter vitamin supplement. That's your daily dose for today. We'll chat again tomorrow. Send your question or comment to Dr. Sue.

Daily Dose

Stomach Virus

1:30 to read

What a week in the office as there has been an outbreak of presumed Norovirus in our community, and we are seeing tons of sick kids. I guess the virus does not realize that it is still in the 90’s in Texas, as this virus is more often seen during the winter months….but it seems there are occasional outbreaks throughout the year.

Norovirus is EXTREMELY contagious…and you may already be shedding the virus (expose others) before you even get sick. At the same time…you may also be contagious for 2 -3 days after you are better. Norovirus is the most common cause of the “stomach flu” or “food poisoning.” 

Knowing this, it is difficult to know when you have been exposed to this virus. But, a day or two after exposure, your child (or the parents ) may suddenly develop abdominal cramping, vomiting (more common in children) and diarrhea  more common in adults). Some children and their parents are “lucky” enough to get both!!  

The mainstay of treatment is to stay hydrated. This illness is typically “fast and furious”, but you have to make sure that you are replacing the fluids that you are losing ( from both ends).  After your child has vomited you want to wait for at least 30 minutes before offering your child sips of CLEAR FLUIDS, some sort of liquid with electrolytes ( very important to replenish what you are losing) ….and I mean SIPS. If you  give the fluid too quickly and in too large a volume you may see it come right back up.  As your child tolerates sips you may advance to a larger volume each time.  If they are doing well for several hours, but then your child vomits again…start back over with smaller volumes. Continue to make sure your child has tears when they cry, wet diapers ( they may not be soaked), urine when asked to go try and “potty” and drool or a  moist mouth. These are signs that your child (and you) are hydrated.

Once the vomiting has subsided you can let your child begin to eat, but I would avoid all dairy. It is important to offer foods with some protein as well.  I start with crackers, noodles and rice and then add in chicken or beef. Veggies and fruit are okay as well ….as your child is feeling better their appetite will return…don’t push them. You probably don’t want a big meal either if you have been sick. Fluids are more important than food. Adding probiotics is also helpful to put “good bacteria” back into a damaged gut. 

Prevention is key, but difficult as there are millions of viral particles in your child’s stool and vomit….and these particles can be spread via the air as well.  Clean surfaces with a dilute bleach solution, wash your hands and “don’t breath??”

Daily Dose

Treating Altitude Sickness

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What can you do if your child suffers with altitude sickness.With winter breaks in full swing, many families are traveling. Some families are heading to the mountains to ski and encounter higher altitudes.

I seem to get several calls each year about “acute mountain sickness” which may occur when traveling to altitudes above 5,000 feet (1,500 meters),  but is typically associated when travelling to altitudes of 8,000 – 14,000 feet (2,440 – 4,270 meters).  To give you a frame of reference, Denver, Colorado is 5,280 feet above sea level, while Vail, CO is 8,200 feet. Fortunately, most people will not have serious problems when traveling to higher altitudes.  The human body acclimatizes to higher altitudes by allowing your body to function with less oxygen without having distressing or debilitating symptoms.  Despite that, the body is not functioning as well as it does at sea level, as the air is less dense at higher altitudes and consequently there is less oxygen available for breathing. The first thing you may notice is a slight increase in respiratory rate, which will help to increase oxygen delivery to the lungs but at the same time results in the loss of extra CO2.  Some people may also notice an increase in heart rate. I think that most children without underlying medical problems (chronic pulmonary or cardiac problems), seem to actually acclimate better than adults. But in some cases you may notice that your child has non-specific symptoms such as irritability (I must admit hard to tell if altitude, traveling or just having a bad day), decreased appetite, headaches, disrupted sleep (always seems to happen when travelling with children) and occasionally vomiting. All of these symptoms usually resolve after several days and may be minimized by planning a gradual ascent to higher altitudes.  So, driving may be better than flying, but…..I can remember several days while driving to Colorado with cranky children and we were not even out of Texas! I also think one of the boys vomited due to the driving and not altitude. Oh well, fond memories nonetheless. For some children and teens who have experienced repetitive episodes of altitude sickness I have used a prescription medication called Diamox to minimize symptoms.  I would not recommend this for young children.  You should speak with your doctor about the use of this medication, as it aids in acclimatization by increasing the excretion of bicarbonate in the kidney, which will stimulate the respiratory rate and improves oxygenation.  Some families who are frequently sick when skiing or hiking also have portable oxygen to use to help alleviate symptoms for the first several days they are at higher altitudes. For most of us, just maintaining hydration and taking the first few days of exercise a little slower is enough for our bodies to acclimate and enjoy the trip! That's your daily dose.  We'll chat again tomorrow. Send your question to Dr. Sue right now!

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