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Daily Dose

Migraines in Children

1:30 to read

I received an email via our iPhone App inquiring about migraines in children. Headaches are a common complaint throughout childhood, but pediatricians have recognized that children have many different types of headaches which include migraine headaches. 

Migraine headaches are best diagnosed by obtaining a detailed history and then a thorough neurological exam. There are several characteristics of childhood migraines that are quite different than adult migraines. While adult females have a higher incidence of migraine headaches, males predominate in the childhood population. 

Childhood migraines often are shorter in duration than an adult migraine and are less often unilateral (one sided) than in adults. Only 25-60% of children will describe a unilateral headache while 75-90% of adults have unilateral pain.  Children do not typically have visual auras like adults, but may have a behavioral change with irritability, pallor, malaise or loss of appetite proceeding the headache.  About 18% of children describe migraine with an aura and another 13% may have migraines with and without auras at different times. When taking a history it is also important to ask about family history of migraines as migraine headaches seem to “run in families”. 

Children who develop migraines were also often noted to be “fussy” infants, and they also have an increased incidence of sleep disorders including night terrors and nightmares. Many parents and children also report a history of motion sickness. When children discuss their headaches they will often complain of feeling dizzy (but actually sounds more like being light headed than vertigo on further questioning). 

They may also complain of associated blurred vision, abdominal pain, nausea and vomiting, chills, sweating or even feeling feverish. A child with a migraine appears ill, uncomfortable and pale and will often have dark circles around their eyes. It seems that migraine headaches in childhood may be precipitated by hunger, lack of sleep as wells as stress. But stress for a child may be positive like being excited as well as typical negative stressors. 

Children will also tell you that their headaches are aggravated by physical activity (including going up and down stairs, carrying their backpack, or even just bending over). They also complain of photophobia (light sensitivity) and phonophobia (sensitive to noises) and typically a parent will report that their child goes to bed in a dark room or goes to sleep when experiencing these symptoms. 

Children with migraines do not watch TV or play video games during their headaches. They are quiet, and may not want to eat, and may just want to rest.  Nothing active typically “sounds” like fun. To meet the diagnostic criteria for childhood migraine, a child needs to have at least 5 of these “attacks” and a headache log is helpful as these headaches may occur randomly and it is difficult to remember what the headache was like or how long it lasted, without keeping a log. 

There are many new drugs that are available for treating child hood migraines and we will discuss that in another daily dose.  Stay tuned! 

Daily Dose

Miley Cyrus Smoking Salvia

Video of Miley Cyrus smoking salvia has been making the rounds on-air and online. What is salvia and why are tweens/teens smoking this herb? As you know, I always try to stay abreast of new stories and pop culture trends that might affect my patients (as well as my own family). One recent event caught my eye. The video of Miley Cyrus allegedly smoking salvia has been viewed by many. Prior to this I had not heard very much about salvia. As it turns out, I should have.

It seems that this plant (a member of the mint family) is a well-known naturally occurring hallucinogen.  Salvia is actually the most potent naturally occurring hallucinogen (LSD is a synthetic hallucinogen) and has become quite a sensation among the adolescent crowd who often post videos of themselves after smoking or ingesting salvia. It is in this manner that adolescents became aware of the effects of salvia and realized that it is easy to obtain either on line or in smoke shops. Over the last several years as salvia has gained more attention, it has been banned from being sold in 20 states in the U.S. with even more states considering legislation.  That does not seem to prevent its sale on line as a Google search listed pages of sites with salvia for sale. The effects of salvia typically occur almost immediately after smoking the herb, and typically last about 5 – 8 minutes. It is common to see speech and coordination problems, along with a feeling of giddiness and disorientation.  Salvia activates opioid receptors in the brain which causes the differing hallucinogenic symptoms.  It has the potential to be both physically and psychologically addictive, especially in the adolescent population who are dealing with multiple issues during their maturation. For a teen who is sad, depressed or anxious, the use of salvia may become a way to mask their problems rather than dealing with their issues. While a teen’s first encounter with salvia may be a ”one time” exposure at a party, the easy availability of this plant on line may make it more appealing for repetitive use.  Salvia may also be chewed or consumed in a liquid, as well as inhaling herb.  The latest “Monitoring the Future Survey” which ask teens about their recent drug use did not show an increase in salvia use among 12th graders, but it did show that 1.7% of eighth graders had admitted to using salvia at least once. The concern is that these numbers may rise and the DEA has labeled salvia a “drug of concern”.  With the YouTube video of Miley Cyrus using salvia, there are now even younger kids aware of the plant and its effects.  Children as young as 10-12 years are reporting salvia usage.  I have asked many of my pre-teen and adolescent patients about salvia, and while most deny usage they all seemed to “know” what salvia was and how they could get it. So, yet another discussion for parents to have with their children. This also brings home the necessity of monitoring not only what your children watch on line but what they buy. Salvia appears to be pretty cheap and is easily purchased with a PayPal account.

Daily Dose

Get Your Baby to Sleep!

1:30 to read

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

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

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

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

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

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

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

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

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Daily Dose

Flu Cases Continue to Rise

1:30 to read

Seeing that most of the United States is experiencing freezing weather and flu is on the rise and kids are all back in school, it is appropriate to discuss good handwashing and cough hygiene to try and keep everyone healthy.  Flu season typically peaks in January and February, so unfortunately the worst is yet to come.

The predominant strain of flu that is circulating right now is Influenza A H1N1 (yes, the old swine flu). Fortunately, this strain of flu is a component of this years flu vaccine. (Surely you have gotten your flu shot/mist by now, but if not run and get it!).  The CDC sends out a weekly flu report and as of now there are 20-25 states with widespread flu activity The flu is currently more prevalent in the southern states and spreading north.  

Besides the flu vaccine the best prevention for flu continues to be good handwashing.  This is the time of year that many of us have chapped hands due to the cold dry weather and frequent handwashing.  Using antibacterial gels is also a good way to prevent germs from spreading and may not cause as much drying. Try not to touch your own face with your hands as those pesky viruses enter our bodies through our nose, eyes and mouth and keeping hands away from the face is helpful. With that being said, how do you keep a child’s hands away from their face???  Another reason that young children pick up so many viruses.  

If your children are feeling badly and have any fever they need to stay home from day care and school. Many people don’t realize that you start shedding virus even before you are actually sick and once you feel badly staying home is a must!!! Dosing your child with tylenol/ibuprofen before sending them to day care doesn’t help anyone, and your child will be much more comfortable at home. The rule of thumb is no return to school or day care until your child has been fever free for at least 24 hours (without any fever medication). 

Teenager are notorious for wanting to go to school no matter what.....as they get so far behind if they miss all of those difficult classes. The problem is they too spread the flu, even if they are good about covering their mouth and washing hands.  Your teen needs to stay home as well if they are running a fever, no excuses about a calculus test or basketball game.  

To date there have been 6 pediatric deaths secondary to influenza.  Get your child their flu vaccine and make sure that if you have an infant they get their second dose of flu vaccine 4 weeks after their first. You need both doses to have immunity the first year your young child receives a flu vaccine.

I’ll keep you posted with flu news.

Daily Dose

A Germ-free Office?

To keep the germs at bay, it has been suggested to remove all toys & magazines from a doctor's office. Really? Aren't there germs on magazines in a lawyer, dentist or school office?I was just reading an interesting newspaper column in one of the advice columns carried in my daily newspaper. I just had to comment!  The writer had written in to suggest that doctor’s offices needed to change their practice of having magazines and toys for those in the waiting room.

Her feeling was that if doctors would discontinue having magazines in their offices, then patients would bring their own periodicals and that this would then reduce the spread of germs. The columnist also thought this sounded like a good idea and thanked the writer for such a great suggestion. I had to re-read the column as I really could not believe that someone would suggest that doctors should have empty waiting rooms!!!   Have we just gone overboard with “germ fears”?  I understand the need to wash your hands, and to try and keep your hands away from your face, to cover your mouth when coughing etc.  But taking magazines, newspapers, toys and books out of a waiting room seems a little extreme. There are also similar items in the waiting room of my dentist, lawyer, accountant, hairdresser etc.  I guess there could also be germs in those offices too, but no one is suggesting that these professions “sterilize” their waiting rooms and common areas. While I agree it is important to try and keep waiting rooms clean, especially in a doctors’ office (where not everyone is even sick), there is no way to keep any common area totally germ free. The magazines and books are not the only objects that may harbor germs. What about the chairs, the door knobs, the table tops, the counter tops, the fish tank glass, even the floor?  There is just not any way to keep the area entirely germ free, even with good cleaning. In my office we are very conscious about trying to keep the office clean to reduce the spread of germs. Our housekeeping staff that mop the floors and wipe the surfaces between morning and afternoon patients. To try and make an office germ free is as impossible as making a grocery store, a department store, a library or even a school germ free. It is just a fact of life that we will all be exposed to germs. To suggest that discontinuing the long standing tradition of having reading material in the waiting room of a doctor’s office in order to decrease the spread of germs just doesn’t seem to make common sense to me. If you (as a patient) are “afraid” to read a magazine at your physician’s office, then by all means bring your own. But to take away the books and magazines from everyone is just a bit too much. For many parents a trip to the pediatrician’s office is difficult enough without having to lug your own stash of toys and books. I have sweet moms who don’t even remember to bring diapers or wipes as they are just trying to get to their appointment.  Arriving to an empty waiting room to try and entertain 3 children waiting on their doctor seems like torture to me. Schools are full of germs too, but we send our kids there to learn (and occasionally get sick too). Getting sick is never fun, but germs are ubiquitous.  Don’t sweat the small stuff; remember there is a bigger picture. What do you think? I would love to hear from you! Feel free to leave your comments below.

Daily Dose

The Heat is Taking a Toll on Many

1:15 to read

This is a follow up last week’s Daily Dose on the toddler who burned his feet after playing outside on a very hot day. He has been being treated with daily dressing changes and debridement of the skin from the blistering on his feet. HIs mother called to tell me that the first few days were “BRUTAL” and extremely painful as the doctors popped the blisters and removed dead skin and then would scrub the area to prevent infection. His mother was also doing bandage changes at home.

But after those first horrible days, he is no longer having to go for “burn therapy” and she is managing the dressing changes on her own. She is fortunate to be a nurse, but having to change your own child’s dressings is a daunting task for any parent, even one who has done dressing changes before.

Her son is also now off all pain medication except for over the counter acetaminophen and ibuprofen, and is smiling and playing with his older brother. He is still not walking and is being “carried to and fro”, it seems that he realizes his feet have tender new skin.  The doctors also feel as is he will not have any significant scarring over the long term.  

The triple digit heat is continuing in many parts of the country and I just read about another child in Texas who died after being left in a car.  Remember, put something in the front seat to remind yourself that your child is in the car with you. A sleeping quiet baby can be momentarily forgotten when a parent is distracted….and even minutes in a hot car may be deadly.

Be aware of the many risks associated with these extreme temperatures, and make sure that your children have shoes on whenever they are going to be outside!!  Hoping that these extreme temperatures will moderate over the next few weeks…especially as children are heading back to school!

Daily Dose

How to Swallow a Pill

1:15 to read

I have always been a proponent of teaching children to swallow a pill.  In fact, I think I taught my boys to swallow a pill before they were 5 years old, mainly because I was tired of trying to find the measuring cup or syringe for the liquid medicine, which often didn’t go down “like spoon full of sugar”, even though we would sing the song during dosing. 

By the time one child had learned to swallow a pill the other two boys, as competitive as they were, decided that they too could do it, even the 2 year old.  So, based on that experience I have been encouraging young patients to swallow pills, and even teaching them in the office with my stash of mini M&M’s and Tic Tacs!  I also know that if you wait too long it becomes a huge ISSUE.

Well, who knew that someone would actually study “pediatric pill swallowing”?  In an article just published in the May issue of Pediatrics the authors looked at different pill swallowing interventions.  They found that up to 50 % of children were unable to swallow a pill.   Problems swallowing pills included a variety of reasons including fear, anxiety and intolerance to unpleasant flavors. 

The authors reviewed 5 articles published since 1987 which found that behavioral therapy, flavored throat sprays, specialized pill cups and verbal instruction with correct head and tongue positioning all helped children to swallow pills. They also found that pill swallowing training as “young as 2 years helped increase the likelihood of ease of pill swallowing”.

So, like many things....jump in with your young child and master the art of pill swallowing sooner than later. It will make everyone’s life easier.

Last caveat, I always tell my patients who are older “non-pill” swallowers, “you cannot possibly operate a motor vehicle if you can’t swallow a pill”! This is usually a huge motivator for the “late swallower” and they conquer the challenge. 

Daily Dose

War On Zika Virus

1:30 to read

There seem to be updates everyday on the latest cases of Zika virus both in the U.S. (to date all of which have been imported) and in more and more countries in the Caribbean. At the same time, there is more information being released  by the CDC and the World Health Organization on the virus, its effects, how to diagnose it, who should be tested and prevention.  There are also many scientists around the world who continue to work on diagnosing, treating, and preventing the Zika virus. Despite all of this there is still a lot to learn and many questions still remain about this rapidly spreading virus.

The CDC has just documented the first case of the Zika virus being transmitted sexually in this country.  The case was actually confirmed in Dallas after the patient had returned from a trip to Venezuela and was diagnosed with Zika virus. Subsequently his partner, who had had unprotected intercourse within 2 weeks of the initial patient’s return, was diagnosed with Zika virus. Fortunately, there was not a fetus involved in this case and both of the patients have recovered. Because of this the CDC has now issued new guidelines stating “men who live in or travel to areas of active Zika infections and who have a pregnant sexual partner should use latex condoms correctly, or refrain from sex until the pregnancy has come to term”.  Questions still remain about possible viral transmission from saliva and urine and further information will be forthcoming. 

The CDC also changed the guidelines for pregnant women who have traveled to areas with known Zika virus and are concerned about possible exposure.  While they had previously recommended that only those with at least 2 symptoms of the virus (which include rash, fever, joint pain or conjunctivitis) be tested, they now have more data on the accuracy of the tests and the new guidance states “pregnant women without symptoms can be offered testing between two to 12 weeks after travel.” So if you are concerned consult your Ob-Gyn. 

I am also getting questions from young woman who have been “trying to get pregnant” or who are even “thinking about getting pregnant” and they want to know if they should “delay getting pregnant”?  While I am concerned about the spread of the Zika virus, I do not think that women in the U.S. should alter their plans to become pregnant.  But, at the same time, I am advising these women to change their plans and to cancel any and all travel to the Caribbean, Central and South American countries with known Zika virus until after they have conceived and given birth…so in other words for at least 9 -12 months and maybe more. Why risk an exposure when not necessary? 

While this virus is expected to spread to the U.S. this summer there is some thought that it may be our southern states with hotter and more humid weather who will have the greatest likelihood of seeing significant Zika virus. Again, this is based on historical as well as ongoing research.  What is known, is that the Aedes mosquito (the type that carries Zika) has previously been found in most states in the United States. I have had one mother who is pregnant call and ask if I thought she should leave the state of Texas this summer, and move north to a cooler climate!  While that seems a bit extreme,  no one knows what impact Zika will have here until the temperatures warm up. In the meantime I advised her to start wearing insect repellant that contains DEET or picardin, as well as to wear long sleeves and pants and to try and stay inside during peak mosquito hours (dawn and dusk), as we still have mosquitos in Texas even at this time of year.  Might as well get in the routine now.

Stay tuned…

Daily Dose

Diaper Dermatitis

1:30 to read

Newborn babies have the softest little bottoms and they also have a lot of poop! The combination often leads to a raw red bottom and a diaper rash. A newborn often poops every time they eat and sometimes in between....and you don’t even realize they have pooped again.

Even with the constant diaper changing (would you have believed you would use 8-12 diapers a day) it is very common for that newborn to develop their first diaper rash.  Not only will the skin be red and raw....it may even sometimes be so chapped that it may bleed a bit.  This diaper rash is causes a lot of parental concern and will often result in the new parent’s first of many calls to their pediatrician.

A new baby is supposed to poop a lot, so you can’t change that fact,  but you can try all sorts of things to protect that precious bottom and treat the diaper rash.  After using a diaper wipe ( non perfumed, hypo-allergenic) I sometimes bring out the blow dryer and turn it to cool and dry the baby’s bottom a bit. Then I apply a mixture of a zinc based diaper cream (examples:  Desitin, Dr. Smith’s, Triple Paste cream), which I mix in the palm of my hand with a tiny bit of liquid over the counter antacid.  (I don’t measure it:  just a lot of diaper cream and small amount of antacid so it won’t be runny).  I put a really heavy layer of this on the baby’s bottom.

If after several days rash is still not improving it may have become secondarily infected with yeast so I add a yeast cream (Lotrimin AF, Triple Paste AF) to the concoction. If it has yeast this should do the trick to treat all of the problems.

I will also sometimes alternate using Aquaphor on the bottom with the above diaper cream concoction.  It will take some time for it to totally go away but you are trying to get a barrier between the poop and the skin on the baby’s bottom. She keep something on there after each diaper change.

After a few weeks of constant pooping the number of stools do slow down and bit and that will help heal that new baby’s bottom as well. 

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What are those brown spots on your baby's skin?

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