Daily Dose

Ebola Fear Running High

1:30 to read

As the weekend passes and there are thankfully no further cases of Ebola disease in any of the people who had the earliest contact with Thomas Eric Duncan (the first patient to be diagnosed with Ebola),  I hope people may be reassured that we are not in the throes of an Ebola epidemic in the United States and that the people who are at greatest risk of contracting the disease are unfortunately those health care workers who are treating the infected patient. 

Despite every precaution possible, and all of the personal protective equipment available, I am well aware that nothing is ever 100% .  But, with that being said, we (all health care professionals) continue to learn from mistakes as well as victories and I am sure that as we go forward combatting Ebola or other emerging viral infections, there will be new recommendations and procedures to learn, which is not a new concept in medicine.  That is how progress is made.

Unfortunately, the media (of which I must include myself) has once again managed to try to frighten the public and has done a good job of putting the three cases of Ebola out of 318 million Americans (unfortunately including 1 death) at the top of the news 24 hours a day.  The cameras continue to focus on the hospital in which I go in and out of every day.  This continued media presence has also affected the doctors who practice in the hospital as well as the professional buildings on the same campus. These doctors are my colleagues and friends and are great doctors.  

People have been canceling their dermatology visit in a professional building not even attached to the hospital and postponing a mammogram in another building.  Some patients will not come to my practice across the street from the hospital and would prefer to drive 20 minutes north to another office?   

There are parents keeping a child home from school because their classmate’s father is one of the doctors (heroes) taking care of the Ebola patients.  What are they thinking? How is this idea of catching Ebola from walking into an office or down a hallway or being in the same school being sustained?  Basically due to unsubstantiated fear and not fact. Fact is this illness is not airborne you must come into contact with body fluids of the sick patient.

Emotions are running wild in my hometown of Dallas. But emotions will not treat or eradicate Ebola, only good science will. Thankfully we have that available to us in our country. 

So listen to those who are knowledgable about infectious disease not lay people who expose their own ideas based on “what if’s”. Don’t listen to the pundits who are arguing with some of the best scientists and doctors that we have because if they themselves get sick one day, they will be seeking out these very same physicians and nurses to care for them. 

But one thing I am sure of, we will have influenza this winter and you can try to protect yourself and your family with flu vaccine.  There has never been a more important year to get vaccinated. Run, don’t walk and get vaccinated!

Daily Dose

College & Alcohol: A Dangerous Mix

1:30 to read

I have been reading and watching news reports surrounding the University of Virginia article in Rolling Stone and the recent trial of several Vanderbilt University football players charged with rape. I guess it has weighed heavily on my mind as I have had three sons in a fraternity at a large state school, as well as taking care of more than several young women (patients) who have said they were sexually abused while away at college.

To begin with, and I have said this before, my husband and I began talking to our sons, at rather young ages, about how you “treat” girls. This began with explaining to them that there is a “difference between boys and girls”, and I say this as a woman, wife , mother, physician, and now grandmother to a little girl.  

So...we taught our sons that when a girl says “NO” it always means “NO”, no matter the circumstance.  This conversation became even more direct as they got older and started dating.  Now that they are adults, I can only hope and assume that they listened!

I believe in gender equality, but i do think there is a difference between boys/girls, young men/young women and that difference comes when both genders begin drinking alcohol and getting drunk.  My patients will tell you that I discuss this with each of them as they leave for college. While boys get drunk and do some very scary, inappropriate and dangerous things...they do no get raped by a drunk girl. 

In all of the girls I have taken care of, and also in the case of so many other college women in the news, there was excessive alcohol when a sexual assault took place.  Binge drinking on college campuses is one the the biggest problems being tackled by many universities across the country.  But sexual assault and abuse is another university problem that continues to exist.

Back to differences....a girl/young woman who is drunk cannot protect herself, often cannot recall “he said/she said” and sometimes awakens from a drunken stupor without her clothes on. It distresses me to write this. Whether it was consensual, or rape...it is often unclear when the girl was drunk.

Talk to your sons and daughters about this epidemic.  I tell my female patients, and I will tell my grand daughter one day "it is your body and the only way to protect yourself is to be of clear mind...if you drink you need to be able to take care of yourself and always be aware of what is happening". It cannot be a “blurry” memory.

Daily Dose

Kids Who Snore

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Does your child snore?  If so, have you discussed their snoring with your pediatrician.  A recent study published in Pediatrics supported the routine screening and tracking of snoring among preschoolers.  Pediatricians should routinely be inquiring about your child’s sleep habits, as well as any snoring that occurs on a regular basis, during your child’s routine visits.  

Snoring may be a sign of obstructive sleep apnea and/or sleep disordered breathing (SDB), and habitual snoring has been associated with both learning and behavioral problems in older children. But this study was the first to look at preschool children between the ages of 2-3 years.

The study looked at 249 children from birth until 3 years of age, and parents were asked report how often their child snored on a weekly basis at both 2 and 3 years of age.  Persistent snorers were defined as those children who snored more than 2x/week at both ages 2 and 3.  Persistent loud snoring occurred in 9% of the children who were studied.

The study then looked at behavior and as had been expected persistent snorers had significantly worse overall behavioral scores.  This was noted as hyperactivity, depression and attentional difficulties.  Motor development did not seem to be impacted by snoring.

So, intermittent snoring is  common in the 2 to 3 year old set and does not seem to be associated with any long term behavioral issues. It is quite common for a young child to snore during an upper respiratory illness as well .  But persistent snoring needs to be evaluated and may need to be treated with the removal of a child’s adenoids and tonsils.

If you are worried about snoring, talk to your doctor. More studies are being done on this subject as well, so stay tuned.

Daily Dose

When to Worry About Bumps on the Neck

Have you ever been bathing your child and washing their head and neck and suddenly felt little “lumps or bumps” about he size of a pea or dime on their necks?Have you ever been bathing your child and washing their head and neck and suddenly felt little “lumps or bumps” about he size of a pea or dime on their necks? It makes your hand stop for a minute as you feel this small marble and of course “terrible thoughts” race through your mind. Well, it is not uncommon to feel these little lumps on a child’s neck.

Especially if your child is thin and they may have their neck extended for you to get underneath their chin for a thorough washing. The head and neck area is full of tiny lymph nodes and they are sometimes easily felt. Just because you can feel a lymph node does not mean you need to worry! Benign lymphadenopathy, as it is called in medical jargon is quite common. The lymph nodes of the neck “drain” the head and are often palpable around the jaw line, behind the ear, or even at the back of the neck. Benign (meaning, not to worry) nodes are small, mobile (in other words move around like a ball), non tender, and do not appear to be red or inflamed on the surface of the skin. These nodes are usually pretty small, again like a pea or dime. If your child is sick with a cold or has a “zit” on their face or a mosquito bite in their scalp etc, the node or nodes in fact may be a little bigger and some kids may say it is a little tender to the touch, (usually only to the mother’s hand as when I feel them of course they say “they no longer hurt“). That is like taking the car to the shop, gets better once you are there and have waited your turn! Most notably about benign lymphadenopathy is that the node does not really change. You watch it for several days and it is still small, non-tender and mobile and then forget about it for a while. In most cases by the time you think to check it again it is gone. The node should not grow in size, become hard and fixed (again you want it to move around beneath your fingers) and should remain asymptomatic. So, don’t jump to conclusions if you feel one of these and if in doubt let your doctor feel it. We all also have nodes beneath our arms, and in the groin area. Same thing goes for those in most cases, check to see if there is a cut, scratch, or bite nearby and watch the node for a few days. Things that are changing are worth a trip to the pediatrician. Peace of mind is often worth the wait. That’s your daily dose, we’ll chat again tomorrow.

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Daily Dose

The Right Way to Take A Temperature

1:15 to read

During flu season and really throughout the year, the questions surrounding how to take a temperature in a child and how to treat a fever seem never ending. So I thought let’s jump right in with a discussion on taking temperatures in all age children.

There are many different thermometers out there, and many different methods for taking a child’s temperature. The one way that I know that is not accurate is by “touch of hand”. Many parents report that their child had a fever, but have never taken their temperature. Neither your hand, nor mine is accurate in detecting a fever in a child. I am not a fanatic about taking temperatures all day long but it is important to document your child’s body temperature with a thermometer if you think they have a fever. Also, a fever to a parent may mean 99.6 degrees (I know your child has a different body temperature than others), but in terms of true fever most doctors use 100.4 degrees or higher as true fever. For everyone!

Body temperature in infants is very important and a fever in a child under two months of age is something that always needs to be documented. The easiest way to take a temperature in an infant is rectally and is actually quite easy. Lay your child down, like you would be changing their diaper, and hold their legs in one hand while you gently insert a digital thermometer (lubricate it with some Vaseline, makes it slide in more easily) into their rectum (bottom). It will not go too far, don’t worry, only about 1/2”. Keep the thermometer in their bottom for about a minute and by then you will be able to see if they have a fever. Again, over 100.4 degrees. I use rectal thermometers in children up to about two as they are usually pretty easy to hold and it is not painful at all. It is also accurate. Keep this digital thermometer labeled for rectal use.

Axillary temperatures are taken under the arm and can also be taken with a digital thermometer. It is often confusing if your child’s temperature is in the 99 – 100 degree range, so if in doubt take rectal or oral temperature. I am not a huge fan of axillary temperatures, and it actually requires more cooperation than a rectal temp. Oral digital thermometers, which are placed under a child’s tongues, are easy to use in a cooperative child. By the time your child is three or four, it is fun to teach them how to hold up their tongue and then hold the tip of the thermometer under their tongue and close their lips.  Especially with digital thermometers, elementary children like to read you what the thermometer says, and discuss their temperatures. My children always loved to show me they were REALLY sick when it said 103 degrees. It is then a “sick day activity” to take the acetaminophen and watch your temperature come down over the next several hours. They loved making charts of their body temps. It won’t win a science fair but does keep them busy. Also, if they can play this game they are not too sick. Lastly, do not let your child drink a hot or cold beverage right before taking an oral temp (note for parents of older kids, remember Ferris Bueller?), as the reading may not be accurate.

There are also fancy tympanic (ear) thermometers and temporal artery thermometers. I still prefer digital in my own house, and never purchased a “fancy” thermometer. You can buy tons of digital thermometers for every child to have their own, and still save money. We also often hear parents report that there was over a degree of difference between the same child’s ear. I also do not like ear thermometers in little ones, as their ear canals are too small to get accurate readings. Now that you know how to take a temperature I will discuss fever in another post.

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

Daily Dose

Finger Foods & Choking Hazards

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I get a lot of questions in my office and via email about when to start children on table foods.  In reality, as your 9 – 12 month old child begins to eat soft table foods there really are not foods that are off limits. With that being said the issue is not allergic reactions to some foods, but rather airway obstruction and choking. By that I mean that your child can eat almost any food that can be cooked, mashed, squished, slurped, or can dissolve in saliva. (Only rule is no unpasteurized honey until 1 year). 

I saw a mother last week who was so nervous about finger foods that she was cutting up cheerios! How can you even cut up a Cheerio?  I haven’t tried it, but it seems to me that the Cheerio would just disintegrate into little particles of dust. In actuality, if your child put a Cheerio into their mouth they might gag from a new texture, but the Cheerio itself would break up in the child’s saliva and would not obstruct the child’s airway as it was swallowed. The newer version of Cheerio’s is the Gerber Puff and also the Mum-Mum. Any of these work well as an early finger food.

Young children, under the age of 2 ½ to 3 years, don’t know how to chew. Even if they have a lot of teeth they instinctively put the chunk of food in their mouths and swallow (have you seen teenage boys eat?). If the chunk is large enough or cannot be broken down by the saliva in the mouth, the chunk of whatever might be aspirated and go down the wrong way and cause a child to choke. This is obviously true with not only foods, but with small objects.

So, a child can have peanut butter, but not a peanut. Almonds and cashews are a no-no too, but almond and cashew butters are fine.  No worrying about allergies anymore, those guidelines changed several years ago, but I still hear gasps when I tell parents to try peanut butter!  

A child can have a strawberry or melon that is really ripe and has been cut into very small pieces, but not a fancy melon ball. No need to worry about allergies to berries or exotic fruits, just watch for choking issues. 

What about fish? Flaky fish is a great finger food for a child and very healthy too, but avoid scallops or shrimp that are difficult to eat unless you can chew. (maybe you know of a way to prepare mushy shrimp?)

Questions continue about veggies, and they are all fine. Just cook  them well done, some might even say overcooked, and then cut them into little pieces and just hand your child several pieces at a time.

A brussel sprout may be a choking hazard if it is not taken apart, but green beans, peas, carrots, beets, spinach are all great for young children. Experiment with as many fruits and vegetables as you can. You may even find some new foods that you like.

A well balanced diet is the most important rule. Even if your child pushes some of their finger foods away, keep offering a wide variety of foods.  Children only learn to try new foods and textures with repetitive exposure. It may take 12 times for your child to smoosh the broccoli between their fingers before they even put it in their mouths. 

So… remember airway protection is what you are concerned about, and not reaction to foods. Although food allergies do exist they are much less common than previously thought to be.  Let your child try different foods all of the time and eventually you may be surprised at what a good eater your child becomes. It takes practice and time.  A little patience with the mess of finger feeding is important too, toddlers do not start out neat, they have too learn those manners along the way.  

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

Daily Dose

Chubby Toddlers & Weight Gain

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So, what goes on behind closed doors? During a child’s check up, I spend time showing parents (as well as older children) their child’s growth curve. This curve looks at a child’s weight and height, and for children 2 and older, their body mass index (BMI). This visual look at how their child is growing is always eagerly anticipated by parents as they can compare their own child to norms by age, otherwise called a cohort. 

I often then use the growth curve as a segue into the discussion about weight trends and a healthy weight for their child. I really like to start this conversation after the 1 year check up when a child has  stopped bottle feeding and now getting regular meals adn enjying table food. 

This discussion becomes especially important during the toddler years as there is growing data that rapid weight gain trends, in even this age group, may be associated with future obesity and morbidity. Discussions about improving eating habits and making dietary and activity recommendations needs to begin sooner rather than later. 

I found an article in this month’s journal of Archives of Pediatrics especially interesting as it relates to this subject.  A study out of the University of Maryland looked at the parental perception of a toddler’s (12-32 months) weight. The authors report that 87% of mothers of overweight toddlers were less likely to be accurate in their weight perceptions that were mothers of healthy weight toddlers. 

They also reported that 82% of the mothers of overweight toddlers were satisfied with their toddler’s body weight. Interestingly this same article pointed out that 4% of mothers of overweight children and 21% of mothers of healthy weight children wished that their children were larger. 

Part of this misconception may be related to the fact that being overweight is becoming normal.  That seems like a sad statement about our society in general. 

Further research has revealed that more than 75% of parents of overweight children report that “they had never heard that their children were overweight” and the rates are even higher for younger children. If this is the case, we as pediatricians need to be doing a better job.  

We need to begin counseling parents (and their children when age appropriate) about diet and activity even for toddlers. By doing this across all cultures we may be able to change perceptions of healthy weight in our youngest children in hopes that the pendulum of increasing obesity in this country may swing the other way. 

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

Daily Dose

Spring Viruses

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While it is warming up here in Dallas, many parts of the country are still seeing freezing temperatures and even snow! Even so, I am beginning to see typical spring illnesses like Fifth’s disease. 

Fifth disease is a common viral illness seen in children, often in the late winter and spring. Many of these children look like they have gotten a little sun burn on their faces (just as your child starts playing outside) as they often show up in my office with the typical slapped cheek rash on their faces.  At the same time they may also have a lacy red rash on their arms and legs, and occasionally even their trunks.

Fifth’s is also called erythema infectiosum and is so named as it is the fifth of the six rash associated illnesses of childhood. Fifth disease is caused by Parvovirus B19, which is a virus that infects humans. It is NOT the same parvovirus that infects your pet dog or cat, so do not fear your child will not give it to their pet or vice a versa.  In most cases a child may have very few symptoms of illness, other than the rash.  In some cases a child may have had a low-grade fever, or runny nose or just a few days of not feeling well and then the rash may develop several days later. The rash may also be so insignificant as to not be noticed. When I see a child with Fifth disease it is usually an easy diagnosis based on their few symptoms and the typical rash.

Although children with Fifth are probably contagious at some time during their illness, it is thought that by the time the rash occurs the contagious period has passed. This is why you never know where you got this virus. (the incubation period is somewhere between 4-20 days after exposure).  Parvovirus B19 may be found in respiratory secretions and is probably spread by person to person contact.  During outbreaks it has been reported that somewhere between 10-60% of students in a class may become infected.

Most adults have had Fifth disease and may not even have remembered it, as up to 20% of those infected with parvovirus B19 do not develop symptoms, so it is often not a memorable event during childhood.

Fifth disease is another one of those wonderful viruses that resolves on its own. I like to refer to the treatment as “benign neglect” as there is nothing to do!  The rash may take anywhere from 7–10 days to resolve. I do tell parents that the rash may seem to come and go for a few days and seems to be exacerbated by sunlight and heat. So, it is not uncommon to see a child come in from playing on a hot sunny day and the rash is more obvious on those sun exposed areas. 

Occasionally a child will complain of itching, and you can use a soothing lotion such as Sarna or even Benadryl to relieve problematic itching. A cool shower or bath at the end of a warm spring day may work just as well too. Children who are immunocompromised, have sickle cell disease, or have leukemia or cancer may not handle the virus as well and they should be seen by their pediatrician. But in most cases there is no need to worry about Fifth disease, so it is business as usual with school, spring days at the park and Easter parties.

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

Daily Dose

Food Myths & Your Baby

1.15 to read

I really enjoy talking to my young parents about feeding their baby and toddler new foods. But what about food allergies they say?   I believe that healthy nutrition and good eating habits begin early on, actually just as a child starts to eat solid foods. The more foods a child is exposed to initially, the better chance a parent has of having a child who eats a variety of foods when they are older.  This means no making yucky faces if you (parent) don’t like spinach - fake it! 

But, with that being said, so many new parents are still under the impression that there is a “list” of forbidden foods. As I talk to them about finger foods and letting their baby explore new foods and textures they are amazed when I say things like, “let them try scrambled eggs” or “what about trying almond butter or peanut butter?”, “try ripping up pancake pieces”. 

I also like to let a 9-15 month old try all sorts of different fruit, veggies and proteins. In fact, “there are really no forbidden fruits” as long as the food you offer is mushy (we adults might say a bit over cooked at times) and broken/or cut into very small pieces. I am most concerned about the size and texture of the piece and protecting the airway than I am about the food itself.  

Over the last 5-10 years studies have shown that restricting foods and delaying introduction of certain food groups did not prevent the development of food allergies.  So, the idea that delaying the introduction of peanut butter until after a child is 2 yrs old, or waiting to give a child fish until they are older, or not letting your 9 month old child taste scrambled eggs, did not prevent food allergies. Some researchers would say it may actually be the converse, earlier introduction may be preventative.  

But the funniest thing to me, it is like old wives’ tales....these ideas have somehow been perpetuated.  The new group of parents that I am now seeing were often still in college and dancing at parties when it was the recommendation to wait to introduce some foods (egg, peanut , fish etc).  How do they hear these old ideas?  Maybe grandparents or friends with older children. Who knows? 

So, for the record, the rates for most common food allergies are still low at 2.5% for milk, 1.3% for eggs and 1% for peanut and less than that for tree nuts.  Don’t limit what you give your child unless you have seen them have a reaction when a food is initially introduced, and if you are concerned, talk to your doctor.  Most people who report having food allergy actually turn out not to have true food allergies after a good history and further testing. 

More about true food allergies to come.  Stay tuned! 

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