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Daily Dose

Athletes & Injuries

1.30 to read

I see a lot of athletic teens, and while many of them participate in several sports more and more tweens and teens are “specializing” in one sport. In other words, they may only play soccer or basketball, or be a gymnast or a dancer.  In some cases they practice or compete almost 365 days a year. (I think they often are only off on the 6 holidays/year that our office is closed!).  They too work really hard.

I have recently had more than a handful of elite athletes, especially girls who are gymnasts, cheerleaders and dancers, who have come to me complaining of back pain.  In most cases lower back pain is musculoskeletal in nature and will resolve with some anti-inflammatories (like ibuprofen), alternating ice and heat to the back and a few days of rest. But in some cases the back pain worsens, especially with activity and further work up is required.

In several cases the ongoing back pain is due to a spondylolysis, which is a fracture of the pars interarticularis of the vertebrae. It is akin to a stress fracture in other areas.  It is most commonly found in the pediatric population and is thought to be due to mechanical stress of the trunk with repetitive flexion, hyperextension and trunk rotation.  All of those maneuvers are the “usual” for a cheerleader doing back flips or a gymnast doing exercises with hyperextension.  Athletes who are into weight lifting (seems they all do this now) and even children who carry heavy backpacks may be at risk for a “spondy”.

The spondylolysis may show up on a plain X-ray of the back or may require a CT scan to see the fracture.  

In our community there is some difference of opinion on how best to treat the condition.  Unfortunately, it seems that the best treatment is rest which may be for weeks-months.  This is NOT what they competitive gymnast or star football player wants to hear.  

Once the pain has resolved a structured physical therapy program seems to be of benefit as well.  If conservative management for over a year does not help some orthopedists would recommend surgery. Again, there are several different views as to the benefits of surgery in this age group.

But if your child has persistent lower back pain that worsens with activity and hyperextension you should think about this condition and talk to your doctor. It is becoming more prevalent as our kids compete at higher and higher levels.  

Daily Dose

"Glee" Episode: Mono

Dr. Sue discuss Mono and Epstein Barr and how they are related.I have received several questions via our iPhone App regarding mononucleosis, which is commonly called, “the kissing disease”, as the virus is passed in saliva.   I think it's because many were watching the recent "Glee" espisode where Finn and Quinn have mono.

Mono is most frequently caused by the Epstein Barr virus, but there are other viruses which may mimic the symptoms of mono.Many of us have been exposed to Epstein Barr virus (EBV) and may not even realized it, while others will develop a viral illness which typically causes sore throat, fever, congestion, swollen lymph nodes, and fatigue. As you can see, these symptoms mimic many illnesses. In my experience, the most classic cases are in the teenage age group, who are often found to be kissing one another,  as well as sharing glasses, sports bottles, food and even lipsticks which may also transmit the virus via contamination with saliva.  In most cases a person has no idea where they contracted the virus and it takes from 4 – 10 weeks after exposure to develop the symptoms of mono. A teen will often come in to the office complaining of a really bad sore throat with or without fever and swollen lymph nodes in their neck.  They usually think they have strep throat. But, their throat culture comes back negative for strep, so they are assumed to have a viral pharyngitis. A typical  viral sore throat usually improves over a few days, but with mono the patient usually feels worse rather than better after 4-7 days.  Their throat actually becomes more painful, with more swelling of the tonsils and the tonsils are often covered with white patches (called exudate) larger cervical lymph nodes, headache and fatigue. In some cases there may be swelling of the upper eye lids (periorbital edema) and a skin rash may be seen (especially if the patient had previously been put on a penicillin related antibiotic for presumed strep).  It is interesting that younger children who acquire mono often do not have as many of the symptoms as a teen, and indeed they have a shorter illness, so many youngsters with mono are never “officially” diagnosed with the EBV virus, but are now immune to the virus too. The easiest way to diagnose mono is with a blood test called a monospot, that picks up the EBV antibodies in the bloodstream. It usually takes about a week after symptoms begin to have a positive monospot.  There are also other antibody tests that may be run to determine if a patient currently has mono, or  has ever had mono, but these are more expensive and take a longer period of time to get results. The acute symptoms of mono last anywhere from 7 – 14 days but the fatigue may last longer.  Because mono is a VIRAL illness, it is not treated with antibiotics  Treatment like so many other illnesses is simply symptomatic.  Fluids, rest, pain relievers like acetaminophen or ibuprofen (do not use aspirin products in children), and tincture of time. I also recommend that patients take several weeks off of sports due to the possibility of their spleen (which is lymph tissue too) becoming swollen.  The issue with splenic swelling is the risk of rupture if the spleen is hit, bumped or fallen on during an activity. Once the patient is feeling better and has been examined again and their spleen has returned to normal, they may return to their sports.   It is also wise to limit a teens activity so that they may get sufficient rest.  This basically means that once they are feeling well enough they return to school, but other activities are put on hold until they are back in school and their energy is returning.  As one teenage patient aptly put it, “it is like I was grounded, but I didn’t even get into trouble.”  The reason for slow return to full activity with extra rest is to ensure that within 3-4 weeks of diagnosis the patient is fully recovered and back to all activities. I have found if you don’t tell teens specifics about activities, once their acute symptoms are better they do not rest,  and the fatigue lasts longer. Good rest and nutrition are essential to recovery.  The good news, you only get EBV once! By the way, we are all fans of "Glee"! That's your daily dose for today.  We'll chat again tomorrow.

Daily Dose

Cold Season is Here

School starts and colds start almost simultaneously no matter how old your child is.School starts and colds start almost simultaneously. It even amazes me to see kids with their first cold of the season within 15 minutes of starting school, whether it is Mother's Day Out or high school, it affects every age.

The worst part of a having a cold is knowing that it is going to last seven to 10 days, no matter what you do. The old adage of rest, fluids and nasal irrigation is still the mainstay of treatment. Remember that over the counter cough and cold medicines are not recommended for use in children under the age of 2 and really are not very effective in the overall scheme of things. There has been some renewed interest in zinc and reduction of symptoms and decreased duration of colds so stay tuned for more info on that. In the meantime, keep up hand washing and good cough hygiene to try and prevent getting one of the first colds of the season. That's your daily dose, we'll chat tomorrow!

Daily Dose

Why 'Herd Immunity' Does Not Work

With all of the recent anxiety surrounding Swine Flu and the possibility of epidemics, lets be pro active in protecting all of us from diseases that we can prevent with the current immunizations that are available.There is an article in the June issue of the journal Pediatrics, which looked at whether parental refusal of pertussis vaccination could be associated with increased risk of pertussis infection in those unimmunized children. The study was conducted between the years 1996 - 2007 and looked at case controlled studies which compared a child with documented pertussis (whooping cough) to 4 other randomly selected children who did not develop pertussis. This study is important as many parents believe that if they choose not to vaccinate their child, that their child is protected by herd immunity (in other words, by all of the rest of us that are immunized).

In this case the study showed that 11% of all pertussis cases in this pediatric population were attributed to parental vaccine refusal. This study is important for several reasons. It is one of the first to document that herd immunity does not seem to completely protect unvaccinated children from pertussis. Children of parents who refuse pertussis immunizations are at high risk for pertussis infection relative to vaccinated children. One would assume, but further studies need to be done, that similar results would be found if you looked at diseases like measles, or H. flu meningitis. Herd immunity is important to the general health and well being of all of us, but it is not 100% at any time and risk of disease is still there. As we see increases in whooping cough in many communities across the country the need to educate parents about the importance of vaccines is paramount. Parents need to be protected too and we should all have a TdaP as an adult to provide pertussis protection for ourselves, as well as for those infants around us who are too young to be immunized. With all of the recent anxiety surrounding Swine Flu (H1N1) and the possibility of epidemics, lets be pro active in protecting all of us from diseases that we can prevent with the current immunizations that are available. That's your daily dose, we'll chat again tomorrow.

Daily Dose

Getting Your Baby to Sleep!

1:30 to read

Did you know one of the biggest Google internet searches for parents revolves around “how do I get my baby to sleep?”  I guess that any new parent in the middle of the night is online searching for “THE ANSWER”, so of course you “Google it”!

Now that we are grandparents and the baby is about 6 weeks old (although technically she is a week old, as she was 5 weeks early) my son is also looking for answers on the internet to that same to make her sleep, so I can too! He even asked me if their was “magic” to this?

If only there was an answer on Google or in any book. It just takes time and every baby is different.   I guess there are some babies that sleep through the night from the time they get home from the hospital, but I have never seen one.  I think some parents just forget that at some time or another they were up at night with a newborn.

A newborn baby does not understand circadian rhythm and they are really not “trying” to keep parents up at night.  It takes weeks for a newborn to even begin to have some “routine” to their day and I try never to use the word “schedule” when discussing a newborn.  A baby is not a robot, they do not eat every 3 hours and then sleep for 3 more before eating again. They are “little people” and their tummies sometimes need to eat in 2 hours and then later it may be 3 hours before another feeding.  Don’t you sometimes eat an early lunch one day and a later lunch the next? 

But by trying to awaken the baby throughout the day and offering a feeding every 2-3 hours you will hopefully notice after several weeks that your baby is eating more often during the day and suddenly may thrill you and sleep 4 hours at night. it just takes time....YOU cannot make it happen.  I tease new parents that awakening a newborn during the day and prayer is about all you can do....all babies do eventually sleep, but it may not be right after you get them home from the hospital...think several months (as in 2-4) and you will be happy if it happens sooner.

Lastly, with all of the tech in the room, don’t pick up your baby in the middle of the night if they are just “squirming” around. Babies are notoriously loud sleepers and if they are not crying let them be and you may be surprised that they arouse and went back to sleep. If your baby cries you absolutely go get them and console them and feed them too if it is time. An infant should not be left to cry. 

This too shall pass and sleep will come, but there will be new stages down the road that will keep parents up at night, of that you can be assured. Comes with the territory.

Daily Dose

Summer Skin Infections

1:30 to read

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

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

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

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

Daily Dose

All About Naps

1.00 to read

Just how many naps should your baby be taking and how long? When you are an adult, there is nothing better than taking a nap. Shouldn’t it be the same for children?  I get lots of questions from parents who ask when their children should take naps; how many times a day they should be napping and when do children stop napping?

Many new parents expect their newborn infants to take regular naps throughout the day (and then to sleep all night) even when they are only 4-10 weeks old. Unfortunately, a newborn’s sleep cycle is not ready for 2 hour naps in both the morning and afternoon followed by a 10 -12 hour extended sleep at night. But, by the time your child is 6-9 months of age (and sooner for some great sleepers); they should be on a good schedule with a morning and afternoon nap.  Naps are usually anywhere from 45 min – 2.5 hours.  I think naps serve a dual purpose, as they provide rest and rejuvenation for both child and parent. Nap time, just like bedtime should be scheduled, typically mid morning and mid afternoon and a child should be able to put themselves to sleep after a book or a story. Naptime routines can be bit shorter than the bedtime routine. You will be able to tell when your child is ready for a nap as they may rub their eyes, or get fussy, or some may just lay their heads down or point to bed as they know they are tired. By the time a toddler is somewhere between 12months – 2 years of age they will usually drop a morning nap and continue to have their midafternoon nap. This is usually right after lunch. Transitioning from 2 naps to 1 nap a day is a little “dicey” at first, as your child may get quite cranky in the morning as you drop that nap, while at the same time their afternoon nap may become longer. This adjustment period usually only lasts several days to a week and then you will find that they are back on a good nap/nighttime schedule. I get asked about stopping a child’s nap. I think naps are important (and as we adults know a privilege) for children until they are in elementary school. Most kindergartens continue to have “rest” time after lunch and many children will fall asleep for 20-30 min while the teacher reads them a book or music is played and the children lay on their mats. Even if your 4 – 5 year old child doesn’t “want” to nap in the afternoon, they need to have quiet time.  This may be for an hour or so in the afternoon, and is time for them to lay in their bed and read, color, play with dolls etc.  I do not think is the time for video games, or computer time etc. Many a child will fall asleep once they are in bed reading and will continue to take a good nap, they just didn’t know that they needed it! Moms, Dads, babysitters etc all need this quiet time too, to get much needed work done around the house, or dinner started etc. It was just a rule at our house that naps didn’t stop until you were in “big boy” school.  A quiet house for an hour each afternoon seemed to make the rest of the day and evening a happier time for everyone! That’s your daily dose for today. We’ll chat again tomorrow.

Daily Dose

July 4th Food Safety Tips

2.00 to read

Whether it’s spending the day at the lake, by the pool or in the backyard, Americans love a good July 4th celebration. And you can bet there will be plenty of food shared by families and friends!

It’s never a bad idea to review food safety tips especially if you’re going to be cooking and serving food outside.

A little planning and the right tools should will help make sure no one ends up with a bellyache or worse, food poisoning.

Here are the basics in a nutshell:

Keep everything clean. That includes your hands, knives, cutting boards, eating utensils and preparing and cooking surfaces.

Soap and water is the best method of cleaning but may not be convenient. Use prepackaged sanitizing towels or make up a small bucket of diluted bleach solution (2 oz. bleach to 1 gallon water) to use when wiping up spills or cleaning surfaces.

Make sure your hands are clean.  Use soap and water to scrub hands for at least 20 seconds. If washing your hands often isn’t practical, keep hand sanitizer close by and use it each time you handle raw meat, poultry or fish.

Avoid cross contamination. Separate meat, poultry and fish. Package raw items in plastic bags or sealed containers so that spilled juices don’t contaminate other foods.

Never put cooked meat back on the same soiled plate used to transport it while it was raw. Use a clean serving dish for food taken from the grill.

Use separate cutting boards and knives to steer clear of cross contamination. Pork and beef may be cut on the same surface, another for chicken and one more for fish. Using pre-sliced breads, cheese or vegetables to eliminate the need for additional knives and boards.

Make sure foods are thawed correctly. The best method to fend off bacteria is to thaw food in the refrigerator. Make certain that juices from thawing food do not drip into other items. Some food may be defrosted in the microwave or under running cold water. Never thaw food at room temperature, except breads or desserts that are recommended to defrost at room temperature.

Use a thermometer. Make sure your food is cooked thoroughly to kill bacteria that can make someone sick. Use a probe thermometer to check the internal temperature of grilled meat or chicken for doneness. Beef, lamb or veal should be no less than 145º F for medium rare. Chicken or turkey pieces are done at 170ºF and 180ºF for duck. Most prepared foods should reach 165ºF to be safe. Cook in small batches and serve immediately.

Food that is ready to eat needs to be kept hot or cold, as appropriate for each dish. Hold cold food at less than 40ºF and hot food above 140ºF. Any temperature between 40ºF and 140ºF is in the danger zone, ideal for bacteria growth.

If in doubt – don’t eat it. Condiments such as ketchup, mustard and pickles do not require careful temperature monitoring during use but should be refrigerated to extend the product life. Bread, rolls and cakes usually are okay at room temperature at any time. If something doesn’t smell or look right to you or you think it may have been sitting out too long – toss it. It’s much better to be safe than sorry.

These food tips are applicable any day of the year, but it’s easy to get in a rush when there are lots of people ready to chow down. Take your time, plan ahead and remember to have a wonderful and safe July 4th!


Daily Dose

The Dangers of Diagnosing Online

The hazards of using the Internet as your own medical textbook can be great.Here I am on the internet writing about the dangers of diagnosing yourself or your children via information on the web. The internet is a valuable resource, and I cannot remember what I used to do before I could “Google” something to get a quick answer. You don’t need a phone book anymore or zip code directory or even a map, as it is all available online.

But, when it comes to medicine there is still nothing as effective and reliable as seeing a doctor in person and having a physical exam. The hazards of using the Internet as your own medical textbook can be great. The Internet is a resource, and not a doctor. Just like Sir William Osler taught when he published The Principles and Practice of Medicine in 1892, the physician must examine the patient. The best doctors still take a complete history and do a good physical exam!! I often tell parents and patients to use the Internet as an adjunct once the diagnosis has been made. The Internet may be a great resource to provide further information about a specific problem or disease. But when searching online you want to make sure that you are using a resource that has good research and is reputable and reliable. Many postings on the web may be anecdotal rather than factual and there are no requirements on the web to post information. In other words, you don’t have to go to medical school and get a degree to “publish” on the Internet. I sometimes see a worried parent in my office, whose child may have awakened during the night with a “tummy ache”. Despite the fact that the child had already gone back to sleep, the parents stayed up searching the Internet for “abdominal pain”. Due to their Internet “research” the parents have convinced themselves that their child must have appendicitis, and by morning they are convinced that testing is warranted (of course they read every blog about “missed appendicitis”). The child may have had no other symptoms than that “tummy ache”, slept the rest of the night, and awakened feeling just fine, ate breakfast and are ready for their day. But, they appear in my office, many times 8 – 12 hours later and want to run for further tests and are planning for imminent surgery. All of this anxiety provoked by Internet research. Somehow, the most common symptoms have been overlooked during the parent’s panic. The child feels fine now, looks great and is ready to go back to playing! But the poor parents have scared themselves into wanting CAT scans and ultrasounds to “make sure” nothing is missed. A good review of the history and physical exam is often all that is needed in the case of the “mystery midnight tummy ache”. The only thing that came of that internet research is that the parent had 12 hours of a tummy ache worrying about obscure diagnoses rather than heading back to bed themselves. So, beware of using the Internet for research without knowing what you are researching. Always use reputable web sites and check out the credentials of those who are giving information. Beware of people or companies that provide information that are not in the mainstream and who do not provide valid scientific research to back their claims for a “cure”. When in doubt, ask your own doctor, I am sure they have an opinion about the pros and cons of online diagnosing. That’s your daily dose, we’ll chat again tomorrow. How much do you use the internet when it comes to a diagnosis? Let me know and leave your comment below.


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