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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

Toddler Constipation

1:30 to read

I get so many questions about toddlers and constipation.  Constipation relates to stool frequency and consistency.  It is important to understand that everyone has different bowel habits and not all children will have a stool every day.  While some children will have several stools a day another may have a stool every 2 -3 days. Both of these scenarios may be normal and not an indicator of problem.  At the same time, stool consistency is important. If your child has  hard, dry, pebble like stools ( rocks rather than softer snakes or blobs ) this may be an indicator of constipation. Everyone will occasionally have a hard stool, but this should not occur consistently. Lastly, it should not be painful to pass the stool. While toddlers may grunt or push, or even start to “hide” to poop, it should not cause real pain.

With all of that being said, it is not uncommon for toddlers to become constipated as they often are also becoming picky eaters. Due to this “phase”,  some young children will drink too much milk in place of eating meals and this may lead to constipation. Your toddler should be drinking somewhere between 12 -18 ounces of milk per day.  Many children also load up on other dairy products like cheese, yogurt and cottage cheese, which while healthy, may also lead to too much dairy intake and contribute to constipation.

Water intake is also important to help prevent constipation. If your child is drinking too much milk, substitute some water as well.  It is a balancing act to make sure your child is getting both milk and water. If necessary I will also put the smallest amount of apple or prune juice in the water. By the age of 1 year, your child should no longer have a bottle as their main source of nutrition is no longer in the liquid form!

Fiber is also important so offer plenty of whole grains and limit the “white foods” that toddlers love (yes, the bread, cereal, pasta). If you always buy whole wheat pasta and whole grain breads your children will never know the difference. Stay away from processed white foods whenever possible.  It is also easy to throw flax seed or bran into muffins or smoothies (disguising fiber). I also sometimes use Metamucil cookies (they are pre made) and may even resort to dot of icing smeared on it and offer it as a cookie for snack, along with a big glass of water.

Fruits and veggies are a must…even if you think your child won’t eat them! Your toddler needs 2 servings of fruits and veggies every day and rotate what you offer them.  You will be surprised at how one day they may refuse something and they next they will eat it. Don’t give up on fruits and veggies,  it may literally take years for your child to eat peas…but if they aren’t offered a food repetitively they will probably never it eat. I know a lot may get thrown to the floor but just clean it up and persevere.  Not only will this help their stools but their long term healthy eating habits as well.

Movement is also important to help keep the bowels healthy and “moving”.  Making sure that your toddler is moving seems crazy, as they are on the go all of the time.  But with an older child make sure they are getting plenty of time for play and exercise outside or in…and not just sitting in front of a screen.

Lastly, for short term issues with constipation it is also okay to try using milk of magnesia (MOM) or even Miralax….but ask your doctor about dosing in toddlers.   

Daily Dose

How to Treat Croup

1.15 to read

Now that the weather seems to change daily, croup season is here. Have you heard the sounds of raspy, throaty voices in your house lately? This "noise" is ushering in croup season! Croup is an infection that causes swelling of the larynx (vocal box) and trachea (windpipe) that in turn makes the airway just beneath the vocal cords become swollen and narrow. When you have swelling and narrowing of the airway breathing becomes more difficult and noisy and the sound that is made, almost like that of a seal barking, is called being “croupy”. Croup is quite common in young children, but the sound the emanates from that child when they cough, can be scary and concerning for both parent and child. Children are most likely to get croup between the ages of six months and three years. As a child gets older croup is not as common as the trachea gets larger with age and therefore the swelling does not cause as much compromise. When you awaken in the middle of the night to hear your child “barking” in the next room you need to know what to do. Most croup is caused by a common virus, so croup is not treated with antibiotics. The mainstay for the treatment of croup is try and calm you child, as they may be scared both from the tight feeling in their chest, as well as the sound that is made when they are breathing and coughing. The best treatment for croup seems to be taking your child into the bathroom and turning the shower on hot. Let the steam from the hot water fill the room and sit in there and read a book or two to your child. Typically within five to 10 minutes (before the hot water runs out) the moist hot air should help your child’s breathing. They may still have the barking, croupy cough, but they should be more comfortable and will not look like they are having trouble breathing. If the moist steam does not work, and it is a cool fall night, go outside. That is right, taking your “croupy” child from the moist heat in the bathroom, outside to cool night air may also help open their airways. If your child is showing signs of respiratory distress, with color change with coughing (turning blue while coughing, red is always good), is retracting (using their chest muscles between the ribs to help them breath), is grunting with each breath, or seems quite anxious and having trouble breathing you should call for emergency help. If a child is having real difficulty breathing they may be admitted to the hospital to have supplemental oxygen or breathing treatments. Steroids have also been helpful when used for the correct patient population. Steroids may be used in both an outpatient and inpatient setting. Steroids help to reduce inflammation in the trachea and the symptoms lessen over several days. Steroids used in a short burst are not harmful to your child, and are indicated in a child who may have mild respiratory distress due their croup symptoms. Your child may have symptoms of croup for several days, and for some reason they always seem to be worse at night. Put your child to bed with a cool mist humidifier in their room for the next several nights, this will also help to provide moisture to their airway. It is not uncommon for some children to seem more “prone to croup” and may get it recurrently all fall and winter. Have the humidifier handy and in working order! That’s your daily dose, we’ll chat again tomorrow. Send your question or comment to Dr. Sue!

Daily Dose

Don't Miss Out on Summer Fun!

1.00 to read

The lazy days of summer seem like the perfect time to engage in playtime activities. My summer months at the office are particularly busy doing check ups as everyone is out of school. This means that I seem to see a lot of children in the 5-12 year group, and I enjoy getting to talk to them about their summer fun. 

I have suddenly realized that many of the children in this age group seemed to have “missed” some key milestones in child development, which I think most of us adults learned during the lazy days of summer.  I think learning to ride a bicycle and learning how to swim are two MUSTS of child development. While not all children will want to one day participate in a swim team, or a bike race, being able to swim and pedal a bicycle are life long skills. Who knows, with the price of gas we may all be heading back to bicycles as preferred transportation, at least for short distances.  

At the same time I have noticed a fair number of parents who are concerned about their young children’s motor development.  This is the 2-4 year old group where I am sometimes amazed when the parent of a 3 year old tells me that their child “does not jump high enough”. What?  How about getting out the jump rope again, and drawing hopscotch on the sidewalk to practice hopping and jumping. These are free exercises that can help boost coordination while having fun together. What about learning to skip and to balance on a beam (doesn’t have to be at gymnastics) a two by four in the back yard or park works just as well. Learning to pump a swing is another. I can remember how proud I was when I mastered that skill (makes me smile, even today). 

So while the last days of summer are here, make a list of not only summer reading, or computer skills that your child needs to finish, but of some of those childhood milestones as well.  Hop, skip, jump rope, ride a bike, learn to swim. College applications might start asking about those milestones one day too?  Stranger things have happened.

Daily Dose

Potty Questions Keep Coming

1.15 to read

Potty training always gets lots of questions and one of the most common is having a child who will "tinkle" in the potty but is not yet "pooping". When potty training all three of my boys, they all pooped later than they tinkled. I know some people disagree, but I certainly think I hear of more people who have to work a little harder and longer to get to pooping on the potty. It may be due to a toddler's fear of letting their poop go, or the difference in sensation with stooling or any number of issues that toddlers are working through as they are potty trained.

Whatever the reason for children who arenot wanting to poop, you have to continue to be patient and praise their success on the potty with urination. Continue to discuss poop within the family, and let your child see you going to the bathroom. Talk about how animals, birds, fish and people all poop and they don't do it in a diaper or underpants but in the potty. During all of this conversation (and while you are frustrated), make sure that your child is not holding stool and becoming uncomfortable, which only adds to anxiety and fear and further withholding poop. You might want to try putting your child on a prune juice cocktail, milk of magnesia, or Miralax to soften the stool and ensure that they are having a soft stool every couple of days. A toddler will often hold their stool until bedtime when they are in their diaper and will then poop or may ask for a diaper to poop during the day. This is not uncommon and usually does not last terribly long. If they want to poop in their diaper I would have them sit on the potty with a diaper and poop and then put them back in their training pants. I also praise and rewardthem for sitting on the potty to poop, even if it is in a diaper, and use a sticker chart or M&Ms or both. Hopefully, over time they will realize that sitting on the potty to poop is perfectly normal and will give up the diaper. You can even cut a hole in the diaper to let the stool come out into the potty so that they may see that it is not painful, scary or difficult. Always remember to praise and not punish and to be patient and consistent with your messages about poop. Rewards seem to go a long way, and albeit small, they often work wonders. It may take several months of persistence to conquer the poop issue, so remain calm. If they continue to have problems have a further conversation with your doctor about the possibility of stool holding and encopresis. That's your daily dose, we'll chat again soon.

Daily Dose

What a "Bald Spot" Can Mean for Kids

I saw a patient the other day whose mother brought him into the office after her son had found a “bald spot” on his head. It is alarming for parents or a child to find an area of hair loss or a “bald spot” on their head.

One of the reasons for hair loss is called alopecia areata. Alopciea areata is a non-scarring, solitary or multiple circular patch of hair loss. The areas are often described as "coin-shaped", often the size of a nickel or quarter, but may be larger. Alopecia areata is an immune disorder typically seen in children and adolescents. It can run in families and stress may play a role as a trigger. The areas exhibit no scaling, scabbing or irritation, there is simply hair loss. In older adolescents and young adult males the disorder can occur in the beard areas around areas of hair loss. Most of the lesions will resolve within a year, but patients often have repeat episodes. Rarely the hair loss can progress to total loss of scalp and body hair. Parents often confuse the hair loss with the fungal disease known as "ringworm", but alopecia areata is not related to a fungus or any other known contagious disorder. There is no cure for Alopecia areata, but there is treatment. The most common treatment consists of steroid injections into the areas. There can be significant psychological issues associated with the cosmetic consequences of alopecia areata and parents should be aware of that when deciding whether to treat the areas or wait for spontaneous resolution. In this case I sent him on to a dermatologist for further evaluation and treatment. The good news is that the majority of cases will resolve. Like so many things it takes time and patience and that is hard to have if you are a teen with hair loss. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

First Cold

1:30 to read

My office is hopping with a lot of little ones and their first colds. The worst cold that a parent experiences is not their own cold, but their child’s first  one.  Unfortunately, babies that are born in the fall and winter months often get their first cold earlier than a baby born during the spring and summer. 

It is such a helpless feeling for a new parent to see their baby with a runny nose, red rimmed eyes and a cough.  While newborns routinely experience nasal congestion, a cold is different. With a cold the baby’s nose will run and have clear to colored mucous,  and they will typically cough, just like all of us with a cold. They just look so pathetic...but you need to know what to watch for....as there will be more colds throughout the winter.

A baby (over the age of 2 months) may run a bit of a fever with their cold. A fever is defined as a temperature over 100.4 degrees. I am old school and still do rectal temperatures....just don’t think the temporal and ear thermometers are accurate.  The fever, if they even have one, should not last more than a day or two and should respond to the appropriate dose of acetaminophen for your child’s weight.

The biggest concern for a baby with a cold is how they are breathing. While they may look pitiful with that gunky nose, and have a loose junky cough, how your child is breathing is most important. You need to actually look at your child’s chest while they are breathing and coughing to make sure that they are not having any respiratory distress. Undo their onesie or take off the nightgown and look at their chest.  You do not want to see your child’s chest moving in and out (which is called retracting) or see that they are using their tummy (which is going up and down) to help them breathe.  The cough may sound horrible, but always look at their chest (visual more important than audible). They should also be nice and pink...even when they are coughing.  A cool mist humidifier in their room at night will also help.

Best thing for gunky nose is a nasal aspirator or nose Freda with some saline drops. Clearing the nostrils is often one of the best ways to help your child breathe, which will also help them to take the bottle or breast. A baby may not eat as well when they are sick (same as you and me) but they will take enough to stay hydrated and have wet diapers.  Being sick at any age typically effects your appetite and as your child is feeling better their appetite will improve as well.

Getting past that first cold is a milestone for baby and parents....but if you have any concerns about your child’s breathing, hydration or persistent fever, always call your doctor.

Daily Dose

How to Treat A Vomiting Child

We are definitely in the throes of "sick season" in our office and with that comes a lot of kids with vomiting. I remember the first time that one of my own children vomited.

We were in Target, he was about two and he had said he "was sick". Now, seeing that he was not very specific and did not elaborate, I just went on shopping. Several minutes later, as he sat in the cart (with seat belt fastened), he just looked at me wide eyed and suddenly vomited. This is the moment as a parent that you understand the difference between babies that "spit up", and true, projectile vomiting! Now what do you do once your child has vomited (besides rush out of Target as fast as you can)? Once a child has vomited it is important not to give them anything else to eat or drink, for at least 30 to 45 minutes. That means even if they are "begging" for a drink, as you will probably see it come right back at you if you do. After waiting, you want to begin re-hydrating with clear liquids. Not a good idea to pull out the milk or food yet. In an infant you can use Pedialyte, which is an oral electrolyte solution, and instead of breast milk or formula you can try feeding your infant about an ounce of Pedialyte every 10 to 15 minutes and see if they can keep Pedialyte down. In toddlers and older children I use Gatorade, as it is not quite as "salty" and kids seem to take it better. Again, frequent small sips of Gatorade while you wait to see if the vomiting is persistent. Don't go too quickly on giving them larger volumes. The key is small amounts, frequently, which are easier to handle. As your child keeps down the Pedialyte or Gatorade you can increase the volume that they are taking and decrease the frequency. The main thing you are trying to do with a child of any age is to keep them from getting dehydrated and their vomiting is typically due to a viral illness affecting their GI tract. Because it is typically a virus that is the culprit for nasty vomiting, it just takes time to get through the illness. There is no "miracle" cure, and watching your child vomit, or cleaning up the vomit that invariably is usually not in the toilet, is one of the worst parenting jobs. That being said, there are very few children who will not experience vomiting at least once or twice during their childhood, so you need to keep "clear liquids" on hand in the pantry. Having powdered Gatorade around is a lifesaver at 2 a.m when your four-year-old wakes up and throws up. If you are giving the clear liquids, and your child tolerates larger volumes, but then vomits again later on, you just back up and start all over with smaller amounts more frequently. It is somewhat like a "balancing act" to give enough that they are hydrated, but at the same time to not give too much at one time that they vomit again. Slow and steady is the mantra. You should always be looking for your child to have tears, a wet and moist mouth (put your finger in there, it should come out with some saliva on it), and urine. It is often hard to tell if a child in diapers has had a wet diaper as they will not be "soaking" the diaper and smaller amounts of urine are "wicked" with the new super absorbent diapers. Children will also be pitiful after vomiting and may seem "lethargic" to you, but if they are an infant and can smile and make good eye contact or they are an older child who can tell you they feel terribly and don't want to drink Gatorade or play with their blocks they are probably not dehydrated. If in doubt, give your doctor a call to discuss what is going on. After using Pedialyte and Gatorade, and your child has not vomited for six to eight hours you can try adding some formula or breast milk, or other liquids such as chicken soup or a Popsicle. I still would not start solid food until the child has kept down other liquids. We parents all worry if our children don't "eat" but the fluids are the important part, and as we all know, a day without out chicken nuggets or peanut butter will be okay. Keep up the fluids!! If your child continues to vomit despite your best efforts with "slow and steady" fluids you need to call the doctor. We have plenty of patients that we see everyday to make sure they are hydrated, and to even watch them while they take fluids in our office. Occasionally, when all else fails we will have to hospitalize a child for IV hydration. Oh yes, remember to wash your hands frequently as these nasty viruses are contagious and parents will often find themselves getting sick after their children. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Have Your Child's Blood Pressure Checked

1:00 to read

When you take your child in to the pediatrician for a check-up do they check their blood pressure? The American Academy of Pediatrics (AAP) recommends that children, beginning at the age of three years, should routinely have their blood pressure checked.  

In certain circumstances a younger child should have their blood pressure checked too. With the growing epidemic in obesity, pediatricians are seeing more children with abnormal blood pressure readings. It is important that the right sized blood pressure cuff is used for measuring a child’s blood pressure. There are standards for blood pressures for different age children. The standards are also based on a child’s height.

When a child’s blood pressure reading is greater than the 90th percentile for their age they are said to have pre-hypertension. The prevalence of childhood hypertension is thought to be between one and four percent and may even be as high as 10 percent in obese children. Obesity plays a role but, related to that is also inactivity among children, diet, and their genetic predisposition for developing high blood pressure. Then it is appropriate for further work up to be done to evaluate the reason for the elevation in blood pressure.

If I find a child with a high blood pressure reading during their physical exam, it is important to re-take their blood pressure in both arms. I also do not depend on automated blood pressure readings, as I find they are often inaccurate and I prefer to use the “old fashioned” cuff and stethoscope to listen for the blood pressure. If the blood pressure reading is abnormal, then I have the child/adolescent have their blood pressure taken over a week or two at different times of the day. They can have the school nurse take it and parents can also buy an inexpensive blood pressure machine to take it at home. I then look at the readings to confirm that they are consistently high. The “white coat” syndrome, when a doctor assumes that the elevated blood pressure is due to anxiety, may not actually be the case, so make sure that repeat blood pressures are taken. If your child does have elevated blood pressure readings it is important that further evaluation is undertaken, either by your pediatrician or by referral to a pediatric cardiologist.

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

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