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Daily Dose

Mumps Outbreak!

1:30 to read

The latest infectious disease outbreak is in the Boston area where several colleges have reported cases of mumps. Mumps is a viral illness that causes swelling of the salivary glands as well as other symptoms of fever, fatigue, muscle aches and headache.    Harvard University has been hit the hardest and has now documented over 40 cases this spring.  Boston is a city with numerous colleges all in close proximity, and there are documented mumps cases at Boston University, University of Massachusetts  and Tufts as well.  These Boston area colleges are all in close proximity and are merely a walk, bike or train ride away from one another, so these students, while attending different universities may all co-mingle at parties and athletic events.

Mumps is spread via saliva (think kissing), or from sharing food, as well as via respiratory droplets being spread after coughing or sneezing. It may also be spread via contaminated surfaces that will harbor the virus. People may already be spreading the virus for  2 days before symptoms appear and may be contagious for up to 5 days after their salivary glands appear swollen….so in other words there is a long period of contagion where the virus may inadvertently be spread. It may also take up to 2-3 weeks after exposure before you come down with mumps.

All of the students who have come down with mumps had been vaccinated with the MMR vaccine (mumps, measles, rubella).  Unfortunately, the mumps vaccine is only about 88% effective in preventing the disease. Despite the fact that children get two doses of vaccine at the age of 1 and again at 4 or 5 years….there may be some waning of protection over time. This  may also contribute to the virus’s predilection for young adults in close quarters on college campuses. Something like the perfect infectious disease storm!

In the meantime there are some studies being undertaken to see if adolescents should receive a 3rd dose of the vaccine, but the results of the study are over a year away.

In the meantime, be alert for symptoms compatible with mumps and make sure to isolate yourself from others if you are sick.  Harvard is isolating all of the patients with mumps for 5 days….which could mean that some students might even miss commencement.  Doctors at Harvard and other schools with cases of mumps are still on the watch for more cases …stay tuned.

 

 

 

 

Daily Dose

Confusion Over Cough & Cold Medicines

The confusion over cough and cold medications continues and I must admit I am a little confused too. The Consumer Healthcare Products Association recently announced changes to the labeling of over-the-counter (OTC) cold products to state "do not use in children under 4 years of age". The FDA monograph still states "do not use in children under 2 years". The American Academy of Pediatrics recommends not using OTC cough and cold preparations in children under six years.

Looking at the little research on these products two things come to mind:

  1. There have been multiple studies done on these products (in adults) that do not show them to be efficacious for treating common cough and cold symptoms.
  2. The research among children using these products show that dosing errors and accidental ingestions are the leading cause of adverse events.

This kind of leaves me thinking why use them at all in children? I really have never been much of a cold medicine giver in general, as I personally did not see my patients getting better any faster nor my own children. We continued to use the good old grandmother tested remedies of lots of rest, fresh squeezed orange juice (sometimes in pays to be sick), chicken noodle soup (canned or home made), and a vaporizer or humidifier in their rooms at night. I also know that younger children get more colds than anyone and no matter what you do you have to get through that too. But miraculously, as kids get older they get less colds and seem to tolerate them a little better. So... for this winter in our practice we are not recommending the use of any of these products for kids and trying the gold standards rest, fluids, cool mist humidifier and tincture of time. We'll see how it goes. That's your daily dose, we'll chat tomorrow.

Daily Dose

Ear Infections Can Develop Quickly

1:15 to read

One of the things that I sometimes see in my practice, which is interesting to me as a pediatrician, and was equally interesting when I had young kids, is how quickly a child's ear exam can change.

You are taught that in medical school, but when you really see it happen it with your patients or your own child you become a real believer. As the saying goes, seeing is believing. I can remember checking one of my boy's ears for an ear infection early in the morning before heading out to work, and declaring, "his ears are perfectly clear". How could it be, my husband would inquire, "that they seem worse after we have been at work all day" and lo and behold, I would re-check their ears and a normal morning ear is an abnormal evening ear. What a difference 12 hours can make! Not a very good warranty on ears and infections.

I was reminded of this yesterday when a patient called and said that her little boy had developed "disgusting" eye drainage which was worsening since I had seen them in the office a few days ago. They had just returned from taking both of their young children to Disney World, and she "couldn't believe they came home sick!" That's a whole 'nother column. At any rate, seeing that they lived fairly close I told them to swing on by and let me look at him again. I think she was just hoping I would call in eye drops. The two precious boys arrived at my doorstep on Saturday night and lo and behold after looking in the youngest child's ears, both of his ears were so infected. So, once again I was a believer in ears changing, and he did not need eye drops he needed to have oral antibiotics to clear up his ears (and subsequently his eyes). There are several lessons from all of this. Ears can change quickly, eye drainage in a toddler with a cold may often really indicate that their ears are infected, and house calls are a good thing.

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

Daily Dose

National Poison Prevention Week

1:30 to read

It is National Poison Prevention Week and it seem appropriate since I just received a call last week from an anxious mother whose toddler had gotten into some medication at their house. The child was fine but I reminded her that more than 2 million people each year, about half under the age of 6, ingest or come into contact with a poisonous substance.  The majority of these incidents occur when parents or babysitters are present but are not paying attention at the time. As I remind parents, it is IMPOSSIBLE to watch your child, even with just one child, all of the time. So…it is necessary to take steps to try to prevent accidental poisonings.

 

The most dangerous potential poisons are medicines, cleaning products, liquid nicotine, pesticides, gasoline and kerosene. I am always surprised to hear that a child will drink gasoline (YUCK right?) but toddlers do crazy things and put EVERYTHING in their mouths.

 

When “child-proofing” the house against so many dangers, try to keep as many poisonous products outs of a child’s reach and view as possible.  Install safety latches on all cabinets that may contain any hazardous products …including laundry products and cleaning products. I would advise against using any detergent “pods” with children under the age of 6 and use powder or liquid instead.  A safer product is worth a little bit of hassle!

 

Make sure that ALL medications, even vitamins are in containers with child safety caps (adults can’t open them but kids seem to?), but you must also keep them out of reach of children and I would recommend a cabinet that you can lock.  There have been several occasions when a parent has left a pill out on a counter for another child to take and then suddenly the toddler has chewed it up…this has been most common with stimulant medications.  Grandparents who are visiting also forget and leave their medications out and kids seem to find these as well.

 

Another common potential poison comes in the form of a button cell battery. These are common in remote controls, key fobs, greeting cards and even musical children’s books and not only pose a choking hazard but may cause tissue damage. If your child ingests a battery it is imperative that you seek immediate treatment at an emergency room.

 

If you are ever in doubt about the potential for poisoning call Poison Help at 1-800-222-1222. They are experts in walking you through potential side effects, treatments and need for an ER visit!  One of my patients just asked me if there is a limit to how many times you can call Poison Control…she seems to be a frequent flyer.

 

 

 

 

 

 

 

 

Your Child

Crypto in Swimming Pools Doubles in 2 Years

2:00

Many kids and adults won’t be waiting till the first official day of summer before cooling off in a waterpark or pool. Unfortunately, the chance of getting a pool-linked infection has doubled in the last year.

At least 32 outbreaks of cryptosporidiosis were reported in 2016, compared with 16 outbreaks in 2014, according to a new report from the U.S. Centers for Disease Control and Prevention.

Cryptosporidium is a microscopic parasite that causes the diarrheal disease cryptosporidiosis. Both the parasite and the disease are commonly known as "Crypto."

While this parasite can be spread in several different ways, water (drinking water and recreational water) is the most common way to spread the parasite.

Crypto is spread when people come in contact with the feces of an infected person, the CDC says. Not a pleasant thought.

Otherwise healthy people can be sick for up to three weeks with watery diarrhea, stomach cramps, nausea or vomiting, the CDC warns. The infection can become life-threatening in people with compromised immune systems.

The cause? Adults or children sick with crypto-caused diarrhea are swimming in public pools despite their illness and further spreading the parasite, said Michele Hlavsa, chief of the CDC's Healthy Swimming Program.

Not only do humans spread the parasite, but also infected animals. Swimming in ponds or “swimming holes,” or anywhere animals have access, is not a good idea.

You can become infected after accidentally swallowing the parasite. Crypto may be found in soil, food, water, or surfaces that have been contaminated with the feces from infected humans or animals. Crypto is not spread by contact with blood.

Once infected, people with decreased immunity are most at risk for severe disease. 

People also can contaminate pool water with crypto through just physical contact, said Lilly Kan, senior director of infectious disease and informatics with the National Association of County & City Health Officials (NACCHO).

For example, parents might spread the parasite if they change a child's crypto-contaminated diaper and then hop in the water without properly washing their hands, Kan said.

Hlavsa explained that crypto is resistant to chlorine, and can survive up to 10 days in even properly chlorinated pool water.

Parents should take kids on bathroom breaks often, and shouldn't count on swim diapers protecting other swimmers from exposure to a child's diarrhea, Hlavsa added.

"Swim diapers do not contain diarrhea," she said. "If water is getting into that diaper, then water is getting out."

To protect themselves, swimmers should avoid swallowing any pool water, and make sure that kids don't have pool toys that encourage swallowing the water, Hlavsa said.

While home pools are safer, because of the fewer number of people sharing the water, they are not fool proof. Make sure that no one with diarrhea or a stomach illness has been in the pool before you allow your kids to jump in a friend or family member’s pool. And it goes without saying, make sure your own kids stay out of your pool if they’ve had or have diarrhea. Crypto can easily spread to family and friends.

Good hygiene and common sense should help make this summer’s pool party a special one - where everyone just has a good time and no one goes home with an unwelcomed guest inside them.

Story sources: Dennis Thompson, https://consumer.healthday.com/gastrointestinal-information-15/diarrhea-health-news-186/the-water-s-not-fine-u-s-pool-linked-infection-doubles-in-2-years-722869.html

Https://www.cdc.gov/parasites/crypto/infection-sources.html

Daily Dose

It's Cold Season!

1:30 to read

It is already starting....fall and colds and parents are already wondering why their toddler or young child may have already had 2 colds and it is not even winter!  It is incredible how often a toddler can get sick....I even had a hard time believing there were so many viruses for one child to get.

But, I do know that there does not seem to be any way “around” the frequent runny noses, coughs, mystery fevers, and episodes of vomiting and diarrhea that a parent has to get through!! There is not a short cut to get through this desert of illness...you have to walk the walk.

Yes, it takes a lot of little viral illnesses to help build a child’s immune system. We can give vaccinations to prevent meningitis, whooping cough, polio, mumps, measles and rubella.  But there are hundreds of viruses that cause colds and coughs....and there is not a vaccine for any of these viruses.  

So, once your child reaches the age where they are walking and touching a million things a day (even though you wash their hands), you should not be surprised or alarmed that they seem to have a new illness every few weeks. Parents ask me everyday, “what vitamin works to prevent colds?”, “do probiotics prevent those fever viruses?”. If I had the “secret” potion, trust me I would tell them, but I would also bottle it and sell it on the internet and retire to an island , after receiving the Nobel Prize in medicine for finding the “secret”.  But in the meantime, I will continue to reassure parents that they will get through these early illnesses.....everyone does. 

Daily Dose

Constipation

1:30 to read

Constipation is a topic that every pediatrician discusses….at least weekly and sometimes daily. It is estimated that up to 3% of all visits to the pediatrician may be due to constipation. Constipation is most common in children between the ages of 2 and 6 years. I have been reading an article on updated recommendations for diagnosing and treating common constipation. The most important take home message is “ most children with constipation do not have an underlying organic disorder. Diagnosis should be based on a good history and physical exam for most cases of functional constipation”.

 

Like many things in medicine….the evaluation and treatment of constipation has also changed a bit since the last guidelines were published in 2006. It is now appropriate to define constipation with a shorter duration of symptoms (one month vs two) and some of the most common diagnostic criteria (Rome IV Diagnostic Criteria) include the child having less than 2 stools/week, painful or hard bowel movements, history of large diameter stools (parents will tell me their 3 year olds “poops” clog the toilet), and some may have a history of soiling their underpants. 

 

By taking a good history you can avoid unnecessary tests..including X-rays which are not routinely recommended when evaluating a child with possible constipation.  In most cases physical findings on the abdominal exam will confirm the diagnosis in combination with the history. I often can feel hard stool in a child’s left lower quadrant and when asked the last time they “pooped”, no one can really recall. 

 

The preferred treatment is now polyethylene glycol (PEG) therapy. PEG is now used to help “disimpact a child” as well as to maintenance therapy.  Where as enemas were often previously prescribed, PEG therapy has been shown to be equally effective in most cases, is given orally and is much less traumatic (for parent and child!). PEG works by drawing more water into the stool, causing more stool frequency. There are many brands of PEG including Miralax and GoLytely among others. Miralax works well for children as it is tasteless and odorless and can easily be mixed in many liquids without your child knowing it is there. 

 

The guidelines now state that for children with functional constipation maintenance therapy with PEG should continue for as least 2 months with a gradual tapering of treatment only after a full month after the constipation symptoms have been resolved. I usually tell parents that this is equivalent to about how long it takes for them to forget that they have been dealing with constipation….and then begin tapering.

 

Lastly, there is no evidence that adding additional fluid or fiber to a child’s diet is of benefit to alleviate constipation….although it may “just be good for them in general”.

 

 

Daily Dose

Migraines in Children

1.15 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

Why Kids Faint

2.00 to read

Last week, we chatted about younger children and fainting so now it’s time to talk about older kids who faint. I’ve seen many teens that have fainted…even my own son (he fainted numerous times while he was an adolescent).   I decided to “read up” on causes of syncope (fainting) and I found out just how common it was. The highest incidence of syncope (and pre- syncope as in “I almost fainted”) occurs in up to 40% of adolescents and may be even higher among females!

The most common form of fainting among this age group is called “vasodepressor, vasovagal or neurocardiogenic” syncope. These terms all have the same meaning and describe the typical fainting event: a teen’s been standing for a period of time, and they begin to feel light headed and dizzy.

This often progresses to the feeling of having tunnel vision, the skin becomes pale, there may be the sensation of a rapid heartbeat, and feeling hot, although they may be cold and clammy to the touch. If these symptoms are not recognized and the teen does not sit down or lie down then fainting will occur.

The biggest fear from this type of fainting is really not due to the fainting episode itself (which usually does not last more than 15-30 seconds) but rather concern over a head injury when the patient falls. It is important to teach these “fainters” about the importance of paying attention to these symptoms and to sit down or lie down to prevent injury. Simple syncope will not hurt you!!

When seeing your child’s pediatrician it is important that a good history is taken.  I always ask my patients “when the fainting episode occurred, had they eaten, were they standing when fainting occurred and most importantly did the fainting happen with exercise or while at rest?  Did anything provoke the episode such as being anxious while standing to give a speech, or scared or grossed out during a movie etc.” Most patients have a good history as to why the fainting occurred.  Anyone fainting DURING exercise should be referred to a pediatric cardiologist for evaluation.

For all other fainters who have negative family history for sudden cardiac death, who have history consistent with simple syncope and who have a normal physical exam, the only test I order is an EKG, which should also be normal.  When all of this is done, I reassure both the patients and their parents that this is solely a fainting episode and may likely reoccur.

So, stay well hydrated, make sure not to skip meals, don’t get up too fast from bed first thing in the am and above all if you feel like you are going to faint, LIE DOWN.

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

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