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Daily Dose

Swollen Lymph Nodes

1:30 to read

A parent’s concern over finding a swollen lymph node, which is known as lymphadenopathy, is quite common during childhood.  The most common place to notice your child’s lymph nodes are in the head and neck area.

Lymph nodes are easy to feel  around the jaw line, behind the ears and also at the base of the neck, and parents will often feel them when they are bathing their children.  Because young children get frequent viral upper respiratory infections (especially in the fall and winter months), the lymph nodes in the neck often enlarge as they send out white cells to help fight the infection. In most cases these nodes are the size of nickels, dimes or quarters and are freely mobile. The skin overlying the nodes should not appear to be red or warm to the touch. There are often several nodes of various sizes that may be noticed at the same time on either side of the neck.   It is not uncommon for the node to be more visible when a child turns their head to one side which makes the node “stick out” even more.

Besides the nodes in the head and neck area there are many other areas where a parent might notice lymph nodes.  They are sometimes noticed beneath the armpit (axilla) and also in the groin area.  It your child has a bug bite on their arm or a rash on their leg or even acne on their face the lymph nodes in that area might become slightly swollen as they provide an inflammatory response. In most cases if the lymph nodes are not growing in size and are not warm and red and your child does not appear to be ill you can watch the node or nodes for awhile.  The most typical scenario is that the node will decrease in size as your child gets over their cold or their bug bite.  If the node is getting larger or more tender you should see your pediatrician. 

Any node that continues to increase in size, or becomes more firm and fixed needs to be examined. As Adrienne noted in her iPhone App email, her child has had a prominent node for 7 months. Some children, especially if they are thin, have prominent and easily visible nodes.  They may remain that way for years and should not be of concern if your doctor has felt it before and it continues to remain the same size and is freely mobile.  Thankfully, benign lymphadenopathy is a frequent reason for an office visit to the pediatrician, and a parent can be easily reassured.

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

Daily Dose

Zika Virus

1:30 to read

If you are pregnant or planning on becoming pregnant in the near future you need to be aware of the Zika virus.  This virus is spread via the Aedes mosquito (as is West Nile Virus, Dengue fever and Chikunguyna), and has been found in Africa, Southeast Asia, the Pacific Islands , South America and Mexico.  The Zika virus was also just confirmed in Puerto Rico and the Caribbean in December.  There are new countries confirming cases of Zika virus almost every day, as the Aedes mosquito is found throughout the world.  

When bitten by a mosquito that has the Zika virus, only about 1 in 5 people actually become ill.  The most common symptoms are similar to many other viral infections including fever, rash, joint pain and conjunctivitis.  For most people the illness is usually mild and lasts for several days to a week and their life returns to normal.  Many people may not even realize that they are infected. 

Unfortunately, if a pregnant mother is infected with the Zika virus, the virus may be transmitted to the baby.  It seems that babies who have been born to mothers who have been infected with the Zika virus may have serious birth defects including microcephaly (small head) and abnormal brain development. There have been more than 3,500 babies born with microcephaly in Brazil alone…and just recently a baby was born in Hawaii with microcephaly and confirmed Zika virus. In this case the mother had previously lived in Brazil and had relocated to Hawaii during her pregnancy.  The virus to date has not been confirmed in mosquitos in the United States.

Because of the association of the Zika virus and the possibility of serious birth defects, the CDC has announced a travel advisory stating, “until more is known and out of an abundance of caution, pregnant women in any trimester, or women trying to become pregnant, should consider postponing travel to the areas where Zika virus transmission is ongoing”.  

Should pregnant women have to travel to these area they should follow steps to prevent getting mosquito bites during their trip. This includes wearing long sleeves, staying indoors as much as possible, and using insect repellents that contain DEET.

Researchers are continuing to study the link between Zika virus and birth defects in hopes of understanding the full spectrum of outcomes that might be associated with infection during pregnancy. There will be more data forthcoming.

At this point the safest way to avoid being bitten is to stay away from the countries who have had confirmed cases of the Zika virus.  But as the weather warms up in the United States and mosquitos become more abundant there is concern for Zika virus to be found here.  It only takes one infected mosquito to bite one person who then contracts the virus….should that person be bitten by another mosquito, that mosquito may acquire the infection and so it spreads.  There is not known to be human to human transmission of the virus.

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

Ear Tubes

1:00 to read

I had been seeing a 3 year old VERY verbal patient for several months as he would intermittently complain to his mother that his “ears were ON?”.  He would tell her this off and on but could not explain what he meant by this statement. He did not say his ears hurt, he did not have a fever, he was sleeping well….but he seemed to be bothered enough to talk about it from time to time.

 

His mother brought him in to see me a few times and his exam was normal…but one day when she brought him in I noticed that he had clear fluid behind his ear drum(serous otitis). His eardrum was not inflamed and his exam was otherwise normal.  When a child has fluid behind their ear drums it is not always a sign of infection, and in this case you watch and see if the fluid goes away on its own. 

 

Well, he continued to talk to his mother about his “ears being ON”, and he even told his teachers a few times.  Because he continued to talk about it ( over about 3 months) I sent him to see a pediatric ENT.

 

When the ENT saw him he also noted that he had some fluid behind one of his ear drums. Because he had had persistent fluid it was decided to place ear tubes….

 

And guess what? Once he had ears tubes placed he told me his “ears had turned off”!!  I guess he sometimes felt funny or heard sounds differently and that was his way to express his ear issue - on and off! What took me so long?

Children continue to amaze me. 

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

Keep Your Newborn at Home

As the weather gets colder, I get a lot of questions now about taking newborns "out" during their first months of infancy.Thank goodness it's Friday!! The office is getting busy as weather gets colder and I get a lot of questions now about taking newborns "out" during their first months of infancy. My answer to that at this time of year is to keep that precious newborn away from crowds, indoor areas and lots of sick people, which means just about everywhere you go. I encourage new parents to take their babies for walks outside. Even if it is cold outside, but clear, bundle up the your-baby in all of those cute new buntings and take a walk in the neighborhood or park but not the mall or Target and Toys R Us!!

Most of the germs during this time of year are airborne and despite everyone's best efforts to cover their mouths there are lots of coughs and sneezes out there. Babies that are within several feet of these sneezes may then be exposed to the latest virus which may be more serious in an infant. My recommendation is to keep your infant as germ free as possible during these winter months. Once they are little older they will handle the viruses better and by next winter they will become a toddler who will then "get everything". That time comes soon enough, so don't rush their exposure this winter. What a great excuse to enjoy "nesting" at home this holiday season. My pediatrician says "we shouldn't bring the your-baby to the mall for Christmas pictures with Santa." A four-week-old your-baby does not need to stand in line with all of those cute, but coughing toddlers and be exposed. Better to delay the picture for a year, dress that sweet your-baby up in Christmas clothes at home and take a picture, and stay out of the hospital! Spring is only four months away. I am sure we will revisit this topic as winter progresses, but I am protective of infants, plenty of time to get sick later on. That's your daily dose for today, we'll chat again soon.

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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.

Your Baby

Teething May Make Your Baby Fussy, But Not Sick

2:00

Parents sometimes have trouble distinguishing between whether their cranky baby is actually ill or is just getting his or her first teeth. Because a baby’s gums may be tender and swollen as their teeth come in, a slight rise in temperature can occur.  Other changes may happen as well such as fussiness and increased drooling. All- in –all, babies can be pretty miserable till those first teeth break through.

That said, teething does not cause a full-fledged fever above 100.4 degrees Fahrenheit or any other signs of illness according to a new review led by Dr. Michele Bolan, of the Federal University of Santa Catarina, Brazil.

Certain symptoms can be confusing for parents says Dr. Minu George, interim chief of general pediatrics at Cohen Children's Medical Center, in New Hyde Park, N.Y.

"I get questions about this on a daily basis," said George, who was not involved in the study.

When a baby’s temperature reaches 100.4 degrees F or higher, it becomes an actual fever, not just a slight increase in temperature.

"Fevers are not a bad thing," she pointed out. "They're part of the body's response to infection." But, George added, parents should be aware that a fever is likely related to an illness.

Of course, new parents are going to be somewhat edgy when it comes to caring for their infant. It’s a new world of responsibility that can seem overwhelming at times. 

Pediatricians and family doctors regularly answer questions about this topic with an explanation of how a typical teething experience presents.

Over the ages, other symptoms have been linked to teething that should never apply. They include sores or blisters around the mouth, appetite loss and diarrhea that does not go away quickly. Any of these symptoms warrant a call to your pediatrician.

Babies differ in age as to when their teeth begin to come in.  Typically, the fist tooth begins to erupt around 6 months of age. It can also be as early as 3 months and as late as 1 year of age. There really isn’t a set age for teething to begin, just an average.

Baby’s teeth usually erupt through the gums in a certain order:

·      The two bottom front teeth (central incisors)

·      The four upper front teeth (central and lateral incisors)

·      The two lower lateral incisors

·      The first molars

·      The four canines (located on either side next to the upper and lower lateral incisors)

·      The remaining molars on either side of the existing line of teeth

By age 3, most children have all 20 of their primary teeth.

As for helping babies get through the misery of teething, George advised against medication, including topical gels and products that are labeled "natural" or "homeopathic."

Instead, she said, babies can find relief by chewing on a cooled teething ring or wet washcloth, or eating cool foods.

The analysis was published in the February online edition of the journal Pediatrics.

Sources: Amy Norton, http://www.webmd.com/parenting/baby/news/20160218/teething-makes-babies-cranky-but-not-sick-review

http://www.webmd.com/parenting/baby/tc/teething-topic-overview

Daily Dose

RSV is Still Lingering

1.30 to read

I can’t believe that I am writing another post on RSV! After another long day in the office with tons of wheezing and coughing, I decided to take a look at the national RSV statistics. Guess what, most of the country is still in the throes of RSV season (Florida is lucky as their rates are on the decline). So I know that everyone is still dealing with RSV (respiratory synctial virus) and we may still be several more weeks away from declining viral rates and the end of the RSV season. 

I am still seeing many parents who are “fearful” of RSV, as their day care or schools have sent home notices that there are cases of RSV. I am still confused by the need to send out notices which may only scare parents, as at this time of year, RSV is virtually everywhere. 

RSV is a virus that occurs every fall, winter and often into early spring. It causes cold symptoms for most of us, and most of the population (both child and adult) can never name the virus that caused their terrible runny nose and cough.  By the time a child is 2 years old the majority of them (upwards of 90%) have had at least one RSV infection. Again, most parents never need to know the name of the virus that is causing their child to have that terrible cough and runny nose. It is just another bad cold! 

But, with that being said there are children, especially those under the age of 2 who will have more problems with RSV. In some cases, especially young infants, the virus will cause not only a runny nose, congestion and coughing, but wheezing as well, and in a few, respiratory distress. It is in those cases that we “name that tune” and test to confirm that the baby has RSV. 

Our office does not routinely test every child with a cough, runny nose or even all of the kids that are wheezing to see if they have RSV. (If we did we would be testing almost every child!) We only do the tests on the sickest children that end up needing to be hospitalized. The real reason behind the testing is to confirm our suspicions and to follow the epidemiology of the disease during RSV season. 

The treatment of the symptoms does not really change based upon the confirmation of RSV. Other respiratory viruses such as rhinovirus and metapneumovirus are also lurking out their wrecking havoc with coughs, colds and wheezing as well. 

So once again, don’t worry about “naming the virus” or rush to the doctor because your next door neighbor’s child or a friend in day care has been diagnosed with RSV. Rather, pay attention to your child’s symptoms and how they are breathing and handling the virus. RSV is still around will hopefully move out of the country in the next 6 weeks. But guess what, it will surely return next year too.  Keep covering those coughs and washing hands!  

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

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DR SUE'S DAILY DOSE

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