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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

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

Swollen Lymph Nodes

1.45 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

Why Fever Is Your Child's Friend

Every parent is concerned about fever and why their child is running a fever. During the "sick season" I see 20 - 30 patients a day with a fever. Every parent is concerned about the fever and why their child is running a fever. Fever is one of the most common symptoms of childhood. Younger children run fevers quite frequently when they are sick. As we have talked about before, that may be four to eight times during the fall and winter season.

"Fever is our friend" has been one of my mantras for years. It is comforting for parents to understand that fever is a symptom that the body is fighting an infection. That is usually a viral infection that only lasts a few days, and lo and behold the fever is gone. The biggest myth is that fever, in and of itself, causes brain damage. Remember again, fever is simply a symptom.

The height of a fever does not correlate with severity of illness. Once again, higher fever does not necessarily mean you are sicker. Your child may feel awful with a fever of 101 or 104 degrees. Typically, once given either acetaminophen or ibuprofen for their fever, the temperature comes down a little and they symptomatically feel better for a while. Once the anti-pyretic (fever reducing) medications wear off, the fever will often return.

Children typically have more fever in the night, seems like darkness brings out the fever monster (that is the mother in me, but it was always true at my house) and those nights of fitful sleep, and hot little bodies seem very long. The other thing I have noticed, why do children who have had little sleep due to fever, coughs etc get up in the morning and do not long for a nap like their parents?

The other thing you need to keep in mind is that the higher the fever, the faster your child's heart will beat and the higher respiratory rate they will have. It is easy to climb into bed with your "hot" two year old and feel their heart pounding away, and know they have a high fever, even before the thermometer is out. This is the body's natural way of expending heat. Once the fever comes down you will notice that they are breathing less rapidly and their heart rate has come down too. Remember to offer plenty of fluids to a child with a fever, as they need extra fluids. They can eat too, but if not interested, a Popsicle or jell may be a good alternative. Just keep chanting, "fever is our friend." 

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

Daily Dose

The Dangers of Using Baby Aspirin

1.15 to read

During a recent office visit, I saw a 4 year old child who is not one of my routine patients.  He had a fever and runny nose. His mother was giving me the child’s medical history during the time I was beginning to examine the little boy.  I had my back slightly turned from her. 

The mother was explained to me that her son had had a fever the previous evening and said, “I gave him some ASPIRIN before putting him to bed.”  I immediately turned around and with a stunned voice said, “you mean you gave him Tylenol or Motrin or Advil,” right? She really looked at me like I was crazy or that I had not been listening to her and she said, “No I said baby aspirin.”  “He likes the chewable ones.”  

I was shocked, as I had not heard of anyone giving aspirin to their children for a fever in over 20 years!! This very nice, young, concerned mother could not figure out why I was so worried about the aspirin.  I then had to explain to her about the risk of Reye’s Syndrome. She had never heard of Reye’s Syndrome and said that her mother had kept baby aspirin in the house for her, so that is what she bought to use for her own child.  

I know that they sell enteric coated baby aspirin for adults to take to help prevent a stroke. I guess I didn’t even realize that regular old baby aspirin was even around. There was so much publicity in the 1980’s about the link between aspirin or any salicylate containing medication and the development of Reye’s Syndrome, as well as warning labels about not giving aspirin to children that had a fever or chicken pox that I had not heard of anyone using aspirin for years! 

I explained to her that Reye’s syndrome affects the brain and liver and is a very serious disease, which may lead to death.  It occurs in children between the ages of 4-18 and causes recurrent vomiting, lethargy and coma and was often seen after a child had the flu or chickenpox. 

I saw several patients with Reye’s during my training, but have not seen a case since that time. This mother had never even heard of it, but was quite concerned that she had already given her son the aspirin the previous evening. 

This was a great lesson in the necessity of telling every new parent about the use of appropriate medicine to treat a fever. I typically have this discussion at the time of the first vaccines as I tell parents that prior to that time I don’t even want them to have fever reducing medications available. 

Many pediatricians, including me, had been in the habit of using “Tylenol” as the name for acetaminophen, in the same way as you say Kleenex. Since Tylenol was withdrawn from the market last year, we are now correctly saying that you should treat a child’s fever, which is usually due to a viral illness, with acetaminophen, and NEVER aspirin or aspirin containing products!! 

So as you prepare for this winter and lots of viruses with fever go stock up on acetaminophen of ibuprofen and leave the BABY ASPIRIN for ADULTS ONLY! 

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

Daily Dose

Treating Kids Who Suffer with Motion Sickness

1.15 to read

If you’re planning the perfect getaway this summer with your family, don’t let motion sickness spoil your plans. Did you know 58% of children between the ages of four and 10 experience the symptoms of motion sickness? 

Motion sickness occurs when the inner ear, eyes and other areas of the body that detects motion, sends a mixed signal to the brain. 

Your child may begin to feel queasy with the initial nausea followed by a cold sweat, fatigue and loss of appetite. A younger non-verbal child may become restless, pale, sweaty and cries. At some point these symptoms are usually followed by vomiting. By then you have figured it out!

The best treatment for motion sickness is prevention! If you have already experienced motion sickness with your child then plan ahead.

If your child is over the age of two, place them in their car seat in the middle of the backseat and face them forward. Provide a small nutritious snack prior to the trip rather than a big meal, and avoid dairy.

Open the windows and do not let your child play video games or read while the car is in motion. Try to distract them by singing or talking. Sleeping may also be helpful, so at times you may plan your trip around naps and bedtime.

Frequent stops for a child who is feeling sick are a necessity. Letting them lay flat for a few minutes while the car is stopped and even applying a cool rag may make them feel better. Try small sips of carbonated beverages or crackers to help the nausea.

Expect the unexpected and be prepared.  Bring along zip lock bags and hand wipes in case of emergency. This will make everyone in the car a little happier.

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

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.

Daily Dose

Baby's First Cold

I find myself in the office each day amid a host of babies who are finally succumbing to their first colds. I walk into the room and see their little runny noses, their red rimmed eyes and hear their frequent coughs, while simultaneously see them sitting on their mom or dad's laps, playing with a toy and making good eye contact with the parent.

The parents of course are "worried sick" but I am immediately reassured as I watch their bright-eyed, runny nosed your-baby interact with me. So it goes in the winter.... No one is immune to those nasty cold viruses and many of these babies have managed to ward off illness for months, but are finally battling their first cold. The babies actually are fairing pretty well, but the parents are both worried about the cold and sleep deprived, because one thing about most kids with colds whether they are four months or 15 months, they just don't sleep as well. Colds are an unfortunate fact of life and each cold that a your-baby suffers through actually makes them a little stronger. Their bodies are making antibodies to that virus and helping to shore up their immune system. Small victories amid the myriad of viral infections they get in those six to 24-month period. There is still no real treatment or cure for the common cold. The recommendations for a your-baby are fairly similar to the rest of us. Hydration (milk is okay), fever control if they need it, and TLC and tincture of time. The first cold is the hardest, at least for the parent. You can try putting a humidifier in their room and irrigating their noses with saline to help clear the mucous and make it easier for them to breathe. Tylenol for fever, which is common in the first several days, may also make them more comfortable. After several days, the worst of the cold is over and they should feel a little better. Watch for fever that re-occurs or worsening of their sleep habits or mood which my signal an ear infection. Most ear infections don't occur on the first day of the cold, so give it a little time and if they are not improving it warrants a trip to the pediatrician. Best news, I saw very few ear infections today, but lots of colds. That's your daily dose, we'll chat again tomorrow.

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