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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

Staph Infections Often Appear Quickly

1:30 to read

There has been a lot of questions lately about staph skin infections.  In fact, I am typing this just after seeing one of my patients with a fairly “classic” staph infection on their leg. 

Staph is the common term used when doctors are discussing Staphylococcus aureus, a bacteria that is known to cause infections and is  commonly seen with skin infections. These skin infections present as a boil, or cellulitis (infection of the skin and soft tissues), or impetigo, or other infections related to the skin. But in this case we are going to look at a boil (an abscess within the skin) and  surrounding cellulitis.

Staph infections often appear quickly, “almost overnight”, when a parent or child may notice a bump that may resemble a bite. But in this case this “bite” rapidly reddens and becomes tender and warm to the touch. It really looks “angry” and as my grandmother used to say “festers”. Parents will often call and say, “I think my child has a spider bite”, when in reality it is a brewing staph infection. When I hear spider biter, out of the blue, I think staph. I jokingly tell parents, “I don’t think there are enough spiders in the world to cause all of these “bites” that are really staph infections.” Since staph is a bacteria it is susceptible to antibiotics. But over the last several years we have seen children of all ages presenting with resistant staph infections, typically with MRSA or methicillin resistant staph. This is an important distinguishing factor, as this will determine which antibiotic is used to treat the infection.

In order to figure out which antibiotic to use, the doctor needs to culture the “pus” that is in the boil. That means growing the bacteria from the “bite, boil, infection” and identifying the bacteria, and from that culture the lab will also determine which antibiotic the bacteria is susceptible to. All of this information will ensure that your child is put on the appropriate antibiotic to treat the infection. At times it is necessary to drain the infection and in more serious cases, a child may be admitted for IV antibiotics. I often have parents ask, “Where did we get this?” Staph is everywhere, on our hands, in our noses and on other commonly shared objects like towels, changing tables and in locker rooms. Encourage your child to wash their hands, try to avoid touching their noses, and to avoid picking at cuts and bites.

Despite all of this, we all have micro-abrasions on our skin that are not even visible and that tiny staph bacteria can just hop on in and develop a random infection. Staph skin infections really do have a “typical” appearance. That is why I am showing you this picture. If you see your child suddenly develop a “bite” that looks like this, you need to call the doctor. The sooner the infection is treated the better. That’s your daily dose, we’ll chat again tomorrow! Send your question to Dr. Sue.

Daily Dose

Salmonella Scare

1:30 to read

I have been watching the news about the ongoing salmonella outbreak. Unfortunately, there have now been two reported deaths, and over 300 people have been infected. This outbreak has been linked to American cucumbers imported from Mexico. Over 50% of those infected have been children younger than 18 years.

Salmonella infections are a bacterial infection, and cause fever, diarrhea (it may be bloody) and abdominal cramping.   In most cases you develop signs and symptoms 12-72 hours after being exposed to the bacteria. For most people the infection is self limited and the diarrhea resolves after 4-7 “uncomfortable days”.

While contaminated foods are the biggest cause of salmonella infections, children may be exposed from sources other than food. This includes pet turtles, baby chicks, ducks and hamsters. Having your child wash their hands with soap after handling these pets, even if the animal has no symptoms, is an important way to prevent an infection. 

In some cases, especially in a young child, the diarrhea may be so severe as to cause dehydration which requires hospitalization and IV re-hydration. The signs of dehydration are dry mucous membranes (mouth, eyes), increased thirst, decreased urine output and lethargy.  

Dehydration is often more difficult to diagnose in a baby as they obviously cannot tell you how they are feeling. Look for a dry mouth and tongue and when you put your finger in your baby’s mouth it should always be moist.  If your baby is drooling that is a good sign that they are not dehydrated.  They should not have sunken eyes or a sunken fontanelle (soft spot), but these are late signs of dehydration. Wet diapers are also a good sign that your baby is getting enough fluids, but with the new diapers which are “super absorbent” it is sometimes difficult to tell if your child has a wet diaper or not. For an older child you can look at the color of their urine….it should always be clear to light yellow, and never amber or cola colored which means you are dehydrated.

In order to maintain hydration in the face of prolonged diarrhea it is important to drink a lot of fluids including an oral electrolyte solution such as Pedialyte. Many children (and adults) will not drink Pedialyte and then I would recommend gatorade over other “sugary” juices or carbonated drinks as you need to replenish the salt and electrolytes that are being lost in the stools.  It is important to offer frequent small amounts of fluid. Parents often worry if their child is not eating,  but fluids are the most important way to maintain hydration. You can also try popsicles of Pedialtye pops as a way of getting fluids into your child.

If you have prolonged symptoms or are worried about dehydration call your doctor’s office. In the meantime, I guess I won’t be having cucumbers from Mexico in my salads! This is when I wish I had a green thumb and a garden!

Daily Dose

Spider Bite or MRSA

Is it a spider bite or staph infection?While walking down the hallway in my office, I keep hearing more and more patients concerned about a “spider bite”.  Think about this: how many spiders could there be out there, especially in the winter and early spring months? Also, these “spider bites” occur on really weird places; a baby’s bottom, the inner thigh, or even on the palm of the hand.

The poor spiders are being maligned when in fact they have nothing to do with these random skin lesions at all. In most cases, a patient had never even seen the offending spider! In reality, all of those “spider bites” are often due to a community acquired MRSA (methicillin resistant Staph Areus) infection of the skin and soft tissue. The frequency of these infections continues and parents should be aware of the fact that an unusual “bite” that is becoming more tender, has surrounding redness (erythema), feels warm to the touch and may have the appearance of a large pimple or boil needs, to be examined. In some cases that I have seen, a parent has tried to open the lesion with a needle. DO NOT take needles, pins, finger nails or anything else to open the lesion!! I tell the older kids, “if your mom or dad comes at you with a needle run Toto run!!” Once a “spider bite” has been correctly diagnosed as a MRSA infection, it is appropriate to try and drain some of the purulent material for a culture. This is usually easily done in the pediatrician’s office. By obtaining some of the purulent discharge the correct diagnosis may be made, and an antibiotic that treats community acquired MRSA may be prescribed. For larger lesions it is appropriate to drain them, and this may be done under sterile conditions (no home needles). There are certain times a pediatric surgeon may need to actually drain these larger lesions. There have been numerous journal articles debating the pros and cons of drainage versus antibiotic use. In most cases in my office, we culture the drainage, and prescribe an oral antibiotic.  There are some articles that advocate drainage only without the use of antibiotics. There is not a definitive opinion on this and I would defer to your doctor to decide the appropriate individual treatment. So… if you think the spiders have invaded your home, think MRSA instead. That's your daily dose for today.  We'll chat again tomorrow.

Daily Dose

Ear Infections

1.30 to read

The American Academy of Pediatrics (AAP) has released new guidelines for the diagnosis and treatment of acute otitis media (AOM) which is ‘doctor speak’ for an ear infection.  

An ear infection is one of the most common infections of early childhood and is also one of the most common reasons that antibiotics are prescribed.  Guidelines from 2004 recommended that pediatricians use “watchful waiting” before prescribing antibiotics for an ear infection in some children. 

The new guidelines for treating an ear infection with oral antibiotics are even more specific than those in 2004, and further clarify who are the best children to observe and those that should be treated right away.  This will reduce the number of unnecessary antibiotics that are prescribed, which in turn may help prevent antibiotic resistant bacteria. 

Many parents worry that their child may develop an ear infection after having a cold, but for a child between 6 months and 12 years of age, a mild ear infection found during a visit to their pediatrician may now be observed for 72 hours.  

According to the new AAP guidelines, children need to receive immediate antibiotics if they have a severe ear infection (with a fever of 102.2 degrees or higher or significant pain), have a ruptured ear drum with drainage or an ear infection in both ears in a 2 year old or under.  This will really change current treatment and the number of antibiotics prescribed. 

As both pediatricians and parents know, there are all sorts of things that cause ear pain:  an erupting new molar, a cold, or a sore throat can all result in ear pain and a “cranky” child.  But if the eardrum is not bulging the best treatment is pain control. This can be accomplished with acetaminophen or ibuprofen and watchful waiting to see if a child’s symptoms worsen or if the pain and symptoms resolve.  In studies, 2 out of 3 children get better without an antibiotic. 

More and more parents are responsive to using fewer antibiotics for their children and these recommendations reinforce that antibiotics don’t treat viral infections or pain.   Save the antibiotics for use when there is evidence of a bacterial infection. 

The next time your child has a cold and complains of an earache, try this approach and you may see that the ear pain resolves in 24-48 hours and you have one less trip to the pediatrician!

Daily Dose

MRSA & Your Family

1.15 to read

I continue to see cases of community acquired methicillin resistant staph (caMRSA) in my practice. So, I just read an interesting article in this month’s Archives of Pediatrics about households contacts of children who had been diagnosed with caMRSA. 

It is well known that there outbreaks of caMRSA among members of a family, and this is thought to be due to close contact. It seems that some members of a household may not develop an infection, but may be asymptomatic carriers. 

Traditionally staph aureus colonization has been reported to occur most frequently in the nose. But this study looked at other areas of the body that might also be colonized with staph. 

Interestingly, 21% of household contacts of pediatric patients with a caMRSA infection were colonized with staph. In addition, parents of the patient were more likely to be staph carriers than other family members. It was also found that there was a high rate of staph carriage in the groin as well as beneath the arms. In the study nearly 1/4 of the study participants were colonized in the groin and not the nose.  

So.....the fact that household members might be have staph in other areas outside of the nose is clinically important.I often have all family members and household contacts use an antibiotic cream placed into the anterior portion of the nose to reduce staph carriage.  If indeed  there are other areas that are “guilty” of staph then those areas need to be targeted.  This might mean that dilute bleach baths are important for not only the child who has the staph infection but also for family members. 

Stay tuned for more, but after reading this article I think I may add another step for families who are dealing with caMRSA infections.  Get out the bleach!

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

Daily Dose

An Infected Toe: Ouch!

iPhone App question for Dr. Sue: what to do for an infected toe?It's media office day and I just received an email via our new iPhone App (The Kid’s Doctor) from a parent who has a child with an infected toe.  I suspect that her child might be a ‘toenail’ picker which often leads to a local infection along the edge of the toenail.

This seems to involve the ‘great toe’ more often than other toes, due to the development of an ingrown toenail. I also seen it when a child or parent has cut the toenail too short and the toenail wants to grow down into the skin rather than ‘out’. Because the edge of the nail has penetrated the skin, and therefore there is a break in the skin, bacteria (remember our feet are dirty) can easily get into the skin and cause a local infection. The term for an infection of the toenail is a paronychia. But, regardless of the fancy term, it causes an infection which is painful. On occasion if the infection is minimal and you recognize it early you can treat it by using warm water soaks with an antibacterial soap and then applying a topical antibiotic such as Polysporin or a prescription called Mupiricin (many parents may have this from their doctor for a previous skin infection for a child after a bite or something). If the toe is getting more red, inflamed and tender then this will require a visit to your doctor. When I see a paronychia in the office I typically treat it with not only local care, but with an oral antibiotic that treats skin infections.  If there is a lot of “pus” at the site (some can get really bad before they are seen) then I like to take a culture of the pus to determine which bacteria I am dealing with in order that the appropriate antibiotic may be selected. It is always preferable to send a culture when possible as you not only identify the bacteria in question, but you also get the antibiotic sensitivities which allows you to select the most appropriate antibiotic for the infection. Often it seems that a paronychia will become recurrent, which will then require an appt with a foot doctor to remove the offending nail matrix. Best advice, don’t cut the nail too short and no toenail biting or picking!!  Easier said than done. That’s your daily dose for today. We’ll chat again soon.

Daily Dose

Stomach Virus

1:30 to read

What a week in the office as there has been an outbreak of presumed Norovirus in our community, and we are seeing tons of sick kids. I guess the virus does not realize that it is still in the 90’s in Texas, as this virus is more often seen during the winter months….but it seems there are occasional outbreaks throughout the year.

Norovirus is EXTREMELY contagious…and you may already be shedding the virus (expose others) before you even get sick. At the same time…you may also be contagious for 2 -3 days after you are better. Norovirus is the most common cause of the “stomach flu” or “food poisoning.” 

Knowing this, it is difficult to know when you have been exposed to this virus. But, a day or two after exposure, your child (or the parents ) may suddenly develop abdominal cramping, vomiting (more common in children) and diarrhea  more common in adults). Some children and their parents are “lucky” enough to get both!!  

The mainstay of treatment is to stay hydrated. This illness is typically “fast and furious”, but you have to make sure that you are replacing the fluids that you are losing ( from both ends).  After your child has vomited you want to wait for at least 30 minutes before offering your child sips of CLEAR FLUIDS, some sort of liquid with electrolytes ( very important to replenish what you are losing) ….and I mean SIPS. If you  give the fluid too quickly and in too large a volume you may see it come right back up.  As your child tolerates sips you may advance to a larger volume each time.  If they are doing well for several hours, but then your child vomits again…start back over with smaller volumes. Continue to make sure your child has tears when they cry, wet diapers ( they may not be soaked), urine when asked to go try and “potty” and drool or a  moist mouth. These are signs that your child (and you) are hydrated.

Once the vomiting has subsided you can let your child begin to eat, but I would avoid all dairy. It is important to offer foods with some protein as well.  I start with crackers, noodles and rice and then add in chicken or beef. Veggies and fruit are okay as well ….as your child is feeling better their appetite will return…don’t push them. You probably don’t want a big meal either if you have been sick. Fluids are more important than food. Adding probiotics is also helpful to put “good bacteria” back into a damaged gut. 

Prevention is key, but difficult as there are millions of viral particles in your child’s stool and vomit….and these particles can be spread via the air as well.  Clean surfaces with a dilute bleach solution, wash your hands and “don’t breath??”

Daily Dose

Pink Eye

1:30 to read

This is another time of the year that I see a lot “pink eye”.  Any time the eye is have “pink eye”, which mothers seem to be quite confused by!!   They often comment…”this is pink eye?” , to which I respond, “well, the child’s eye (conjunctiva) is pink (red), so yes…this is pink eye”.  The term is just a description of the eye….but then you need to determine why the eye is “pink”.


Conjunctivitis is one of the most common causes of a pink eye….and there are many different types of conjunctivitis.  As with any condition the history is really important in helping to determine why a child’s eye is inflamed.  Several of the most common causes of the “pink eye” are bacterial, viral and allergic conjunctivitis.


Bacterial conjunctivitis often shows up in younger children and they have lots of matting of the eye lids and lashes and a mucopurulent discharge (gooey eyes). Some moms say that the “goo of gunk” comes as quickly as they can wipe it.  The child often has a lot of tearing and will rub the eyes as they feel that something is in their eye and it is irritated.  Bacterial conjunctivitis will typically resolve in 8 -10 days on its own, but antibiotic eye drops are used to shorten the course  of the pink eye and also reduce the contagiousness.  It seems as if every child in a day care class room will get conjunctivitis as they constantly rub their eyes and touch toys!!  Hand washing helps….but you can’t wash a child’s hands every time they touch their eyes.


Viral conjunctivitis usually occurs in combination of with systemic viral illness. Sore throat, fever and bright red eye are often seen in older children and teens and is due to adenovirus.  While the eye is red, the discharge is typically watery and matting is much less common. These patients are contagious for up to 12 days so it is important to practice good eye/hand hygiene, especially in the household. Artificial tears may help the feeling of eye irritation, but antibacterial eye drops rarely help except in cases of a secondary infection.  I get many phone calls from parents saying, “we tried prescription eye drops and they are not working”. I make sure to tell my older patients to take out their contacts and wear glasses for 7-10 days.


At this time of year I am also seeing a lot of seasonal allergic conjunctivitis.  These children have intensely itchy and watery eyes, as well as swelling of the eyelids and area surrounding the eyes. They look like they have been crying for days as they are so swollen and miserable. Many also have a very watery nasal discharge. They do not have fever. Using over the counter medications for allergy control, such as nasal steroids and anti-histamines will help some of the allergic symptoms. There are also over the counter eye drops (Zaditor, Patanol) that help when used daily.  During the worst of the season I make sure that the child has daily hair wash and eyelash and eyebrow wash with dilute soapy water to make sure the pollen is removed after they have been playing outside. It is nearly impossible to keep a child indoors for the 6 or more weeks of allergy season!



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