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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

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 pink..you 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!

 

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

RSV Season is Here

Boy oh boy, RSV is really here and so more thoughts on that topic. The office is just full of coughing and wheezing kids of all ages, much of which is RSV.Boy oh boy, RSV is really here. The office is just full of coughing and wheezing kids of all ages, much of which is RSV.

But the ones I am really concerned about are the infants and babies under the age of one year. They have a harder time with the virus and this infant age group is the group that statistically gets hospitalized more often. The buzz among moms about RSV continues (but at least less buzz about vaccines). They are all concerned and confused about when they need to come and see the pediatrician and also what “they” as parents need to watch for. Both of these concerns are important. As we talked about before, almost all children get RSV by one year of age. In most cases it will just be a bad cold, but in some babies they will develop bronchiolitis (or airway inflammation of the lower respiratory tract) and they have a classic, frequent, non-productive cough, lots of secretions and often have a wheeze when listened to with the stethoscope. In most cases these babies are fairly “pathetic” and cough and awaken throughout the night, may not eat quite as well, and just feel “puny” and require a lot of parental care and TLC. Babies and therefore their parents don’t get a lot of sleep when RSV is around. The babies I worry about are those that have true difficulty breathing. They not only cough frequently, they have signs of increased work of breathing which is evident by “pulling or retracting” while breathing. When you take off their shirts (which is what you should do at home too to look at how they breath), you see their ribs pulling or their abdomens working to help them breath. They look uncomfortable, not just while coughing, but also while just trying to get a breath. If this gets worse they may even grunt with each breath. I also worry about the baby that coughs and coughs and has “duskiness” with their cough. Most parents report that their baby gets bright red with cough, and eyes water and they may even vomit with cough. But a baby that turns even A LITTLE dusky needs to be seen immediately. Remember, red is good, blue is bad! Unfortunately RSV is here for a while. This is the peak season in most of the country and will be for weeks. Keep those young babies away from others and if your baby develops cold symptoms, look at how they breathe. If in doubt, take them in. That’s your daily dose, we’ll chat again tomorrow.

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

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

Teens And Sexually Transmitted Infections

An alarming study in Pediatrics reveals a rise in STD among sexually active teens. Recently, I was reviewing an alarming study in an issue of Pediatrics. Although I use the word alarming, unfortunately it is better stated as “sobering reality” as the statistics only corroborate what I have seen in my own pediatric practice where I take care of many adolescents.

Despite our parental and societal “admonitions” not to have sex before marriage, teenagers are engaging in sexual activity, and they are also developing sexually transmitted infections. The statistics continue to show that somewhere between 60 to 70 percent of high school seniors have had “sex”, and by 12th grade, more girls than boys admit to having had intercourse. More than 15 percent have had multiple partners. In this study, which was done by the Centers for Disease Control and Prevention (CDC), 838 girls ages 14 to 19, who were participating in the National Health and Nutrition Examination Survey 2003 – 2004, provided specimens that were tested for gonorrhea, Chlamydia, trichomonas, herpes, and HPV (human papilloma virus). The prevalence of any of the five sexually transmitted infections (STI) was 24.1 percent. When results were broken down further those teens who reported only one lifetime sexual partner had 19.2 percent prevalence of any STI and for those teens who had more than three sexual partners the prevalence increased to 53.3 percent for an STI. Once again, as in previous studies the most common STI was HPV (types 6 and 11), followed by Chlamydia. HPV infections accounted for nearly three- quarters of the overall STI prevalence. Both of these infections may be silent, in other words, young girls may not have outward evidence of these infections but HPV may lead to cervical cancer and Chlamydia may cause problems with infertility. Unfortunately, I don’t think many teens are thinking about long-term consequences when they engage in pre-marital sexual behaviors. Teens are impulsive, live in the moment and typically feel that “these things happen to other people.” Even when talking about these issues with my own teenage sons I often hear “Mom, we get it we are smart!!” Smart kids get STI’s too. We need to continue discussing sexuality with our children, even at young ages. The more knowledge the better and while still supporting abstinence, they need to learn how to protect themselves if they do have sex. Abstinence only education has not been successful as we see our teen pregnancy rates rising and now the rate of sexually transmitted infections are even more prevalent and occur quickly after a girl’s sexual “debut”. All girls (and now boys) ages 11 – 26 should receive HPV vaccinations and sexually active adolescent females need to be screened yearly for Chlamydia. We need to ensure that all of our adolescents have access to sex education and sexual health care.  Keep up the dialogue. That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

How to Treat a Baby With Thrush

I have received some recent e-mails and now an office visit regarding the possibility of a baby having thrush. Thrush is a yeast (fungal) infection that involves the mouth, and is most typically seen in infants.I have received an email via our iPhone App and now an office visit regarding the possibility of a baby having thrush. Thrush is a yeast (fungal) infection that involves the mouth, and is most typically seen in infants.

The yeast infection usually involves the inside of a baby’s cheeks and lips and occasionally the tongue. It appears as white, almost cottage cheese like patches, and is often visible when a baby is yawning or crying. A baby who only has a white tongue typically does not have thrush, but just a milk coated tongue (see if you can wipe some of the milk off of the tongue, as yeast is usually more adherent). Thrush is fairly common as we all have yeast in our digestive tracts, and babies are often colonized with yeast as they travel through the birth canal. For unknown reasons, in some infants there is an overgrowth of yeast and thrush may develop. Many mothers feel guilty that they “gave their baby” a yeast infection. They worry that thrush has something to do with cleanliness (NOT) and somehow that maternal guiles thing is already beginning. (Dads have already cut to the chase and say, how do you treat it?!) Thrush can happen to any infant. In a breast feeding baby it may also cause a mother to have inflamed and tender nipples, and the baby and mother actually pass the yeast back and forth during feeding (no guilt, as breastfeeding is good!) In most babies thrush does not cause a lot of problems and may go away by itself. But if the infection becomes extensive it may become painful and cause an infant to be uncomfortable when nursing or taking a bottle. If you notice that your baby has white plaques in their mouth or under their lips it may be worth a phone call to your pediatrician. (This is not an emergency and can wait till office hours.) There are several prescription preparations that may be used to treat thrush. The most common being Nystatin, which is a liquid medication that is given to the baby after they have been fed, and is squirted into the mouth on the inside of the cheeks, to treat the yeast infection.  It is also beneficial to treat a nursing mother’s nipples with an anti-fungal agent. I usually tell patients to use the medications for at least seven days or until the white patches have been gone for several days before stopping treatment. It is not uncommon to get thrush again, so don’t fret if your baby develops another infection, at least you know what it is and how to treat it. A yeast infection in the mouth may often lead to a yeast infection in the diaper area (candidal diaper dermatitis), because as you know what goes in the mouth comes out in the poop. But that rash is for another day…. That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

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.

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