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Daily Dose

Dog Bites

1:30 to read

I am a dog lover and we have always had a dog in our house….even before we had our children.  But, some dogs will bite and unfortunately there are more than 800,000 people every year who receive medical care for a dog bite…more than half of these are children.

 

Children are also more likely to be severely injured from a dog bite…and I was reminded of this today when I saw a very serious dog bite to a child’s face.  The child was brought to my office by his nanny after being bitten on his cheek by the family’s dog.  It was one of the worst bites I have ever seen! He was severely injured and should have actually gone straight to the ER….the good news is that he will ok, but he had to undergo surgery to repair the bite and will probably require another small surgery at some later date. 

 

In this case as in most, the dog bite occurs when a child is interacting with a familiar dog, and in this case it was the family pet. The little boy is a toddler with a twin sister and they were playing when he was bitten.  The dog had been around the children since they were born…and it is unclear what precipitated the bite.  Sometimes a dog becomes aggressive if they are bothered while they are eating or sleeping…and you know toddlers, they can “bother” anyone. 

 

One of my “boys” is also a dog bite statistic.  He was raised with dogs (my sweet lab Maggie is at my feet as I am writing), so I was totally caught off guard one night when the phone rang. My son had been spending the night at a friend’s house (he was about 10 years old) and the voice on the other end of the phone was the father of the friend (he too a doctor), informing me that my child had been bitten by their dog.  It seemed the boys were laying on the floor on blankets watching a movie and eating popcorn and for some “unknown “ reason the dog bit my son on his face.  The bite was not precipitated by anything…they had not been playing or rough housing with the dog and the dog had not been known to be aggressive. The next words out of the father’s mouth…”do you know a good plastic surgeon?” Not words you want to hear from another physician.

 

Thankfully, I did know a good plastic surgeon who I awakened after his long day in the OR….and he got out of bed and met us to suture my son’s face with over 20 stitches. Luckily it only involved his nose, cheek and chin, just barely missing his left eye. I am sure I cried more than my son.  He still has a scar across his nose..which only bothers his mother.  Incredibly, he never “blamed” their dog, went back to play at their house, and still loves his own dogs more than anything.  My brother who is a vet still thinks that any dog that bites without provocation should not stay in the home with children…but that is one vet’s opinion. 

 

It is especially important to teach your children never to approach a dog to pet it without first asking the owner if it is okay.  Children should learn to move slowly and let the dog “sniff” them first and to stay away from their face and tail. Teach your child how to gently pet an animal and to always be gentle.  If they are around a dog who is behaving in a threatening manner by growling or barking, they should slowly back away from the dog and try to avoid eye contact with the dog. If they are ever knocked over by a dog they should curl up in and ball and protect their face with their arms.

If your child is bitten and it is superficial it will probably just require care with soap and water. For bites that break the skin you should check in with your pediatrician.  Make sure you know the rabies vaccination status of the dog that bit.  You also need to make sure that your child is up to date on their tetanus vaccination. In some cases your child may also need an antibiotic.

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Daily Dose

Summer Viruses

1:30 to read

June….now seems like officially summer, although there are still some schools around the country in session, and even a couple in Dallas.  So, with summer here it is check up time in my pediatric office.  That means most days I am seeing very few sick patients, and most of the patients who come in for a visit other than a check up have a rash, a bug bite or maybe a swimmer’s ear.

 

But, with that being said there are also always some of those pesky summer viruses hanging around and many of them appear with just a fever. Many of the “sick” children I am seeing only have a fever, some of whom have a temperature as high as 103-104 degrees, with very few other symptoms.  Although these kids have a significant fever, once they are given an over the counter product like acetaminophen or ibuprofen they feel pretty well and even play for awhile. 

 

Fever is often just a symptom of a viral infection and these summer viruses have names…enterovirus, adenovirus, and even some left over parainfluenza virus.  We are definitely out of flu season….at least till next year.

 

Some of these summer viruses may have associated rashes which are more common with summer viral infections than winter viruses.

 

I have seen some kids with these summer viruses with prolonged fever, even 5-7 days which is a bit longer than a pediatrician and a parent want to see. But, with that being said, when I have seen these children they appear to look well and have not had any other physical findings.  I have often seen them again after having 5 or more days of fever, and it seems that many of them have adenoviral infections.  Adenovirus may also cause a myriad of other symptoms than just fever, including pink eye, sore throat, abdominal pain and vomiting and diarrhea and tummy cramps.  Rarely, some children will develop blood in their urine without having a urinary tract infection. 

 

Parents often ask me….where did they catch this? Remember that these are just viral infections and that there is not a vaccine for adenovirus. Once we see one virus in the community I know I will continue to see more and more children as it is “passed around”.  Best thing to do is to keep up good hand washing and keep your child home from the pool or summer activities if they have a fever.  

 

Daily Dose

Plants That Cause Summer Rashes

1:15 to read

Now that summer is upon us and everyone is enjoying being outside I am seeing patients with contact dermatitis (rashes) after coming into contact with poisonous plants.  While allergies are slowing down a bit with the hotter weather, plants like poison ivy, oak and sumac (depending where you live) are full of leaves.  About 50% of people who come into contact with the leaves of these plants will have a reaction.

The adage “leaves of three, let them be” continues to be the best way to prevent getting a rash. That also means wearing long sleeves, and pants...and gloves. But what child goes off to play in the yard, or by the creek dressed like that for summer?  Sunscreen yes, gloves, probably not. 

If you realize you have been exposed to the plant leaves and therefore the urushiol (oil on leaf) , wash all areas of exposed skin as soon as possible with some products that are available like Tecru, Sanfel and Goop Hand Cleaner....if you don’t have those use dish washing soap.  

It may take up to 4 days after exposure to develop the rash and lesions may also appear at different times depending on the location and length of exposure to the urushiol.  The rash is usually really itchy and is often is linear clusters or little vesicles or blisters.  The rash does not spread by scratching or from the fluid inside the blisters, that is a myth. You cannot give anyone else poison ivy if you have washed off the urushiol.  

The best treatments relieve the itching and irritation.  Keeps nails short and hands clean so that scratching will not cause a secondary bacterial infection.  You can use oatmeal baths (Aveeno) or cool compresses (Dommeboro) to help control itching. An over the counter steroid cream is a good place to start to help the inflammation, but it may be a stronger prescription steroid cream will be needed. 

I also try calamine lotion or astringent to soothe the irritation. Sarna is another good lotion for itching....Oral antihistamines like diphenhydramine (Benadryl) really don’t help with the itching as it is not due to histamines, but may cause a bit of sedation so a child can sleep.

If the rash is getting worse, spreading to the face and around the eyes or begins to look infected it is time for a visit to the pediatrician. For severe cases oral steroids may be necessary.

It sometimes takes 10-14 days for the rash to go away.  Oh, and getting overheated only makes you itch more.

Daily Dose

Don't Miss Out on Summer Fun!

1.00 to read

The lazy days of summer seem like the perfect time to engage in playtime activities. My summer months at the office are particularly busy doing check ups as everyone is out of school. This means that I seem to see a lot of children in the 5-12 year group, and I enjoy getting to talk to them about their summer fun. 

I have suddenly realized that many of the children in this age group seemed to have “missed” some key milestones in child development, which I think most of us adults learned during the lazy days of summer.  I think learning to ride a bicycle and learning how to swim are two MUSTS of child development. While not all children will want to one day participate in a swim team, or a bike race, being able to swim and pedal a bicycle are life long skills. Who knows, with the price of gas we may all be heading back to bicycles as preferred transportation, at least for short distances.  

At the same time I have noticed a fair number of parents who are concerned about their young children’s motor development.  This is the 2-4 year old group where I am sometimes amazed when the parent of a 3 year old tells me that their child “does not jump high enough”. What?  How about getting out the jump rope again, and drawing hopscotch on the sidewalk to practice hopping and jumping. These are free exercises that can help boost coordination while having fun together. What about learning to skip and to balance on a beam (doesn’t have to be at gymnastics) a two by four in the back yard or park works just as well. Learning to pump a swing is another. I can remember how proud I was when I mastered that skill (makes me smile, even today). 

So while the last days of summer are here, make a list of not only summer reading, or computer skills that your child needs to finish, but of some of those childhood milestones as well.  Hop, skip, jump rope, ride a bike, learn to swim. College applications might start asking about those milestones one day too?  Stranger things have happened.

Daily Dose

Summer Skin Infections

1:30 to read

I have been seeing a lot of skin infections and many of these are due to community acquired methicillin resistant staph areus (caMRSA). The typical patient may be a teen involved in sports, but I also see this infection in young children in day care, or summer camp. The typical history is “I think I have a spider bite” and that makes your ears perk up because that is one of the most common complaints with a staph infection, which is typically not due to a bite at all.

The poor spider keeps getting blamed, and how many spiders have you seen lurking around your house waiting to pounce? The caMRSA bacteria is ubiquitous and penetrates small micro abrasions in the skin without any of us every knowing it. The typical caMRSA infection presents with a boil or pustule that grows rapidly and is very tender, red and warm to the touch. The patient will often say that they “thought it was a bite” but the lesion gets angry and red and tender very quickly and typically has a pustular center.

For most of us pediatricians, you can see a lesion and you know that it is staph. It is most common to see these lesions in athletes on exposed skin surfaces such as arms and legs, but lesions are also common on the buttocks of children who are in diapers in day care. The area is angry looking and tender and the teenage boy I saw the other day would not sit on the chair, but laid on the table on his side as he was so uncomfortable. If the lesion is pustular the doctor should obtain a culture to determine which bacteria is causing the infection, but in most cases in my office the culture of these lesions comes back as caMRSA or in the jargon Mersa. When I say Mersa, I often cause widespread panic among my patients, but in most cases to date these infections may still be treated with an oral antibiotic that covers caMRSA, such as clindamycin or trimethoprim-sulfa. Many of the lesions improve dramatically once the site is drained and cultured. I will reiterate that if possible you want your doctor to obtain a culture to identify the bacteria that is causing the infection.

To prevent caMRSA remind your student athlete not to share towels, clothing or other items. Make sure that common areas are disinfected and once again encourage good hand washing. The closure of schools or disinfecting an entire football field or area with turf is not recommended. Lastly, this is a good reminder that you only want to take an antibiotic for a bacterial infection and that overuse of antibiotics leads to resistance. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Swim Lessons Can Reduce Risk of Drowning

1:15 to read

Now that hot weather is with all of us, the issue of childhood drowning is an ever-present concern. The American Academy of Pediatrics recommends that after the age of five years, all children be taught to swim. The AAP does not recommend for or against swimming lessons as a measure to prevent drowning in children younger than five years. Between 2000 and 2005, 6,900 children died from non-boating accidental drowning. The rate of drowning was almost four times higher for children one to two years of age, and twice as high for those younger than five.

An article in Archives of Pediatric and Adolescent Medicine looked at the association between swimming lessons and risk of drowning specifically in the one to four year old age groups. Previous concerns had been raised about the potential for swimming lessons to increase the risk for drowning in younger children. This study provided good news that kids aged one to four who have taken formal swimming lessons have an 88% less risk of drowning. Researchers found that only three percent of the children who had drowned had taken swimming lessons. So with this news, it might be prudent to start swimming lessons at a younger age than previously thought.

But swimming lessons alone will not prevent drowning and even in this study, many of the older children who drowned were noted to have been proficient swimmers. It is still important to have other drowning prevention strategies in place including pool fencing (some parents with pools feel like their child will not be able to unlock a door and head to the pool and do not have a fence in place, and I totally disagree with that argument), constant and age appropriate adult supervision and training in CPR. Children are amazing at finding ways to unlock doors, and windows that lead outside and no parent can know where their child is for every minute of the day. If you have a pool and a child is missing always check the pool first, as a child can quietly slip into the water and lose consciousness in as little as two minutes and drown in five minutes.

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

Daily Dose

Why All Kids Need Sunscreen

Unfortunately, I have already seen several rather severe sunburns on children who had forgotten to use sunscreen and came in with blistered shoulders or noses and ears.It certainly felt like summer in Texas today. Most of our schools are out and children are already heading to the pool. Unfortunately, I have already seen several rather severe sunburns on children who had forgotten to use sunscreen and came in with blistered shoulders or noses and ears. The majority of our sun exposure occurs before the age of 20, somewhere between 50 - 80 % is the number often quoted. Sun exposure is directly related to the risk of melanoma, and melanoma is on the rise in youth.

To prevent sunburn damage it is imperative that parents begin using sunscreen on their children at very young ages, even younger than 6 months. Sunscreen needs to be applied about 15 minutes before your child heads out to the park to play or to swim or for any outdoor activity, and re-applied at least every 2 hours, and more often if swimming or perspiring. An ounce of sunscreen is about the amount necessary to coat a child each time it is applied. There are two types of ultraviolet rays, UVA rays which penetrate more deeply into the skin damaging DNA, which leads to wrinkles, aging and skin cancer. UVB rays which penetrate the first layer of the skin and typically causes sunburn. There are 20 times more UVA rays in the environment than UVB. So, look for a sunscreen product with both UVA and UVB protection. It is good to also look for a sunscreen that will provide a physical block like a zinc oxide (now micronized so it is transparent on the skin) or titanium oxide. These blocks help scatter the UV light and are typically less irritating and less allergenic than chemical sunscreens. These products may be preferable in young children, and remember you can use sunscreen on children under six months if they will be sun-exposed. Chemical sunscreens contain compounds that absorb some the sun's damaging rays, including PABA, cinnamates, Parsol, and helioplex. I have had lots of questions about sunscreen in infants and the AAP and AAD all state that sunscreen may be used on infants, but that preferably an infant is not in the sun for lengthy exposure. Their skin contains less melanin and therefore is even quicker to burn. If you are taking your infant out, have them wear a hat, sun-protective clothing and put sunscreen on sun-exposed areas. Do not rely on an umbrella for complete sun protection either, as the rays can penetrate through an umbrella or awning. Better to keep the your-baby inside than on the beach for an extended period of time. That's your daily dose, we'll chat again tomorrow.

Daily Dose

The Joy of Fun Summer Activities

1:15 to read

While doing summer checkups and discussing everyone's summer plans I started thinking that I should really be asking about some of the basics like summer and all of the wonderful activities to do. We have talked about swimming and camps and staying abreast of academic work, but what about the basics of summer? The good, old-fashioned leisure time activities that we all used to do. While doing summer checkups and discussing everyone's summer plans I started thinking that I should really be asking about some of the basics.

So here are the things that come to my mind: Basic summer skills for all of us to remember and to teach. All of this is free, easy and are really akin to life skills that all children should probably master at some point in their childhood.

  • Jumping rope
  • Riding a bike (of course with a helmet)
  • Skipping a stone
  • Pumping a swing
  • Blowing bubbles
  • Catching a ball
  • Throwing a ball (don't think I have still mastered this, wonder if it is too late?)
  • Turning a somersault
  • Playing hopscotch
  • Playing four square
  • Learning how to float on your back
  • Fly a kite
  • Catching fire flies

Don't feel pressured to do this all at once, as childhood is a long time. But enjoy the time spent with your children accomplishing these simple pleasures. Why don't you let me know things that you think of and that you feel are essential skills of summer? I am sure I have missed many. That’s your daily dose, we’ll chat again tomorrow.

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