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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

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

Vomiting Kids

1:30 to read

Pick a virus ….and it is probably circulating in your area!  Seems we are at the peak of upper respiratory season, influenza like illness season and also vomiting and diarrhea season. In other words, lots of sick kids right now.

 

I just started seeing a lot of vomiting again!!  It is the worst for both the child and the doctor’s office where it seems many a child has vomited either in the car, coming up the elevator or in the exam room.  YUCK for all.

 

Remember, norovirus is the most common virus that causes vomiting and diarrhea and it is VERY contagious. Not only via “dirty hands” but it is also airborne…so in other words, those standing near by a child who is vomiting (parents, other sibs) are probably being exposed as well. That is the main reason you probably see an entire family who gets sick almost simultaneously.  

 

If your child vomits….DO NOT give them anything to eat or drink for at least 30 min. I know that is hard as they are asking for a drink,  but you need to give their tummy a minute to “recover” before challenging them with a few sips of Pedialyte or Gatorade.  A SIP is the key word too….tiny amount to start in hopes that they do not vomit again.  

 

I just saw a 6 year old little boy who had been vomiting several times during the night.  His Dad said that he had given him Zofran to help stop the vomiting (this is a prescription).  I use a lot of Zofran in children who are vomiting as it can go under the tongue.  But after the Zofran his son felt better….so he gave him strawberries and a waffle!! Surprise? He vomited again!!

 

Don’t be fooled and start trying to feed your child too quickly after they are vomiting. I know parents worry that “their child is not eating”, but fluids are the important part of staying hydrated. As one little boy told me, “ it feels like there are grasshoppers in my tummy”!! So well put. I grumbling tummy needs time to heal and frequent sips of clear liquids (no dairy) are the best way to prevent dehydration. As your child tolerates a small volume you can go up a bit and gradually increase the amount that they take.  I usually wait a good 4-6 hours after a child has successfully tolerated fluids before I even consider giving them food. Then I start with crackers, noodles or something bland (that I also don’t mind cleaning up) in case they vomit again.  

 

You are just wanting to make sure your child stays hydrated…tears, saliva and urine!  Keep washing those hands. 

Daily Dose

The Truth About Antibiotics

1:30 to read

Despite warmer than normal temperatures in much of the country it is certainly already cough and cold season. Our office background music is already a lot of coughing coming from children of all ages…and a few of their parents too. In fact, a few of our nurses and docs are fighting a fall cold as well.

 

This makes it timely to discuss (once again) the difference between a cold which is a viral infection and a bacterial infection (example strep throat).  Viruses are NOT treated with antibiotics!! In other words, antibiotics are not useful when you have the common cold. Asking your doctor to put you on an antibiotic “just in case “ it might help is not advised, and doctors should be taking the time to explain the difference between a viral infection and a bacterial infection, rather than writing an unnecessary antibiotic prescription.  

 

While some people (fewer and fewer young parents) still think an antibiotic is necessary, the overuse of antibiotics has been called “one of the world’s most pressing public health problems”s, by the CDC. Not only does the overuse of antibiotics promote drug resistance, it may also cause other health concerns as well. While antibiotics kill many different bacteria, they may also kill “good bacteria” which in fact help the body to stay healthy. Sometimes, taking antibiotics may cause diarrhea and may even allow “bad bacteria” like clostridium difficile to take over and cause a serious secondary infection.  

 

At the same time that there are too many antibiotic prescriptions being written for routine viral upper respiratory infections, a new study in JAMA also found that bacterial infections (sinusitis, strep throat, community acquired pneumonias), are not being treated with appropriate “first line” antibiotics such as penicillin or amoxicillin.  Of the 44 million patients who received an antibiotic prescription for the treatment of sinusitis, strep throat, or ear infections, only 52% were given a prescription for the appropriate first line antibiotic. When a doctor prescribes a broader spectrum, often newer antibiotic, instead of the recommended first line drug, they too are responsible for increasing antibiotic resistance.

 

So, you should actually be happy when your pediatrician reassures you that your child does not need an antibiotic, and that fever control with an over the counter product, extra fluids and rest will actually do the trick to get them well.  I “brag” about my patients who have never taken an antibiotic…..as they have never had a bacterial illness, and tell their parents how smart they are for not asking for an antibiotic “just because”.

 

At the same time, if your child does have a bacterial infection, ask the doctor if they are using a “first line” drug and if not why…? It could be because your child has drug allergies to penicillins, or that your child has had a recent first line drug and has not improved or has had ‘back to back” infections necessitating the use of a broader spectrum antibiotic.  Whatever the reason, always good to ask.

 

Keep washing those hands, teach your child about good cough hygiene and run don’t walk to get your flu vaccines….November is here and flu usually won’t be too far behind.

 

 

  

Daily Dose

HPV Vaccine

1:30 to read

I don’t think I have posted the latest good news about vaccines. As you know I am a huge proponent of vaccinating children (and ourselves), and remind patients that there continue to be ongoing studies regarding vaccine safety, as well as efficacy.  The CDC and ACIP recently announced that the HPV vaccine may be protective and effective after just 2 doses of vaccine rather than the previous recommendation of a series of 3 vaccines.  That is good news for teens, especially those that are “needle phobic”!  

 

The ACIP (Advisory Committee on Immunization Practices  recommended  a 2 dose HPV vaccine series for young adolescents, those that begin the vaccine series between 11 and 14 years.  For adolescents who begin the HPV vaccine series at the age 15 or older, the 3 dose series is still recommended.

 

This recommendation was based upon data presented to the ACIP and CDC from clinical trials which showed that two doses of HPV vaccine in younger adolescents (11-14 years old) produced an immune response similar or higher than the response in older adolescents (15 yrs or older). 

 

The HPV vaccine, which prevents many different types of cancer caused by human papilloma virus, has been routinely recommended beginning at age 11 years  approved to use as young as 9 years), but unfortunately only about 42% of girls and 28% of teenage boys has completed the 3 dose series.  

 

By showing that a 2 dose series (when started at younger ages) is effective and protective the hope is that more and more young adolescents will complete the series.  The two doses now must be spaced at least 6 months apart and may even be given at the 11 year and then 12 year check up which would not require as many visit to the pediatrician.

 

According to the CDC more HPV - related cancers have been diagnosed in recent years, and reported more than 31,000 new cases of cancer each year (from 2008 - 2012) were attributable to HPV, and that routine vaccination could potentially prevent about 29,000 cases of those cancers from occurring.  But, in order to see these numbers shrink, more and more adolescents need to be immunized…before they are ever exposed to the virus. Remember, the HPV vaccine is protective against certain strains of HPV, but does not treat HPV disease.

 

So..once again a good example of using science based evidence to provide the best protection against a serious disease…with less shots too!! Win - Win!!

 

 

Daily Dose

Home From School

1:30 to watch

I continue to talk about it being  the “sick season” and thankfully it is now February!  Parents are all tired of having sick children and I can now at least assure them that we are halfway to the end of upper respiratory and flu season.

 

But, with that being said that means I am still seeing children with RSV, Flu and every other virus I can think of. Remember, the majority of the illness I see every day in my office is VIRAL.  It really doesn’t matter if you can put a name to the virus, as the treatment is the same. Rest, fluids, fever control and watch for any respiratory distress or symptoms of dehydration. As I told one young mother who said that her other child had been tested for RSV (by another doctor), testing the child I was now seeing will not make any difference in how we treat the illness. So, why make the child uncomfortable when doing the swab and also drive up health care costs, for no change in treatment recommendations.  I think people are confused about what the test actually does….it does not change how a child is treated, and it also causes a lot of “alarm” as the mother of one patient goes home to tell her friends that her child has RSV and then the school starts sending out emails and parents become more anxious and alarmed that they may have been exposed….as they are every day all over our city.

 

So…when do you know it is time to keep your child home from day care or school as we all know these viruses are spread at home, school and work as well.  

 

If your child has a fever over 100.5 degrees (by any method of taking their temperature) they should not go to day care or school for at least 24 hours after becoming fever free (without fever lowering medication).

 

If your child is vomiting, 2 or more times in the last 24 hours, they should stay home. Some young children may vomit after coughing as well, but if infrequent they may attend school. 

 

Diarrhea as defined by two or more loose, watery stools that are “out of the ordinary stool pattern” for your child. Any child having diarrhea that does not stay contained within a diaper should stay home. A child who has blood in their stool should not attend day care or school (and should see the doctor).

 

Children with strep throat may return to school after 24 hours if they are fever free and have received the appropriate antibiotic therapy.  (Newer article suggests 12 hours if they are feeling well).

 

Your child does not need to stay home due to a cold, cough, runny nose (of any color) or scratchy throat if they do not appear ill and do not have a fever. Look at how your child is behaving…some times a day of rest may be needed (even when you get sick, right?) 

 

Most importantly, it is not necessary to name the virus that your child might have, but to follow the guidelines for keeping them home (as well as out of stores, church, and after school activities) until they are feeling better. Wash hands, cover coughs and yes….still get the flu vaccine. It is not too late…the ground hog even said we still have a lot of winter left.

 

 

 

Daily Dose

How to Treat A Vomiting Child

We are definitely in the throes of "sick season" in our office and with that comes a lot of kids with vomiting. I remember the first time that one of my own children vomited.

We were in Target, he was about two and he had said he "was sick". Now, seeing that he was not very specific and did not elaborate, I just went on shopping. Several minutes later, as he sat in the cart (with seat belt fastened), he just looked at me wide eyed and suddenly vomited. This is the moment as a parent that you understand the difference between babies that "spit up", and true, projectile vomiting! Now what do you do once your child has vomited (besides rush out of Target as fast as you can)? Once a child has vomited it is important not to give them anything else to eat or drink, for at least 30 to 45 minutes. That means even if they are "begging" for a drink, as you will probably see it come right back at you if you do. After waiting, you want to begin re-hydrating with clear liquids. Not a good idea to pull out the milk or food yet. In an infant you can use Pedialyte, which is an oral electrolyte solution, and instead of breast milk or formula you can try feeding your infant about an ounce of Pedialyte every 10 to 15 minutes and see if they can keep Pedialyte down. In toddlers and older children I use Gatorade, as it is not quite as "salty" and kids seem to take it better. Again, frequent small sips of Gatorade while you wait to see if the vomiting is persistent. Don't go too quickly on giving them larger volumes. The key is small amounts, frequently, which are easier to handle. As your child keeps down the Pedialyte or Gatorade you can increase the volume that they are taking and decrease the frequency. The main thing you are trying to do with a child of any age is to keep them from getting dehydrated and their vomiting is typically due to a viral illness affecting their GI tract. Because it is typically a virus that is the culprit for nasty vomiting, it just takes time to get through the illness. There is no "miracle" cure, and watching your child vomit, or cleaning up the vomit that invariably is usually not in the toilet, is one of the worst parenting jobs. That being said, there are very few children who will not experience vomiting at least once or twice during their childhood, so you need to keep "clear liquids" on hand in the pantry. Having powdered Gatorade around is a lifesaver at 2 a.m when your four-year-old wakes up and throws up. If you are giving the clear liquids, and your child tolerates larger volumes, but then vomits again later on, you just back up and start all over with smaller amounts more frequently. It is somewhat like a "balancing act" to give enough that they are hydrated, but at the same time to not give too much at one time that they vomit again. Slow and steady is the mantra. You should always be looking for your child to have tears, a wet and moist mouth (put your finger in there, it should come out with some saliva on it), and urine. It is often hard to tell if a child in diapers has had a wet diaper as they will not be "soaking" the diaper and smaller amounts of urine are "wicked" with the new super absorbent diapers. Children will also be pitiful after vomiting and may seem "lethargic" to you, but if they are an infant and can smile and make good eye contact or they are an older child who can tell you they feel terribly and don't want to drink Gatorade or play with their blocks they are probably not dehydrated. If in doubt, give your doctor a call to discuss what is going on. After using Pedialyte and Gatorade, and your child has not vomited for six to eight hours you can try adding some formula or breast milk, or other liquids such as chicken soup or a Popsicle. I still would not start solid food until the child has kept down other liquids. We parents all worry if our children don't "eat" but the fluids are the important part, and as we all know, a day without out chicken nuggets or peanut butter will be okay. Keep up the fluids!! If your child continues to vomit despite your best efforts with "slow and steady" fluids you need to call the doctor. We have plenty of patients that we see everyday to make sure they are hydrated, and to even watch them while they take fluids in our office. Occasionally, when all else fails we will have to hospitalize a child for IV hydration. Oh yes, remember to wash your hands frequently as these nasty viruses are contagious and parents will often find themselves getting sick after their children. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Spring Viruses

1.30 to read

While it is warming up here in Dallas, many parts of the country are still seeing freezing temperatures and even snow! Even so, I am beginning to see typical spring illnesses like Fifth’s disease. 

Fifth disease is a common viral illness seen in children, often in the late winter and spring. Many of these children look like they have gotten a little sun burn on their faces (just as your child starts playing outside) as they often show up in my office with the typical slapped cheek rash on their faces.  At the same time they may also have a lacy red rash on their arms and legs, and occasionally even their trunks.

Fifth’s is also called erythema infectiosum and is so named as it is the fifth of the six rash associated illnesses of childhood. Fifth disease is caused by Parvovirus B19, which is a virus that infects humans. It is NOT the same parvovirus that infects your pet dog or cat, so do not fear your child will not give it to their pet or vice a versa.  In most cases a child may have very few symptoms of illness, other than the rash.  In some cases a child may have had a low-grade fever, or runny nose or just a few days of not feeling well and then the rash may develop several days later. The rash may also be so insignificant as to not be noticed. When I see a child with Fifth disease it is usually an easy diagnosis based on their few symptoms and the typical rash.

Although children with Fifth are probably contagious at some time during their illness, it is thought that by the time the rash occurs the contagious period has passed. This is why you never know where you got this virus. (the incubation period is somewhere between 4-20 days after exposure).  Parvovirus B19 may be found in respiratory secretions and is probably spread by person to person contact.  During outbreaks it has been reported that somewhere between 10-60% of students in a class may become infected.

Most adults have had Fifth disease and may not even have remembered it, as up to 20% of those infected with parvovirus B19 do not develop symptoms, so it is often not a memorable event during childhood.

Fifth disease is another one of those wonderful viruses that resolves on its own. I like to refer to the treatment as “benign neglect” as there is nothing to do!  The rash may take anywhere from 7–10 days to resolve. I do tell parents that the rash may seem to come and go for a few days and seems to be exacerbated by sunlight and heat. So, it is not uncommon to see a child come in from playing on a hot sunny day and the rash is more obvious on those sun exposed areas. 

Occasionally a child will complain of itching, and you can use a soothing lotion such as Sarna or even Benadryl to relieve problematic itching. A cool shower or bath at the end of a warm spring day may work just as well too. Children who are immunocompromised, have sickle cell disease, or have leukemia or cancer may not handle the virus as well and they should be seen by their pediatrician. But in most cases there is no need to worry about Fifth disease, so it is business as usual with school, spring days at the park and Easter parties.

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

Daily Dose

Strep Throat

1:30 to read

It is still what I call “sick season” and strep throat is here and for some reason even seems to “flourish” during early spring.   Strep throat is a bacterial infection that is typically seen in school aged children between the ages of 4-16 years (but may be seen in younger children and adults on occasion).  Strep symptoms begin with a sore throat, often a fever, swollen lymph nodes in the neck, and some children may have a headache as well as abdominal symptoms with vomiting. 

Because strep throat is due to a bacterial infection it is treated with an antibiotic.  But in order to diagnose strep throat your child will need to have a rapid strep test which entails having a swabbed specimen taken from your child’s throat (tonsils and posterior pharynx).  The test is pretty easy and most children don’t mind a throat “swab” or specimen (we call it tickling your tonsils), although some children may gag and even vomit.  But rest assured, there is not a needle involved in a strep test!!  The rapid strep test takes about 5 - 10 minutes and will determine if your child needs an antibiotic. This test if really accurate, but in our office we also do a back up overnight culture (old school) on all negative rapid strep screens so as not to miss any false negative tests.

While strep is treated with an oral antibiotic (on occasion a shot for a vomiting child ), the rule of thumb was 24 hours at home after beginning antibiotics before returning to school or outside activities. An interesting study published in the Pediatric Infectious Disease Journal concluded that “children treated with amoxicillin (who are not allergic ) by 5 pm, and if fever free, could attend school the following day” and not put other children at risk.

Although this was a small study (only 111 children ), the authors found that 91% of the children who had received an appropriate initial dose of amoxicillin, had undetectable group A Strep on the rapid test and on a  throat culture on the second day. 

While this study is interesting, I also think that there are several important points to be made. A child with strep throat may no longer be contagious after 12 hours, but how are they actually feeling?   Did they sleep well that night? Do they still have a sore throat or maybe a headache? (despite being fever free) Is it better for that child to stay at home for a day rather than rushing back to school when “not at the top of their game”?

I do realize that it may be helpful for working parents as it would get them back to work more quickly as well, we still need to consider how their child is feeling.  Sometimes, while an antibiotic will “treat” the infection, a day of rest, fluids and no school may be just what the doctor ordered.  I still think we need to look at the individual child…and make a decision based on multiple factors. 

 

 

 

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