Impetigo

/in /by
What is impetigo?
It is an infection of the skin.
What does it look like?
It most often looks like golden crusted blisters or weeping sores on the skin.
Where does it occur?
It occurs mostly around the nose and mouth but can occur on any part of the body.
Is it contagious (“catchy”)?
It is contagious and can be spread to other parts of the body as well as to other persons.
How is it treated?
Your child’s physician will most often prescribe an antibiotic ointment or an antibiotic to be taken by mouth. More serious staph infections, especially those due to methicillin resitant staph aureus (MRSA) are treated differently. Ask your doctor about MRSA infections.
What can be done at home?
·         Use a separate wash cloth, towel and linens.
·         Bathe or shower your child daily and gently wash sores with soap and water.
When can my child go back to school?
A child with impetigo can most often go back to school after he has been treated for 1 day.

Strep Throat

/in /by
What is pharyngitis?
It is a sore throat caused most often by a virus, but it can be caused by the strep germ which is called “strep throat”.
What are the symptoms of strep throat?
A strep throat often causes a bad sore throat and fever.  It may also cause headache, stomach ache, pus on the tonsils, swelling of the neck glands and a rash.
How can I tell if my child has a virus or strep throat?
The symptoms of a virus sore throat are often milder than strep and include a cough or runny nose.  The physician may be able to tell the cause by exam alone.  Often a strep test is needed.
What is the treatment for a strep throat?
The usual treatment is amoxicillin or penicillin which should be taken for 10 full days.  This will help prevent rheumatic fever and keep the sore throat from coming back.  A single shot of penicillin is also available and treatment for 10 days is not needed.
Do antibiotics help fight a virus?
It is often helpful to take acetaminophen (Tylenol).
Should my child’s tonsils be taken out if he has repeated strep throats?
If your child has many strep throats in a year or if the tonsils are very big and cause trouble with eating or breathing, your child’s physician, may want to refer him to a surgeon for an evaluation as to whether your child’s tonsils should be removed.  Some signs of tonsils or adenoids which are large include snoring at night, mouth breathing, as well as nasal speech.

Enuresis

/in /by
Children with enuresis (bedwetting) often have daytime symptoms of urgency, urinary frequency and daytime urine accidents.  Medication is often helpful as are voiding schedules and techniques. Behavioral modification techniques are also helpful.
Some children sleep soundly and do not wake when they feel the urge to urinate. For many children genetics and gender play a role. Boys are twice as likely to wet the bed as girls and if a mother had bedwetting when she was a child there is a 3-4 times higher likelihood of bedwetting in her offspring.
Children with primary enuresis have never been consistently dry at night. These children make more urine during the night than their bladder can hold and do not wake during the night to urinate. Physical causes are rare and include defects in the genitourinary tract or spinal cord problems. Each child with primary enuresis must be carefully evaluated for these rare conditions.
Secondary enuresis, also called temporary enuresis, is often seen in children with recent life stress issues. In secondary enuresis children who had been previously dry for many months begin to bed wet.  These causes include physical, emotional or sleep related issues.
The most common primary and secondary cause of enuresis is constipation. Over a period of days to weeks or months a child develops a pattern of stool retention. This causes the child’s rectum to become a reservoir for stool and pushes on the bladder causing the bladder to become overactive and have “less room” to store urine. This results in frequent urination and night time accidents. A comprehensive history and physical examination are essential to this diagnosis as is an effective and comprehensive treatment protocol that addresses all physical, dietary and social-emotional issues.
Uncommon secondary issues include diabetes and infection.
Your pediatrician will work with you to identify and assess the causes and any family dynamics issues related to the enuresis. A collaborative treatment program focused on you and your child’s needs, including financial and medication concerns, must be developed and supported so you can make the right decision about a treatment program for your child.

Leg Pain in Children

/in /by
Musculoskeletal pain in the lower extremity is very common in children. By observing your child, providing your pediatrician a complete history and arranging for a thorough physical examination the right decision can be made about what tests and evaluations are necessary to assess and diagnose the pain.
Common causes include traumatic strains, sprains, dislocations and fractures as well as pain from infection or immune mediated pain. The pain may be referred from or due to age related issues including a slipped capital femoral epiphysis or Legg-Calve-Perthes disease. Although rare the risk of cancer and pain due to leukemia, lymphoma or a sarcoma must also be considered. The most common pains other than due to trauma are benign growing pains and tendonitis.
By providing an in depth pain history the possibility of missing an untreated disease is minimized. Provide information about when the pain began and the events surrounding the onset. Was there any trauma and how did your child respond when the event or trauma occurred? Were there any signs of bruising, swelling, warmth or localized tenderness? How has your child been acting since the onset of the pain? Are they easily distracted? Has your child been limiting any of her previous activities? Was a witness present?
Other information includes when the pain occurs. Immune mediated pain as is seen in rheumatoid arthritis is present in the morning and improves throughout the day.
Growing pains occur mostly at night as do pains from malignancy. The pattern of pain in terms of making it worse or better is helpful as are any associated symptoms such as fever, fatigue, weight loss, rashes, and appetite loss or sleep changes.
Since most children have difficulty providing much of the above information you must be a good observer and use “point and ask” questioning techniques to gather as much information as possible. These same techniques can be used for the physical examination that will include a general exam as well as pertinent orthopedic and neurologic examinations.
With your help the pediatrician can usually narrow a long an extensive list of possible causes to a very short list and allow a decision to be made as to what test(s) are needed and whether patience and observation are all that is needed.

Eye Examinations in Children

/in /by
Eye and vision examinations are important and need to be included in newborn and subsequent well child health supervision visits. If an infant or child is at high risk for a problem they need to be seen by a pediatric ophthalmologist or an ophthalmologist experienced in the care of children. At risk children include those who were very premature or have a family history of congenital cataracts, retinoblastomas or genetic/metabolic disease. Children with neurodevelopmental problems or physical conditions that affect the eye also require referral.
Most children do not complain of vision difficulty and cooperation for testing can be difficult. Screening for vision should be initiated at 3 years of age and any child with concerns needs to be referred for further evaluation.
The eye assessment in infants and children includes the following: a thorough history including family history, external inspection of eyes and lids, eye movement assessment, pupil examination and red reflex examination. Children starting at age 3 years need a visual acuity measurement and ophthalmoscopy if cooperation allows. If cooperation limits testing at age 3 then repeat screening is done 4-6 months later and referral can be pursued if testing concerns or if cooperation is not possible. For children age 4 years and older the same routine is followed with earlier repeat testing and referral as needed.
The assessment of ocular alignment is very important in the pre-school age child. Strabismus may occur at any age and can be a sign of serious underlying medical conditions. Some children will appear to have strabismus on observation due to prominent inner epicanthal lid folds that cover the inner portion of the eye. This is normal and does not require treatment. A referral to a pediatric ophthalmologist at the earliest age possible is necessary for children with eye muscle imbalances since this can lead to a loss of visual acuity that cannot be reversed.

Diarrhea From Food Contamination

/in /by
Foodborne illness is a major problem. Over 40 million cases of foodborne illness occur in the US each year and most of the cases do not require seeing a doctor. Most of the episodes resolve with routine measures including drinking adequate fluids and changing your solid food intake to a complex carbohydrate diet for several days and then the gradual reintroduction of foods with more protein and fat. Young children under age 5 years are at highest risk and almost always do well and do not require hospitalization.
The elderly, on the other hand, have the highest risks of mortality and the highest complication rates. They are also at the greatest risk for hospitalization.
The most common cause is a norovirus infection. Other infections include bacterial infections due to Salmonella, C perfringes, Campylobacter and Staphylococcus aureus. The most common symptoms include crampy abdominal pain with vomiting and diarrhea. A low grade fever is common and the diarrhea mayor may not be bloody. If bloody diarrhea is present then the cause is most likely E coli, Campylobacter, Salmonella or Shigella.
The greatest risk from these illnesses is dehydration. Your child will become cranky and listless with dry mouth and lips, urination will decrease, skin color will be pale with a doughy turgor and heart rate will increase.
If these symptoms are mild then rehydration with an electrolyte containing sports drink is generally all that is needed. Stay in close contact with your pediatrician and monitor fluid intake and urine output as well as the amount of ongoing diarrhea and vomiting. If vomiting and diarrhea continue or the above symptoms continue or worsen then your child needs to be seen. Oral rehydration is the mainstay of treatment but intravenous fluids are also used. Medication to decrease vomiting, such as ondansetron, can be used but antidiarrheal medications are not recommended. Stool test are rarely needed unless symptoms are severe, prolonged or the child has underlying medical problems.
Various bacteria cause foodborne illness. Staphylococcus aureus produces a toxin that causes the rapid onset of symptoms within a few hours and can last for 1-2 days. No antibiotic treatment is usually needed. Illness due to Bacillus cereus is usually brief and may cause either predominately diarrhea or vomiting. Like those illnesses due to S. aureus it is usually self-limited and resolves in 24 hours. Salmonella is longer in duration and symptoms often last for up to 1 week. In young children the bacteria continues to be shed in feces for up to several weeks. Safe hygiene is very important for these children to prevent further spread. Shigella is another common illness and duration of symptoms is several days. Antibiotics can be helpful especially for young or immunocompromised children. Vibrio gastroenteritis is another bacterial infection that is spread through the ingestion of contaminated seafood, including raw oysters, and other foods. Most of the symptoms resolve within 5 days and are self-limited and do not require antibiotic treatment unless the child has severe symptoms or is immunocompromised. Campylobacter infections are commonly caused by the ingestion of contaminated water, poultry or unpasteurized milk. Bloody diarrhea and abdominal pain are common and symptoms can last longer than 1 week. Antibiotic treatment is not usually needed but can reduce the duration of illness.

Toddler’s Diarrhea

/in /by
This is a type of diarrhea that is chronic and non-specific. It is often called chronic non-specific diarrhea (CNSD). It is felt to be due to a problem with intestinal absorption. The onset of symptoms is typically between 6 and 30 months. The diarrhea is often increased by the ingestion of fruit juice. On occasion the onset of symptoms is associated with a recent course of antibiotics. There is not an associated weight loss and the child continues to grow. Height and weight are in the normal range for age.
The most common treatment is to limit juice intake and continue to provide a healthy diet. With observation and reassurance symptoms generally resolve.

Celiac Disease

/in /by
This is an immune mediated disease that is due to exposure to gluten protein found in barley, wheat and rye. It can begin at any time from infancy to adulthood. Children commonly begin to have symptoms 6-24 months after the introduction of gluten into their diet and should be considered in the evaluation of any child who has a history of chronic diarrhea and poor weight gain.
Many different signs and symptoms can be associated with celiac disease. These include anemia, diarrhea, bloating and constipation. Some children with celiac disease present with no clear complaints except poor weight gain. Some conditions are associated with an increased risk of celiac disease. These include Down syndrome and type 1 diabetes. If a family member has celiac disease then the risk increases for other family members.
Common evaluation tests include an antibody test to tissue transglutaminase (TTG IgA). This is the best screening test for children. IGA testing is also commonly done since children with an IGA deficiency may have a false negative test. Children under age 3 may also have a false negative test. Although serologic testing is helpful the best diagnosis is made from intestinal samples taken during endoscopy. Multiple sites are sampled and changes are looked for including villous atrophy. These changes can be very non-specific and serologic results and a comprehensive history can help pin down a diagnosis.
Treatment is elimination of gluten through a gluten free diet. This is a lifelong treatment and symptoms and intestinal changes resolve. Diet adherence is the key and is often difficult.  Anyone with celiac disease should eliminate gluten even if they are symptom free. There is an increased risk of other medical problems for untreated celiac disease.
A repeat TTG IgA test after 6 months of diet adherence is usually done.  Repeat testing is also done if symptoms do not stop. If the level is still high then dietary nonadherence is usually the culprit.

Sports and Bowlegs

/in /by
Infants frequently have bowlegs and as they age into early childhood they develop knock knees. The development of bowlegs during late childhood is unusual and often is associated with load bearing sports participation. Although physical activity is healthy the participation in certain sports that stress the lower skeleton of children can lead to knee changes (bow legs/ genu varum) which can increase the tendency to develop osteoarthritis and overuse syndromes later in life. Certain sport activities appear to cause an imbalance in leg and hip muscles which can change the alignment of the leg bones. Recent finding suggest for boys sports that require intense and frequent running, sidestepping and crossover cutting exert stress on the knee and appear to lead to changes that predispose the athlete to future problems. Future studies will be needed to see if the same pattern is seen for girls.
The key intervention to prevent imbalance is to focus on preservation of neuromuscular balance. This is something all the best exercise gurus have been touting for years. By changing up your work-out regimen and building up all the core, leg and hip muscles it can be hoped that the knee symmetry will be maintained and the incidence of bowlegs in adulthood and future secondary associated problems would be reduced.
So how do you do this? Allow boys and girls to participate in and try out many types of sports and engage in different physical activities. Activities such as dance, yoga, gymnastics and martial arts focus on the entire proximal and distal skeletal and muscular systems. Try to work these activities into your child’s schedule. Too much of one sport may not be best for a developing child.

Medicine Taste and Swallowing

/in /by
Children often avoid taking medication due to the taste, aftertaste, smell or texture. Some medications are bitter or gritty and this is a problem for many children. As children age their number of taste buds decrease and their emotional preferences for foods and flavors change.
Most children prefer sweet tasting substances. The addition of sweeteners such as chocolate or strawberry syrup, maple syrup or sweetened drinks can help. Sucking on a lollipop before and after the medication can also be effective. Flavoring agents are also available from most pharmacies.
Check with your pharmacist to see if the tablet your child is prescribed can be crushed into a powder and mixed with a variety of foods or drinks. It is best to choose a masking agent that can be given in a small quantity to make sure your child takes all the medication. Using a small amount of pudding, ice cream, yogurt, jam or applesauce can be very effective.
If the tablet or capsule cannot be crushed or opened your only choice is to practice swallowing pills.  Consider beginning to practice pill swallowing by age 5 years. It is important you avoid fear that is generated by the gag reflex. Once your child realizes they swallow many foods every day that are much bigger than a pill they are willing to practice swallowing pills. It also helps if you have a built in reward system. Swallowing pills and capsules bypasses the issues with taste, texture and aftertaste.
A basic routine to use for pill swallowing is to have your child take several consecutive sips of a liquid they enjoy. Ask him after each sip to swish it in his mouth and then swallow it. After several sips, ask him to place half of a frozen M and M (use a pill splitter to cut) on the tip of his tongue. Allow him to take another larger sip and swish and swallow it. Voila! The pill has disappeared. Reinforce his success with another whole M and M to chew and swallow.