Leg Pain in Children

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

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

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

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

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

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

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.

Head Lice

These are two words no parent wants to hear. Head lice infections are common and each year between 6 and 12 million US children between the ages of 3 and 11 years are infested with head lice. Household members of these preschool and school aged children are also at risk for infestation.
The biggest concern with head live is discomfort due to itching and secondary bacterial skin infections and further spread of the infestation to others. Lice do not transmit disease but the effects on the family in terms of days lost at school and parents being unable to go to work due to child care responsibilities are substantial.
Although hygiene and hair length are not the cause of head lice infection, an infestation often causes many families to be embarrassed and suffer social stress and isolation.
The rash that is seen with a head lice infestation is due to the body developing sensitivity to the saliva of the louse which is injected under the skin when it is feeding on the host. It may take up to several weeks for the sensitivity and subsequent itching to develop.
A louse is about the size of a sesame seed and has six legs. The louse can live for up to a month and lays up to 10 eggs per day. The eggs are attached to the base of a hair shaft. Eggs that are not at the base of the hair shaft are not viable. When the eggs hatch the casings (nits) are white and easier to see. Within 10 days after hatching a louse can begin to lay eggs and the cycle continues. Eggs cannot hatch at room temperature. Body heat is needed to incubate.
Lice will die if not on a host for 24 hours. They do not jump or fly. They crawl quickly and sometimes can be seen easier if you use a lubricant such as oil, hair conditioner or water to slow them down. They avoid light.
It is best only to treat children who have living lice. Over half of all children with nits do not have living lice. Prevention is difficult and depends on avoiding head to head contact. Children need to avoid the sharing of combs, brushes and hats. Prompt treatment of children with living lice is the best way to curtail an outbreak.
Various medications are available for treatment. Choice depends on patient age and medication availability as well as potential side effects. Lice have become resistant to certain medications and often another medication may need to be used if the first medication fails to eradicate the infestation.
Treatment includes OTC medication containing 1% permethrin (Nix). The hair should be shampooed with a non-conditioning shampoo and then towel dried. The medication is applied thoroughly to damp hair and left on for 10 minutes. It is then rinsed off with warm water and the process is repeated in 7-10 days if live lice are seen. Nix is the least toxic lice medication and rarely causes redness, itching or scalp swelling. Permethrin (Nix) does leave a residue on hair that kills newly hatched lice for several days. The use of hair conditioners and hair products with silicone based additives hinders this protection and should be avoided for several days.
Another commonly used medication is malathion (Ovide). It is available by prescription. It is applied to the hair and scalp while eyes are tightly shut. The hair should start dry and end thoroughly wet. Leave hair air dry and uncovered. Shampoo hair after 8-12 hours and use nit comb to remove lice and eggs. It appears to be more effective than Nix but has more side effects. It has not been studied in children under age 6 years and is not used in children under age 2 years. It is highly flammable and contains almost 80% isopropyl alcohol. Avoid high temperatures and open flames while the hair is wet.
Another medication is benzyl alcohol (Ulesfia). It is available by prescription. It is applied to hair to completely saturate scalp and hair. Short hair takes 4 ounces and long hair up to 24 to 48 ounces. Rinse off with water after 10 minutes and repeat in 9 days. It kills lice by suffocating them. It is approved for children over age 6 months and can cause eye and skin irritation. In children under 6 months it can cause severe metabolic disturbances due to skin absorption.
Spinosad (Natroba) was approved by the FDA in 2011. It is used in children 4 years  and  older. It is applied to dry scalp and hair to cover the entire area. Apply up to 120 ml depending on hair length and leave on for 10 minutes. It is then thoroughly rinsed off with warm water and repeated in 1 week if live lice are seen. It is derived from the fermentation of a soil bacterium and may be more effective than Nix. It can cause application site irritation due to benzyl alcohol in the product.
The most recent new product is ivermectin (Stromectol). It comes in a 0.5% lotion called SKLICETM) and is indicated for head lice treatment in patients 6 months and older. It is applied to dry hair to cover scalp and hair and left on for 10 minutes and then rinsed off with warm water. A nit comb is not necessary. The person who applies the medication should wash their hands thoroughly after application. Repeat treatment is not needed.
Lindane (Kwell) is no longer indicated for the treatment of head lice. It can cause serious neurotoxicity and seizures.
Occlusive agents like mayonnaise, margarine and various oils have been used with varying effects in an attempt to suffocate head lice. Head shaving is effective but is undesireable for cosmetic reasons. Frequent wet combing with a nit comb and shampoo or conditioner as a lubricant may also be effective.

When Would My Child See an ENT Surgeon?

If your child has sleep disordered breathing or obstructive sleep apnea with a history of restless sleep, snoring, gasping and sleep pauses your child will be referred to an ENT for a tonsillectomy and adenoidectomy evaluation. A sleep study is usually not needed. Adenoid enlargement alone may be the cause of obstructive symptoms. Often a trial of nasal steroid spray is pursued if the tonsils are not enlarged. In cases of severe tonsillar enlargement do to infection that does not respond to antibiotics and systemic steroid treatment ENT referral may be needed. Another uncommon condition is a retropharyngeal or peritonsillar abscess that would require surgical drainage.

If your child accidentally swallows a small object and it is lodged in the windpipe he will need bronchoscopy to have it removed. General anesthesia is used in the operating room and a small endoscope with a camera is passed into your child’s windpipe and the object is removed. Small pieces to toys, peanuts or small objects like earrings are commonly aspirated. Coughing episodes are common and a foreign body should be considered whenever a previously healthy child has unexplained symptoms of airway obstruction that do not respond to routine asthma treatmentIf your child has a chronic middle ear fluid and is at risk for speech, learning or language problems he will be referred to ENT for tymanostomy (PE Tube) assessment. If your child is not at risk and has had no complications then he will be observed for 3 months before he is referred.
If your child has a suspected cholesteatoma he will be referred to an ENT. A cholesteatoma is a collection of cells that are in the upper anterior part of the eardrum. Although they are rare they are sometimes seen during ear examinations for children who have recurrent ear infections or hearing loss. They are congenital and can block the Eustachian tube opening causing Eustachian tube dysfunction and recurrent serous otitis media and otitis media and can cause other intracranial problems
If your child has a complication of otitis media called mastoiditis he will be referred to an ENT. Mastoiditis can cause brain infections and facial paralysis. Common symptoms include pain, swelling and redness behind the ear with protrusion of the ear.
If your child has a nasal fracture and a septal hematoma he will be referred to an ENT. Most nasal fractures do not require x-rays. If a septal hematoma is present then an ENT will need to evaluate your child for possible incision and drainage to prevent infection which is common several days after the injury.
If your child has orbital cellulitis he will be referred to an ENT. Orbital cellulitis is often a complication of sinusitis and can involve an infection around the eye or a more severe infection. Management is usually with intravenous antibiotics for younger patients with small infections and no complications. A pediatric ophthalmologist will also frequently be involved in the evaluation.
If your child has severe croup (Laryngotracheobronchitis) or stridor (an inspiratory sound due to airway structure collapse or impingement) an ENT referral may be needed. A fiber optic flexible laryngoscopy can be performed to evaluate for possible causes of stridor. All newborns with stridor will be referred to a pediatric otolaryngologist to evaluate for anatomic causes, such as vocal cord paralysis or subglottic stenosis. Older infants with stridor due to laryngomalacia are also frequently referred. In laryngomalacia, the supraglottic structures collapse into the airway during the inspiratory phase of respiration.
If your child has a rare newborn condition involving the ear, nose or throat regions such as a thyroglossal duct cyst, brachial cleft cyst, lymphatic malformation or dermoid cyst an ENT referral will be needed.
If your child has a neck abscess or enlarged lymph node that needs biopsy, drainage or excision an ENT referral may be needed.


A tonsillectomy is commonly performed to improve breathing and decrease sings of upper airway obstruction. Common signs include restless sleep, neck arching during sleep, snoring and difficulty swallowing chunky foods. It is also helpful for children who suffer from recurrent episodes of pharyngitis. The potential benefits of a tonsillectomy, usually in combination with an adenoidectomy, must be weighed against potential risks and the overall discomfort associated with having the procedure performed.
Children between the age of 3 and 6 years are at highest risk for tonsil and/or adenoid enlargement that is commonly called hypertrophy. Tonsil size generally decreases after age 8 years. This is why many children who snore prior to age 8 stop snoring by their teen years. If your child has upper airway symptoms with associated sleep apnea then the benefits of surgery clearly outweigh any risks. Snoring alone is not enough of an indication for the surgery. If the complaints listed above are present as well as other complaints including daytime sleepiness, academic difficulties, attention difficulty, enuresis or behavioral problems then surgery should be strongly considered. Children whose BMI is above the 95th% are considered severely overweight (obese). Their symptoms of nighttime upper airway obstruction are less often cured by adenotonsillectomy. Pre-operative sleep studies can often assist decision making on whether to perform surgery on these children.
In addition to the above upper airway obstruction indications children who have 7 episodes of severe recurrent sore throats in 1 year, 5 episodes in 2 consecutive years or 3 episodes in 3 consecutive years are candidates for surgery.
The greatest risk with surgery is the postoperative pain. Bleeding occurs in up to 5% of cases and the general anesthesia can cause transient post-operative disorientation, nausea and vomiting. A single dose of intraoperative dexamethasone has been shown to decrease postoperative nausea and vomiting.
The best way to prevent and manage any post-tonsillectomy problems is through good perioperative care. Make the doctor aware of any obstructive sleep issues or any accompanying medical problems including obesity, sickle cell disease, blood problems, heart problems, heart arrhythmias, craniofacial abnormalities or a family history of anesthesia problems.
After surgery a clot composed of fibrin, inflammatory cells and bacteria will coat the area where the tonsils were removed. This clot will come off after about 1 week and can be associated with delayed bleeding. The area will heal over 2-3 weeks.
Pain is usually intense on day 1 and decreases over the next week. There may be a period of increased pain on day 3 after surgery. This increase is associated with the intense healing and inflammation. The pain is usually gone by 2 weeks. Pain is worse if associated with anxiety. Age and prior experience with pain also affect the perception and severity of the pain. Ibuprofen is the present recommendation for pain management. Caution should be used with acetaminophen with codeine since some children over respond to the codeine and become over sedated. Rough foods and vigorous activity should be avoided after surgery. Your surgeon will give you instructions on returning to a regular diet and an active lifestyle.