Infant Neck Rash

Dear Lisa,

My 9 month old daughter has a rash on her neck under her chin. It has been there for months and is not going away. Otherwise she has beautiful skin and has no rashes anywhere else on her body. Normally you can’t see the rash because she has a chubby neck. Every once in a while she stretches her neck and you can see it. I’ve tried putting different lotions and crèmes on it, but nothing seems to work. Sometimes milk drips down her neck but I make sure that I clean it all of the time. The rash doesn’t seem to bother her, but it bothers me because to strangers it looks like I don’t clean my baby. Every time we go to a relative’s house, she stretches her neck and everyone sees it. I keep on forgetting to ask my Pediatrician to check it because it doesn’t bother her and it slips my mind when we are in the office. Have you ever seen babies with a rash under the neck that won’t go away? What can this be from?

“Baby with Rash Under the Neck”

Dear “Baby with Rash Under the Neck”,

From your description it sounds like your baby may have Intertrigo. Although the best way to identify a rash in a child is to see your Doctor or Nurse Practitioner. Intertrigo is a common rash found in infants. Babies with chubby necks tend to get Intertrigo because the rubbing of the opposing skin causes the irritation that breaks down the skin. Intertrigo is also exacerbated by chafing and moisture. Intertrigo can be found in parts of the body where skin rubs together such as under a baby’s neck, under the arms, on the buttocks, in the groin area and in the skin creases of chubby legs. (1) The rash appears as a red maceration and at times may appear to ooze clear fluid.

Basically Intertrigo is a benign condition that will go away on its own in time. The treatment for the condition is exposure to air, elimination of moisture and avoidance of irritating clothing. (1) This sometimes is impossible in a baby that doesn’t move, tends to drool a lot and is a messy eater. As a baby grows and develops, less food drips down their neck, they tend to stretch their neck more to look upwards when learning to walk and the chubby area in the neck thins out. As a result there is less chaffing, less moisture and more exposure to air. Naturally the Intertrigo rash should go away on its own.

In the mean time it is important to keep the area as clean and dry as possible. Avoid clothing that rubs at the neck area. When bathing your child, make sure the area is dry and gently spread the skin folds with your fingers so that the area is exposed to air. It is best not to apply ointments because they tend to hold moisture which may encourage increased maceration. (1) Some practitioners may prescribe Caldesene powder because it may help dry the area, but I prefer to not use powder especially near a child’s face. The inhalation of powders by babies can be irritating to the lungs.

Since Intertrigo is a break in the skin integrity, occasionally a child can develop a super-infection with a fungus or bacteria at the site. Therefore if the rash seems to be spreading, develops an odor or crusting or if your baby develops a fever, it would be important to bring your daughter into the Doctor’s office for an evaluation. Candida Albicans, a fungal rash can commonly co-exist with Intertrigo therefore it would be a good idea to have your baby’s doctor look at the rash during your next scheduled visit. If the rash is infected with Candida Albicans your Doctor or Nurse Practitioner may prescribe an anti-fungal crème to apply to the area if necessary. (1,2)

Intetrigo is not caused by ineffective cleaning therefore you can be assured that it is not related to how you care for your baby. There is no reason to be embarrassed about the rash in front of your relatives. Instead, use the opportunity to educate them in regards to what Intertrigo is. On a positive note, skinny babies usually don’t develop Intertrigo, so look at it as a blessing that you have a thriving healthy child that is gaining weight.

References:
(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 616.
(2)Cham P, Warshaw E. A lone superficial web-space erosion. The Clinical Advisor. 2006. July: 86-93.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily

Rubbery Lump

Dear Lisa,

My 17 months old boy has a rubbery lump at the occipital region on both sides. He is taking orally well and active. He is also teething and likes to put his hands in the mouth. What can be the probable cause for the lump?

“Worried About Lump”

Dear “Worried About Lump”,

During an examination of a toddler, it is common to find pellet-like lumps under the jaw, on the neck and at the base of the skull posteriorly. These lumps are commonly referred to as “Shotty” lymph nodes which are a normal finding. (1) Lymph nodes are dispersed throughout the body and serve to filter out germs, foreign material and debris from the break down of old cells.(2) Normal lymph nodes are round or oval in shape and range from 1 to 25 mm (or 0.04 to 1 inch) in size. In children normal lymph nodes are usually less than 2 cm in diameter and should not be warm to touch, red or painful. If you feel a lymph node under your fingertip it should roll around and not cause any discomfort.(1) Lymph nodes are located just under the skin and the skin above the lymph node should not be discolored or oozing any discharge.

In children, lymph nodes enlarge or become more noticeable when the child’s immune system is working. Since the immune system filters the build up of old cells and germs the area around an enlarged lymph node should be checked for a break in skin integrity or an infection. (1) An enlarged lymph node in the child’s neck area could reflect that a child has a throat or ear infection. Enlargement of lymph nodes in the occipital region or at the nape of the neck could be due to a scratch on the child's scalp, Eczema, Seborrhea, Cradle Cap, a bug bite or Rubella ( German Measles). If your baby was immunized with the MMR vaccine("R" stands for Rubella) Rubella is not likely. Sometimes lymph nodes swell because there is a tick embedded under skin in that area. If you notice an enlarged lymph node at the nape of your child’s neck it is a good idea to inspect the head and scalp. Enlarged lymph nodes in a child should be evaluated and followed by your baby’s Doctor or Nurse Practitioner.

When babies are teething and put their hands in their mouth, they increase their risk of developing an infection. Repeatedly putting hands in your mouth introduces germs to the body from the environment. In some cases a baby can fight these germs on their own and in other cases the germs may be due to bacteria which would require medical intervention. Since your baby is putting his hands in his mouth he could have picked up a germ which is causing his lymph nodes to swell. Many times slight lymph node enlargement is a good sign that tells us that the baby’s immune system is working. It becomes a concern when the increased size persists, if it continues to enlarge or if a child develops other signs along with lymph node swelling. If your child develops fever, a stiff neck, pain, decreased activity level, decrease oral intake, vomiting, diarrhea, a red swollen lymph node, rash or fatigue you should bring him to the Doctor’s office for an evaluation.

In some cases rubbery nodules at the nape of the neck represent a Sebaceous Cyst. Sebaceous Cysts originate in the sebaceous glands which are attached to hair follicles. The purpose of the sebaceous gland is to secrete sebum which lubricates the skin.(1) Sebaceous Cysts feel like a soft mass and are usually found around the scalp area. They vary in size from 0.2 to 5 cm and should be non-tender and mobile.(3) They often show a central black dot which identifies the opening of the blocked sebaceous gland. (4) On occasion these cysts can become infected. An examination by your baby’s doctor should be able to tell you if the lumps you are seeing are Sebaceous Cysts.

Any nodule that is hard, not mobile, painful, enlarging, persisting, limiting motion or located on another part of the body may represent another condition and should be evaluated by your baby's Physician.

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:475.
(2)Tortora, G., Anagnostakos, N. Principles of Anatomy and Physiology. Harper & Row Publishers, New York. Fourth Edition;1984:520-521.
(3)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990: 562.
(4)Batz B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:219.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Moms

Choking Hazard

Hi Lisa,

My 15-month old was recently given a toy with small parts. What is the minimum size of an object that a toddler can safely play with without risk of ingestion/aspiration? Thank you so much for your advice!

“Which Toys are Choking Hazards?”

Dear “Which Toys are Choking Hazards?”,

It is very smart of you to be concerned about the safety of toys. Unfortunately, Asphyxiation due to aspiration of an object into the lungs is the leading cause of accidental death in the home in children under 6 years old.(1) Small balls in particular can easily become lodged into a child’s airway and cause them to asphyxiate.(2) When choosing toys for your child it is important to make sure that there are no small parts that a child could put into his mouth.

In general an object with a diameter of 1.75 inches or smaller poses a high risk of aspiration. (2) Any object, regardless of its size poses a hazard if a child can fit it into his mouth. Young children, older children who are handicapped, or children with a developmental delay are all at risk for putting objects in their mouth and choking on them. There have been reports of children who choked on larger balls that they happened to force into their mouth. The parents didn’t realize the balls were a hazard because they were larger than the size thought to pose a risk. Therefore it is important to teach children not to put any toy into their mouth and for parents to monitor children’s play.

The important thing to remember is that companies are creating new toys and baby products all the time and unfortunately it is not until a number of children become seriously injured will a consumer hear about a problem or recall. (3) The name of the U. S. Government agency that monitors product safety recalls is the Consumer Product Safety Commission or CPSC. The CPSC is committed to protecting consumers and families from products that pose a fire, electrical, chemical, or mechanical hazard or can injure children. (4)

If there is a product recall the CPSC spreads the news to consumers via press releases. (3)This reporting system is not full proof since there is no guarantee that a press release will be picked up by certain media outlets. If the story is picked up there is a chance that the consumer may not hear about the recall if they are not listening to the news at the time. There are no laws or regulations that require manufactures to advertise recalls in newspapers or magazines or to demonstrate that recalled products are returned or taken out of use. (3 ) In many cases it would be impossible for a manufacturer to contact all owners of recalled products. Many toys and baby items are purchased second hand or received as gifts and there is no guarantee that a parent will fill out warranty information cards.

This leaves the responsibility up to the parent to seek out information about product recalls. Parents may find recall information posted in Doctor’s offices and in stores that sell toys and baby products. If a parent is interested in finding out if a product they own has been recalled they can log on to the U.S. Consumer Product Safety Commission website at http://www.cpsc.gov/.

It may take some time from the time an injury occurs to the time a product is recalled. (3) Therefore a parent should always use their judgment and ascertain the safety of an item before giving it to their child. It is not safe to assume that a product is full proof just because it has not been recalled. If you notice that a product is not safe or if your child becomes injured from a product you should call the Consumer Product Safely Commission hot line at (800) 638-2772 or contact the U.S. Consumer Product Safety Commission via the internet at: www.cpsc.gov/talk.html .

Measures that parents can take to prevent their child from choking on an item include:

1. Do not permit children to play with small objects such as coins, buttons or marbles. (1)
2. Keep infants away from balloons whether they are inflated or deflated because they can easily be aspirated.(5)
3. Inspect toys frequently for loose parts and discard them in parts are loose. (1)
4. Do not let infants or toddlers play with stuffed animals that have button type eyes or decorations. Remove the eyes if necessary. (6)
5. Instruct older children to keep their toys away from younger children. (5)
6. Avoid buying young children toys intended for older children because they may have small parts that pose a choking hazard. (5)
7. Look for toys that are well-made with tightly secured eyes, noses and other parts so that children will not be able to twist or pull the parts off. ( 5)
8. Avoid all toys with marbles and games with balls with a diameter less than 1.75 inches. (5)
9. If you receive a product as a gift, buy it second hand or purchase it from a garage sale contact the CPSC via the internet at www.cpsc.gov to see if the product has been recalled.

References:
(1) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 537.
(2)Comsumer Product Safety Commission. CPSC Issues Warning That Choking on Small Balls Can Be Fatal to Young Children. Available at: http://www.cpsc.gov/cpscpub/pubs/5076.html. Accessed Sept 2006.
(3)Understanding Government. UG Report: The U. S. Consumer Product Safety Commission. Available at: http://understandinggov.org/reports/felcher.html. Accessed Sept 2006.
(4) U. S. Consumer Product Safety Commission. CPSC Overview. Available at: http://www.cpsc.gov/about/about.html. Accessed Sept 2006.
(5)U. S. Consumer Product Safety Commission. Toy Safety Shopping Tips. Available at: http://www.cpsc.gov/cpscpub/pubs/toy_sfy.html. Accessed Sept 2006.
(6) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 308.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Kids Safe

Failure to Thrive

Dear Lisa,

Despite seeing several Drs. my 18-mo.old has a bad skin condition, cannot gain wt.

“Getting Desperate from Korea”

Dear “Getting Desperate from Korea”,

It is so frustrating when your baby has a problem and you can’t seem to get to the bottom of it. Your child is very fortunate to have a mother who is so concerned and who has sought out help from your doctor. First, I would like to address the skin condition. Since you have already been to several doctors and you still do not have a diagnosis, it seems that it is time to seek the opinion of a Pediatric Dermatologist. A Pediatric Dermatologist has special training in childhood skin conditions and should be able to tell you the cause of your child’s rash. In some cases a skin biopsy may need to be taken if the skin condition cannot be identified through a physical examination. A skin biopsy can tell you what type of rash your child has.

The term used to describe a baby that doesn’t gain weight is “Failure to Thrive”. There are many reasons why a baby develops Failure to Thrive or doesn’t gain weight. The work up can be quite extensive and may take some time because there are so many factors that need to be addressed.

In the majority of children, problems gaining weight are caused by inadequate nutrition, problems with social interaction, gastrointestinal disease or neurologic disorders. (1)
Most cases of “Failure to Thrive” are due to insufficient nutrition. (1) The best way to determine if your child is receiving the right amount of calories is to keep a food diary. You can keep a food diary by writing down everything that your child eats and drinks in a 24 hour period for 3 days. Add up the amount of calories your baby takes in a typical 24 hour period.

Infants require at least 80 to 125 Kcal/kg per day for growth in the first year, then 70 to 115 kcal/kg for the next three years. (1) For example, since your child is 18 months old, he should take at least 70 calories per kg of his weight per day. If he weighs 10 Kg, then 10 X 70 = 700 calories. He would need to take at least 700 calories per day.

If you find that your baby’s intake is consistently lower than this recommendation you should bring your child and the food diary into your Doctor so that he can make recommendations in order to increase caloric intake. I find that many babies do not gain weight simply because they don’t ingest enough calories. Many times this occurs in babies who drink water which provides no nutritional value and contains zero calories. Other times this occurs in babies who ingest low fat food or low fat milk. Your doctor may recommend a consultation with a Nutritionist who will be able to guide you in the right direction.

When recording your baby’s food diary make note of any problems your baby may have with the process of eating. Does he have difficulties drinking from a cup, swallowing, sipping from a straw, chewing or handling his secretions? Does he have a problem taking food from a spoon or fork? Does he have excessive gagging or an aversion to certain textures? Some babies do not ingest the correct amount of calories because they have feeding problems such as an ineffective or uncoordinated swallowing mechanisms, difficulty chewing, or problems adjusting to different food temperatures or textures.

An 18 month old baby may experience difficulty manipulating food with his fingers or may not be able to use a fork or a spoon correctly. If you notice that your child is struggling in any of these areas it would be important to inform your Doctor. Children with certain developmental issues, low muscle tone, or oral motor dysfunction may need a consultation with a Speech and/ or Occupational Therapist in order to address the problem.

If your baby has no problems eating and is ingesting the appropriate amount of calories, then other causes for “Failure to Thrive” need to be investigated. Repeated history and physical examinations performed in the doctor’s office in conjunction with laboratory testing should rule out most of the common causes of Failure to Thrive. These common causes of Failure to Thrive include Pyloric Stenosis(which presents itself earlier in infancy), Congenital Heart Disease, Hypothyroidism, Liver Disease, Kidney abnormalities, HIV, Tuberculosis, Parasite infestation and urinary tract infection. (1) Since your baby was evaluated by a physician on multiple occasions you can ask him which disorders have been ruled out in and which disorders are still being considered.

Some infants do not gain weight because they have a Malabsorption problem which makes it difficulty for their body to absorb the nutrients that they need to grow. A milk allergy or wheat intolerance (also known as Celiac Disease) can both lead to problems gaining weight. Babies with a milk allergy develop symptoms including crying, irritability, colic, feeding refusal, failure to thrive, vomiting, regurgitation, wheezing, and sleep disturbances. (2) Children with Celiac Disease tend to develop symptoms between 6 months and 2 years old, following the introduction of gluten into their diet. The typical symptoms include impaired growth, abdominal distention, chronic diarrhea, muscle wasting, poor muscle tone, poor appetite and lack of energy. (3)

Gastroesophageal Reflux (GERD) is another common disorder found in children that may lead to insufficient weight gain. Children with GERD present with a variety of symptoms including poor weight gain, vomiting, irritability, disturbed eating, disturbed sleeping and arching of the head and neck. (2,4) When children diagnosed with GERD are treated with anti-reflux medication the symptoms subside and the children tend to gain weight.

All babies who experience Failure to Thrive associated with respiratory symptoms should be evaluated. Children with pneumonia or lung abnormalities can present with Failure to Thrive in conjunction with respiratory symptoms such as a cough or signs of a respiratory infection. If a child has Failure to Thrive along with a chronic cough, recurrent respiratory infections or stool problems, Cystic Fibrosis should be ruled out. (1)

The list of potential causes for Failure to Thrive is extensive. Repeat follow up examinations with your baby’s doctor are usually necessary before a diagnosis can be made. It is very important to report any additional symptoms that your baby may be experiencing. This information may aid in your child’s diagnosis. In some cases the expertise of a Pediatric Gastroenterologist may be needed in order to monitor, treat and identity the cause of a child's failure to gain weight.

I wish you and your baby good health and resolution of his symptoms.

References:
(1)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990: 229-231.
(2 )Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapuetic Spotlight. 2005. August:4-12.
(3 )Gelfond D. Fassano A. Celiac Disease in the Pediatric Population. Pediatric Annals. 2006.35:4:275-279.
(4 )Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006. April;35(4):250-266.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Common Childhood Health Problems

RDA for Iron

Dear Lisa,

I am 39 and pregnant with my third. I know that black strap molasses is a good source of iron. I also know that ingesting Vita C with it improves its bioavailability. How much molasses a day should I ingest in order to get my RDA? Also, for babies and toddlers, what are the recommended RDA of iron/day and how much molasses a day should they ingest to meet the suggested allowances? Thanks.

“RDA for Iron”

Dear “RDA for Iron”,

It is true that black strap Molasses is a good source of Iron. Adding molasses to breads, muffins or cookies is a great way to increase the amount of iron fortified foods that you and your family ingest. The important thing to remember is that the amount of iron that a person ingests does not necessarily correlate with the amount that the body absorbs. Iron absorption varies with age, state of health, source of Iron, amount of Iron, the body’s Iron stores and the interaction of Iron with other dietary components and with intestinal secretions. (1)

As you mentioned, Vitamin C should be increased and administered with Iron fortified foods because it enhances the intestinal absorption of Iron. (2) On the other hand if an Iron containing food also contains phosphates, such as in the case of cow’s milk, there is decreased Iron absorption because the phosphates bind with iron and remove it from the body. (2) As a result less Iron is absorbed, and because of this milk is not considered a good source of Iron. In addition, there are certain medications, such as Tetracycline and antacids that inhibit the absorption of Iron. (3)

Since only a portion of the amount of Iron ingested is actually absorbed, it is not sufficient to compare milligrams to milligrams when deciphering the amount of Iron needed. Only 1 to 20 percent of the Iron that we eat is absorbed into the body. (1 ) Iron from meat sources or animal products are in the upper range where 10 to 20 percent of ingested Iron is absorbed. On the other hand, Iron from vegetable sources, such as beans, corn, wheat and soy beans is absorbed at the lower range at 1 to 10 percent. (1).

The term RDA represents the recommended average daily intake that is needed to meet the nutritional requirements of most healthy individuals in each age group.The amount of Iron that a child needs depends upon their age, weight and state of health. According to the National Institute of Health(4):

RDA for Iron for a child 7 to 12 months old is 11 mg/day
RDA for Iron for a child 1 to 3 years old is 7 mg/day
RDA for Iron for a child 4 to 8 years old is 10 mg/day.

This is assuming the child is an average weight and free from any health conditions. The best way to determine how much iron your particular child needs is to consult with his doctor.

In the Doctor’s office during well child examinations children routinely are required to have a blood test for hemoglobin. This test serves as a screening tool which identifies which children are at risk for Anemia. If a child’s hemoglobin level is below the acceptable range, further blood tests may be ordered in order to differentiate one type of Anemia from another. If a diagnosis of Iron Deficiency Anemia is made, Iron supplementation will be recommended. Serial hemoglobin testing is one of the tools that Doctor’s use to monitor a child for Anemia and determine the amount of Iron supplementation that a child needs.

During pregnancy Iron requirements increase due to the needs of the developing fetus and because of maternal blood losses. According to the National Institute of Health, the RDA for a pregnant woman from 19 to 50 years old is 27 mg of Iron per day. (4) Many pregnant women take Prenatal Vitamins as prescribed by their Obstetrician which provide the RDA for Iron. Additional Iron should not be necessary unless a pregnant woman has a health condition that requires more Iron. Before adding extra Iron to the diet, a pregnant women should contact her Obstetrician since excess amounts of Iron can be toxic.

Children can also easily overdose on Iron, therefore all Iron supplements should be kept locked and out of a child’s reach. Children who accidentally ingest Iron supplements can develop toxicity very quickly. If there is an error in a child's Iron dosage, or if a child ingests Iron by accident it is important to contact The Poison Control Center and your child’s Physician immediately. You should not wait for symptoms to develop because Iron overdose can have serious consequences including severe toxicity leading to death in only a few hours. (5)

In regards to your question, about blackstrap Molasses, it contains 3.5 mg of Iron per Tablespoon. (4) If your child is 3 years old; 2 Tablespoons per day should be sufficient. Then again, Iron absorption is dependent upon many factors and the exact amount of Iron absorption may vary from person to person.

For more information about Iron requirements and foods rich in Iron log on to:

The National Institute of Health Office of Dietary Supplements Website

References:
(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 124-125.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1408-1409.
(3)Greene M. The Harriet Lane Handbook. St. Louis, Missouri: The Mosby-Yearbook, Inc. 1991:194.
(4)National Institute of Health Office of Dietary Supplements. Dieatary Supplement Fact Sheet: Iron. Available at:http://ods.od.nih.gov/factsheets/iron. Accessed September 2006.
(5)Wood D. Teach Adults to Recognize Signs of Pediatric Poisoning. The Nursing Spectrum. 2006. May:18.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Healthy Eating

Career in Nursing

Hi,

I'm interested in becoming a nurse to work in a pediatrician's office. I'm currently trying to get into the nursing program at my school to get a B.S.degree/become an RN. What else will I have to do to work in a pediatrician's office? Do I need to go to graduate school? Any other advice you have please?

“Oxygen”

Dear “Oxygen”,

It’s great that you are focused and know the career path that you want to take. Pursuing a career in Nursing will broaden your opportunities in the future and give you the life skills that you need to take care of yourself and your family. Most Nurse Recruiters and Nurse Educators will agree that a Graduate Nurse should work in a Hospital on an Adult Medical Surgical Unit for two years before making a decision regarding a specialty area. The general thought is that the experience on the Medical Surgical unit will give you the baseline knowledge and experience that you need which will prepare you for future roles. There is also is a shortage of Nurses and the addition of Nurse Graduates to Medical Surgical Units would definitely benefit the hospital regarding their staffing concerns.

On the other hand, there are plenty of Nurses who know exactly what area they are interested in. Many nurses, including myself, go directly into a specialty area without working on an Adult Medical Surgical unit first. This is a viable option, if you have an interest in a specialty area. I do feel that it is important to work in a hospital in that specialty area before branching off into other areas of Nursing, such as outpatient or home care.

If you are interested in working with children, it is a good idea to work on a Pediatric Ward in a hospital first in order to expose yourself to a variety of disease states, interventions and medical equipment. This will broaden your knowledge base and better prepare you for future jobs. After all, if you are working in a Pediatrician’s office and a child needs to be rushed to the Emergency Room or admitted to the hospital, you will need to know how to treat, educate and support a child and his family. This would be very difficult to do if you never actually experienced or worked in a hospital.

As a Nurse, once you have worked in a hospital it is more difficult to make the transition to a Pediatrician’s office in regards to pay scale and benefit package. The level of pay and benefit package are much more impressive in a hospital setting as compared to a private Pediatrician’s office. In general Pediatricians' offices will not be able to offer you the same level of pay, the health and dental insurance, retirement plan, tuition reimbursement, evening and weekend differential pay or any of the other benefits available through the human resource program in a large institution. All of these factors may not be important to you now, but will become very important aspects of your employment in the future.

In order to work in a Pediatrician’s office you do not need an R.N. degree. In many cases the staff consists of medical assistants. Just because the employees are wearing white or scrubs does not mean that they are nurses. You can call the Pediatricians’ offices in your area, tell them that you are a student and are interested in learning about the roles and credentials of the office staff. This can give you a better idea regarding the position that your are interested in.

In some cases you may find that Doctors' offices employ Nurse Practitioners, who are Mastered Prepared Registered Nurses with advanced training. Nurse Practitioners engage in an expanded role which includes seeing patients, doing physical examinations, making diagnoses, writing prescriptions for medication and devices, educating and making referrals. Since Nurse Practitioners see patients they provide income to the doctor’s office which justifies their salary. In general benefits are still lacking, therefore this is something that should be considered before working in a doctor’s office as a Nurse Practitioner.

If you are interested in becoming a Nurse Practitioner, you would need to get your Bachelor’s degree and R.N. License first. In order to gain experience and broaden your knowledge base you should work in a hospital on a Pediatric Ward for a length of time. Next it is necessary to continue your education and obtain a Master’s Degree and Nurse Practitioner Certification.

While in college, one of the best things that you can do is work at a summer job in your field of interest. I recommend working in a doctor’s office for one summer and then working in a hospital for the next summer. This will enable you to experience the role of the nurse and other healthcare professionals first hand and will give you the information that you need to make decisions about your life. No matter what you choose, the most important thing to do is work in an area that you are interested in and choose a position in that area that will give the resources that you deserve.

I wish you much success and happiness in your future.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily

Infant Pillow and Blanket Use

Dear Lisa,

I have a 7 month old son. When can I start using blankets and pillows in my son’s crib?

“Curious Mom”

Dear “Curious Mom”

A baby should sleep on a firm mattress without pillows. Their head should be placed directly on a firm mattress with nothing obstructing the face. Soft mattresses, feather beds, stuffed animals or any fluffy item that could potentially cover the baby’s mouth or nose are not recommended. (1)

It is okay to swaddle a baby by wrapping him in a light receiving blanket up to the level of his chest. Researchers found that 25% of babies are fussy when they are forced to sleep on their backs and swaddling improves the behavior and sleep of most babies who previously did not tolerate the supine sleeping position. (2) Swaddling also promotes restful sleep, is easily accepted by most babies, reduces the amount of times that a baby wakes and diminishes the frequency and intensity of crying.(3) The other benefit of Swaddling is that it does not promote Sudden Infant Death Syndrome (SIDS) as long as the swaddled baby sleeps on his back and the blanket does not cover the baby’s face during sleep. (3) When swaddling, it is not recommended to use layers of blankets or have the heat in the home set at high temperatures. These measures promote overheating which is a risk factor for SIDS. (1) There was a report of twins swaddled with several layers of flannelette, with a room temperature set at 80 degrees Fahrenheit who suffered from the devastating effects of heat injury. (3)

From my experience, by the time a baby is 3 months old they typically break out of the swaddling blanket. At this point a light blanket covering the baby up to the point of his chest is sufficient, using caution not to over bundle the child or use too many blankets. In most cases a blanket is not needed at all as long as the baby wears a one piece pajama outfit to keep him warm. Generally SIDS is a risk of early infancy with most deaths occurring before 4 months old, and a small percentage occurring up until the age of one.(1) Because of this it is not recommended to put fluffy comforters, stuffed animals or pillows in a child’s crib under the age of one. A child can use a pillow at 2 years old or when they are old enough to sleep in a bed.

When putting a baby to sleep it is essential that the baby be placed on his back. The American Academy of Pediatrics recommends that babies go “back to sleep” or sleep on their backs in order to reduce the risk of SIDS. SIDS is defined as the sudden death of an infant which is unexplained after review of the clinical history, examination of the circumstances of death and post-mortem examination. (1) In other words a parent places an apparently healthy baby down to sleep only to find him a few minutes or a few hours later, dead with not adequate explanation for the death. There has been a reduction in the amount of SIDS babies as a result of the “back to sleep” positioning campaign.

Other risk factors for SIDS besides prone sleeping position and overheating include parental smoking, soft sleeping surface and bed sharing. (1) The interesting thing is that sleeping in the same room as mother, but not in the same bed, decreases the SIDS risk. (1). Measures that parents can take to reduce the risk of SIDS include putting baby in a safe supine sleeping position, avoid over bundling, sleep in the mother’s room, but not in her bed, use a firm mattress, free from pillows, stuffed animals or comforters and avoid all smoking in the home.

References:
(1)Carbone, T. Sudden Infant Death Syndrome: The Most Devastating Pediatric Sleep Disorder. Presented at: Pediatric Sleep Disorders Conference;May 31, 2002:Edison.
(2)Gerard CM, Harris KA, Thach BT. Physiologic studies on swaddling: an ancient child care practice, which may promote the supine position for infant sleep. Pediatrics. 2002; 141:398-403.
(3)Schwartz R, Guthrie K. Musings on infant swaddling. Infectious Diseases in Children. 2006. June:14.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Babies Healthy

Jacuzzis

Dear Lisa,

I have heard that it is not good to have a child in a Jacuzzi, is this true?

“Concerned Mother in Jersey”

Dear “Concerned Mother is Jersey”,

There are definitely some health concerns with children going into Hot Tubs or Jacuzzis. First of all the temperature regulatory system in children is not mature enough to withstand extreme changes in temperature efficiently. (1) Children who stay in a Jacuzzi at a high temperature for a long period of time can overheat quickly and develop heat exhaustion.

The signs of heat exhaustion include; hot, dry skin, profuse sweating, unsteady gait, low blood pressure, incontinence, headache dizziness, abdominal pain, vomiting, diarrhea, fast heart rate, fast breathing and seizures. (2,3 ) Heat exhaustion is dangerous because it may progress to heat stroke which can be fatal. Children who develop heat stroke develop a fever up to 104.9 degrees Fahrenheit and exhibit signs of delirium which may progress to shock, coma and even death. (3) Children at risk for developing a heat related illness include those on medication such as neuroleptics or sedatives, use of alcohol, those with fever, those using supplements such as creatine or ephedrine or those engaging in excessive activity. (2)

Secondly, entrapment injuries are a concern for children who go in Jacuzzis. (4) Entrapment injuries occur when a child’s hair gets sucked into the intake suction valves in a Jacuzzi or Hot Tub. This could pose a drowning risk for children with long hair who put their head under water or near an intake valve. If the hair gets stuck, it pulls the child’s head under water which can lead to drowning. It is a good idea to be aware of the placement of the input suction valves and have children stay clear from them. In addition, before going into a spa inquire about the procedure for turning off the Jacuzzi in case of an emergency. Most hotels, spas and cruise ships will have an emergency shut off buttons with clear signage and instructions regarding emergency shut procedures.

Another very important concern about Jacuzzi use in children is the risk of Recreational Water Illnesses (RWIs). Recreational Water illness are skin, ear, eye, respiratory, neurologic and wound infections that children contract after being exposed to germs in a pool or Jacuzzi. Jacuzzis are a particular risk because Chlorine and other disinfectant levels evaporate more quickly due to the higher temperature of the water in the tubs. (5) In addition lower water volume and heavy bather loads only contribute to low disinfectant levels that allow the growth and spreading of germs. (4)

If diligent monitoring and proper disinfection of hot tubs are not maintained the levels of germs can increase to the point where they can cause illness when swimmers breathe or have contact with water containing these germs.(5) Very common Recreational Water illnesses include diarrhea caused by Crypto, short for Cryptosporidium, Giardia, Shigella, Norovirus, and E. coli O157:H7. (6) People who are a high risk for developing Recreation Water Illnesses include, children, pregnant women, people with compromised immune systems, people living with AIDS, those who have received an organ transplant, or those receiving certain types of chemotherapy. People with these conditions can suffer from more severe illness if infected.(7) Activities that children engage in such as putting their head under water and swallowing the water in the Jacuzzi puts them at risk for developing recreational water illnesses. (7)

Hot Tub Folliculitis also known as “hot tub rash” and skin infections are the most common RWI that spread through hot tubs and spas. (5) Hot Tub Folliculitis is the inflammation and abscess of hair follicles which is typically caused by the organism, Staphylcoccus aureus. (3) The symptoms include itchiness and pimple like lesions distributed on the parts of the body where a swimsuit covers. The rash typically is found on a child’s torso, buttocks and groin and usually spares the face and extremities. The rash is worse under the area of the swimsuit because the swimsuit keeps the contaminated water in contact with the skin for a longer period of time. (8) Children with Hot tub folliculitis may develop complications such as ear infections, throat infections, conjunctivitis and pneumonia.

In order to keep your child from developing complications when using a Jacuzzi a few measures should be followed. Young children, especially under 5 years old should not go in a hot tub at all. (4) Most Hotels, spas and cruise ships do not allow children under 12 in hot tubs. Children who go into a hot tub should not stay in it for more than 15 minutes. In addition, the hot tub temperature should be set so that it does not exceed 104 degrees Fahrenheit. (4)

All children who go into a hot tub should have their hair secured high on their head and should never put their head under water or swallow the water. Once a child comes out of the hot tub their swimsuit should be removed right away and not be allowed to remain on the body for any length of time. No children with skin infections, diarrhea illnesses or an altered immune system should go into a hot tub. If your child develops an illness, skin infection, skin rash, cough, eye discharge or diarrhea after spending time in a Jacuzzi, contact your Doctor for an evaluation.

If you own a Jacuzzi or hot tub it is important to carefully follow instructions regarding proper maintenance and disinfection in order to prevent RWIs. You can find instructions on how to maintain your hot tub by logging on to:

http://www.cdc.gov/healthyswimming/pdf/spa_operation.pdf


References:
(1) Bellack J, Bamford P. Nursing Assessment A multidimensional approach. Belmont, CA:Wadsworth Inc.1984:284.
(2)Dawson F. Unusual case of heat stroke in a young boy. The Clinical Advisor. 2006. Mar:50-58.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 626,1132
(4)The Centers for Disease Control. CDC fact sheet for pool staff/owner. Available at: http://www.cdc.gov/healthyswimming/pdf/spa_operation.pdf. Accessed Sept 2006.
(5) The Centers for Disease Control. Where are RWI found. Available at:
http://www.cdc.gov/healthyswimming/where.htm. Accessed Sept 2006.
(6)The Centers for Disease Control. What are recreational water illnesses (RWIs)? Available at: http://www.cdc.gov/healthyswimming/what.htm. Accessed Sept 2006.
(7)The Centers for Disease Control. Who is likely to get Ill from RWI? Available at: http://www.cdc.gov/healthyswimming/who.htm. Accessed Sept 2006.
(8)The Center’s for Disease Control. What is Hot Tub Rash? Available at: http://www.cdc.gov/healthyswimming/derm.htm. Accessed Sept 2006.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Kids Healthy

Vomiting and Weight Loss

Dear Lisa,

My eight week old daughter has had GERD since birth, which seemed to be controlled by Prilosec, but for the last two weeks she has been projectile vomiting breast milk, regular formula, and hypoallergenic formula, only keeping down Pedialyte, she has been exhibiting irritability, slight eczema, increased muscle tone, increased muscle reflex activity, and diarrhea. She has been losing weight. The fecal test ruled out a parasite and it seems too long for a stomach flu bug. She was tested for PKU 12 hours after birth and it was negative. What could be causing this?

"Concerned About 8 week old Daughter"

Dear "Concerned About 8 week old Daughter",

Persistent vomiting in infancy can be due to a variety of conditions. Sometimes it is caused by a gastrointestinal problem and sometimes it may be due to a problem outside of the gastrointestinal tract. Gastroesophageal Reflux is a very common cause and has already been identified in your daughter. Since her symptoms have been under control with Prilosec, the first question to be answered is, has there been something that is worsening her GERD? In some cases a food allergy triggers or exacerbates GERD. Since babies who are allergic to milk exhibit an increase in GERD symptoms, it would be important to investigate the relationship between your baby’s vomiting and milk intake.(1)

Both GERD and Cow's milk allergy exhibit the same symptoms which include; crying, irritability, colic, feeding refusal, failure to thrive (doesn’t gain weight), vomiting, regurgitation, wheezing , apnea and sleep disturbances.(2) When an infant is diagnosed with cow milk’s allergy the treatment is to remove all cow’s milk from the diet by changing to a hypoallergenic formula such as Nutramigen. It is also necessary to remove all milk from a mother’s diet if she is breastfeeding. Switching to a Hypoallergenic formula is the treatment for a cow’s milk allergy because the milk proteins in the formula are chopped into small pieces which are not identified as milk. Since the baby doesn’t identify the formula as milk, allergy symptoms should subside. Once a dietary change takes place it typically takes a few days, up until a couple of weeks to see the resolution of symptoms.

Many times I found that an infant’s milk allergy symptoms did not subside because milk was not totally eliminated from the breastfeeding mother’s diet. I had plenty of mothers who continued to ingest small amounts of milk because they thought it wouldn’t bother the baby. Unfortunately, this was not the case and mother’s who had only a few splashes of milk in their coffee or grated cheese on their pasta ended up with babies suffering from increased GERD and Milk Allergy symptoms. In a few isolated cases, infants with a severe allergy to milk protein needed to be changed to a formula called Neocate which is similar to Nutramigen, but the proteins are chopped up even tinier so the body doesn’t identify or react to them.

Eczema can be triggered by many things including stress, weather changes, irritation and food allergies. Eczema has been associated with food allergies particularly in young children.(3) The types of food that usually trigger eczema in children include milk, soy, egg and wheat.(3) Further investigation into this area would be appropriate since your daughter has eczema and GERD, which are both associated with food allergies.

If all measures to control an Infant’s GER and Milk allergy are exhausted and an infant continues to vomit and lose weight, a further work up is indicated. Infant vomiting can be due to other gastrointestinal conditions, central nervous system problems, urinary tract infections or inborn errors of metabolism. Pyloric stenosis is one of the more likely causes of persistent vomiting in an infant that should be considered. The incidence varies from 1 in 200 to 1 in 750 live births.(4) Pyloric stenosis is a condition that is caused by an overgrowth of the circular muscle of the pylorus which is located between the stomach and the intestines. The symptoms include a gradual onset of non-bilous vomiting which tends to occur within the first two months of life.(4) The vomiting can be projectile and usually is progressive, occurring during or shortly after feeding. Shortly after vomiting the infant usually appears hungry and has an appetite.(4) Pyloric stenosis is diagnosed by physical examination and abdominal ultrasound.

After the more common causes of infant vomiting are ruled out, other causes may need to be investigated. Some infants vomit due to a central nervous system disorder such as infection, hydrocephalus or premature closure of a baby's fontanel (soft spot) or cranial sutures. Infants with a urinary tract infection demonstrate non-specific signs such as vomiting and weight loss. The signs of a urinary tract infection in infants include; vomiting, diarrhea, irritability, poor feeding, slow weight gain, and unexplained jaundice.(5) Other rare causes of vomiting and weight loss in infants include inborn errors of metabolism such as Phenylketonuria or PKU, which you reported was normal in your child. Signs of PKU include irritability, recurrent vomiting, delayed motor skills, seizures, increased muscle tone, tremors, hyperreflexia, microcephaly (a small head), a lingering musty odor to the urine which is mousy or barn-like in character and eczema. (6) Approximately 25% of children with untreated PKU have eczema.(6) Although it is reassuring that your daughter’s PKU screen at birth was normal, persistence of symptoms in an infant consistent with PKU should always be re-investigated.

It can be very frustrating and worrisome watching your baby vomit and lose weight. A lot of patience is needed in order to deal with the situation. You should continue the careful follow up that you have received so far with your baby’s current doctor. Through repeat evaluations and possibly further testing the root of your daughter’s problem will soon be discovered and treated.

I wish you and your daughter well.

References:
(1)Salvatore S.Vanderplas Y. Gastroesophageal reflux and cow milk allergy: is there a link Pediatrics. 2002;110:972-984.
(2)Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapeutic Spotlight. 2005. August:4-13.
(3)Ledford DK. Recognizing and managing atopic dermatitis. Presented at: 2006 American Academy of Asthma, Allergy and Immunology Annual Meeting; March 3-7, 2006; Miami Beach, Fla.
(4)Joshi S, Mahajan P, Kamat D. Infantile Hypertrophic Pyloric Stenosis. Consultant for Pediatricians. 2006. Feb:106-110.
(5)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed.Philadelphia, PA:W.B.Saunders Company. 1994:1525.
(6)Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis Missouri: Mosby –Yearbook, Inc. 1992:429.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily

Toe-Walking

Dear Lisa,

What can cause toe walking, either unilateral or bilateral, and what can a physical therapist do to help the child?

“Toe-walking”

Dear “Toe-walking”,

When a child has a tight heel cord, this makes it difficult for him to bring his foot into a neutral or flat position. As a result the foot favors a pointed position and “toe-walking” develops.(3) The development of a tight heel cord can occur due to improper positioning, ineffective motor control or an inherent problem with the muscles and tendons of the foot and ankle.

Children who learn to walk in a walker or spend a lot of time in an exersaucer maintained at the incorrect height tend to develop a pointed toe position so that their feet can touch the ground. This positioning causes the foot and ankle to develop in such a way that lends itself to toe-walking. Besides the risk of injury, this is one of the reasons why walkers are not recommended for children.

There are some children that normally walk on their toes. (4) When this occurs interventions such as wearing high top shoes or work boots, performing ankle stretching exercises and physical therapy are recommended to help remedy the situation. These measures are recommended in order to stretch the tight heel cord, restore normal foot position and prevent contractures.(2)

Children with toe-walking need to be evaluated and monitored by a Doctor or Nurse Practitioner at regular intervals. Repeat evaluations should be performed in order to determine the child’s progress and to monitor the child’s development. Doctors and Nurse Practitioners become concerned with toe-walking because in some cases it may be a sign of a more serious condition.

Persistent and consistent toe-walking after a child has started to walk independently may be a sign of a musculoskeletal disorder such as Spastic Cerebral Palsy or Muscular Dystrophy.(1,4) Muscular Dystrophy is a degenerative disorder of the skeletal muscles. Children with Muscular Dystrophy tend to walk like a duck, experience clumsiness, sway from side to side when walking, have a waddling gait, have persistent toe-walking, can only walk fast and are unable to run. They have difficulty going up steps and have problems going up a sidewalk curb. (1). Cerebral Palsy is a non-progressive disorder of motion and posture. Children with Cerebral Palsy experience persistent toe-walking, rigidity of the extremities, difficulty in making purposeful movements and movements which are abrupt, jerky, uncontrolled and uncoordinated. (3) Toe-walking can also be due to a congenital shortening of the Achilles tendon and may be a sign of Autism. (4).

It is important to remember that just because a child develops one symptom of a serious condition does not mean that the child has that condition. Medical conditions such as Cerebral Palsy, Muscular Dystrophy and Autism encompass a cluster of many different problems, not just one isolated symptom. It is common for a parent to fear the worst when they see that their child has a symptom that is commonly found in a serious condition or syndrome. Good communication with your child’s Doctor or Nurse Practitioner can keep you abreast of your child’s progress, clarify any misunderstandings and alleviate your fears.

From my experience, most cases of toe-walking ended up being normal behavior due to positioning and not related to any underlying condition. Once identified, most children require the institution of stretching exercises, proper footwear and in some cases physical therapy in order to help them walk flat on their feet. I found that that the symptoms resolved in time with no residual effects in the the majority of the children who were compliant with therapy.

In order to prevent your child from learning to walk on their toes, make sure the height of the exersaucer is low enough so your baby’s feet are positioned flat on the ground, do not put your child in a walker and make sure your child wears shoes for walking. High top shoes or work boots prevent the child’s foot from pointing and keeps a child from toe-walking. If you notice that your child begins to toe-walk bring it to your Doctor’s attention so that the proper interventions can be initiated early.

References:
(1)Ashraf A, El-Bohy D, Wong B. The Diagnosis of Muscular Dystrophy. Pediatric Annals. 2005. 34(7):525-530.
(2)Mandigo C, Anderson R. Management of Childhood spasticity: A Neurosurgical Perspective. Pediatric Annals. 2006. 35(5):354-362.
(3) Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis Missouri: Mosby –Yearbook, Inc. 1992:148-152.
(4) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:861.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Healthy Children

Refusing Solids

Dear Lisa,

My 4 year old won't eat solids after the addition of a new baby. She's always been a terrible eater but is reaching for new heights. Problem is, she needs to gain 2 pounds in three months for another growth hormone test. I'm having problems with her receiving negative attention because of the weight she needs to gain. My kid's are all drug exposed and are adopted. What are some ways to add calories that don't break your bank account (nutritional drinks) and vitamins? I'm using canned milk and a nutritionist (for another child) suggested adding canola oil to creamed soups.

"Refusing Solids"

Dear "Refusing Solids",

It is common for siblings to have a difficult time adjusting to a new baby. Siblings frequently experience jealous feelings of displacement which causes them a lot of stress. (1) A young child does not have the developmental or communication skills to understand or communicate their feelings and as a result may develop physical symptoms and negative behavior. This stress that a sibling experiences can also manifest itself in regressive or attention getting behaviors. Some children may start to go to the bathroom in their pants again; some may start waking at night. It seems like your 4 year old daughter is having a difficult time with the arrival of the new baby and may be using eating as a tool to get your attention. Since you mentioned that she has a history of not gaining weight, she may have learned that eating or not eating gets her the attention that she needs.

As a parent it can be extremely frustrating to deal with a child that is acting out, especially when there is a new baby in the house that takes up all of your time and energy. My first suggestion would be to recruit the help of family and friends and have someone treat your 4 year old to a visit to the library or the park. This will make her feel special and give you a break so that you can regain the mental energy that is needed to deal with a child that won’t eat.

The next step is to try to take the focus away from eating. This is very difficult to institute when you have a child who has problems gaining weight especially when a lot of time and energy is spent at doctor’s offices addressing the issue. Try to avoid coaxing your child to eat, threatening or even talking about eating no matter how hard it may be. Simply put food in front of her three times per day at the table with the family at breakfast, lunch and dinner. Offer snacks in between. When the family is finished eating clear the plates and do not mention anything about how much she did or didn’t eat. If your daughter perceives that you are not paying attention to her diet, she may stop using her diet as a tool.

Try to make eating an enjoyable time, talk about fun things, play games and be an example by enjoying your food when you eat. It is from adult role models that children can learn what to eat, how much to eat and how to eat. (1) Soon your daughter will associate feeding with a happy time and will realize that she will not gain anything from withholding food.

While your daughter is going through this transition it will take an extra effort to provide her with nutrition and calories since she will not eat solids. Some suggestions include liquefying her meals. You can put vegetables in the blender and add seasonings to make them taste better. For example you can add some brown sugar and maple syrup to squash, sweet potatoes or carrots. This will not only add calories, but will make the food more palatable. Cooked Broccoli pureed in the blender with melted cheese sauce is another idea. Adding melted cheese to crème soups also adds calories and is a good source of calcium.

Foods that are high in calories include bananas ( 22 calories per ounce), avocados (25 calories per ounce), olives (30 calories per ounce), prunes (46 calories per ounce), mushrooms (62 calories per ounce), and cheddar cheese (120 calories per ounce). Although your daughter may not eat or like any of these foods by themselves, you can puree them and add them to soups or dishes in order to add calories to her meal. You probably will not be able to get your daughter to eat olives, but you can add a tablespoon of olive oil to her meals in order to add calories. From my experience, if a child doesn’t see the chunks or pieces of food, they will not notice that they are eating something different.

For snacks you can offer puddings, chocolate mouse, ice cream and custard which will all add calories to your daughter’s diet. These items will melt down to a liquid if she won’t try them with a spoon. Once your daughter develops a favorite dish, you can try to alter the consistency of the item by making it thicker or adding it to another dish. If she likes pureed avocados, the next time you feed her; give her guacamole dip with tortilla chips which is a thicker form of avocados. If she likes cheese sauce, serve melted cheese over very soft, cooked cauliflower or very thin mashed potatoes. For an after dinner treat you can make the whole family milkshakes made from ice cream and bananas. Give everyone a “silly straw” so the children can not only enjoy the snack but have fun. On an alternate night, serve a spoonful of chocolate mouse or pudding over a slice of cake or muffin. If your daughter does not eat the solid food, do not bring it up, but instead continue to enjoy the snack with the rest of the family. The hope is that your daughter will eventually try the new variety because she wants to have fun with the rest of the family.

You can add Ovaltine to your daughter’s milk or milk shake in order to ensure she gets the vitamins that she needs on a daily basis. Supplements such as Pediasure and Boost can also be added to a child’s diet when they won’t eat in order to provide nutrition, but as you mentioned these supplements can be expensive. If you contact your insurance company you may find that you are eligible for reimbursement for these products. Although it is not the norm, in some circumstances an insurance plan may cover the cost of supplements if a child has a medical diagnosis, a prescription and letter from her doctor.

Although the most obvious cause of your daughter’s refusal of food is behavioral, an organic cause should be considered if the symptoms persist. Since you mentioned that eating and growth have been an issue in the past, you may want to consider Gastroesophageal Reflux (GERD) as a contributing factor. Symptoms of GERD include vomiting, heartburn, difficulty swallowing, chronic cough, recurrent pneumonia, sore throat, hoarseness, wheezing, bad breath, sinusitis, dental erosions, feeding problems, poor weight gain and weight loss. (2,3,4) In particular children over 2 years old with GERD most often have symptoms related to heartburn as well as abdominal pain, vomiting and cough. (4,5)

From my experiences many children with GERD present with poor weight gain, disinterest in eating and abdominal pain. Those same symptoms resolve with initiation of treatment for GERD. Since the recent addition of the new baby to the family seems to have caused your daughter emotional stress you may want to consider an exacerbation of an underlying condition such as GERD. You can ask your doctor if GERD is a factor in your daughter’s case or contact a Pediatric Gastrointestinal specialist for more information if necessary.

In addition, including your 4 year old in the care of your newborn may help her adjust to the changes in your family.(1) If your 4 year old helps with the feeding, dressing and playing with the new baby it can help her feel involved and part of the infant’s life. In time your 4 year old can develop empathy towards the infant’s needs, and sensitivity to the infant’s cues. Don’t lose heart, positive sibling behavior takes time and can be cultivated with your guidance and support.


Congratulations on your new baby, and I hope your 4 year old daughter feels better soon.

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:111,257.
(2) Waring JP, Feiler MJ, Junter JG. Childhood Gastroesophageal reflux symptoms in adult patients. J Pediatr Gastroenterl Nutr. 2002; 35:334-348.
(3) Christensen m, Gold B. Clinical Management of Infants and Children with Gastroesophageal Reflux Disease: Disease Recognition and Therapeutic Options. Presented at: The Exhibitor’s Theatre Session at the 2002 ASHP Midyear Clinical Meeting, the Georgia World Congress Center; Dec 9, 2002:Atlanta.
(4)Hassall E. Decisions in diagnosing and managing chronic Gastroesophageal reflux disease in children. J Pediatr. 2005;146:S3-S12.
(5)Suwandhi E, Ton M, Schwarz M. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006;35(4):259-266.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents

Blood in Tears

Dear Lisa,

My niece is 15 days old. We found that she is crying with blood. We were told that this could be an incompatibility of the Rh factor with the mother. When we had a second opinion, she was diagnosed with immature tear duct. We are afraid coz when she cries a lot she forms blood as tears. What is the real condition my niece has?

“Blood in tears”

Dear “Blood in tears”,

It is not normal for a baby to cry tears with blood in them. Children with a blocked tear duct have an increase in the amount of tears and mucus discharge. (1) The tears tend to be cloudy or sticky, but they should not be bloody. Any baby with bleeding should be evaluated for a bleeding disorder such as Hemophilia, von Willebrand Disease, a platelet defect, or other blood disorder. (2) A complete history and physical examination along with testing is necessary in order to come up with an accurate diagnosis. Usually when bleeding is found in a baby, other sources of bleeding are also investigated. It is common to also test the baby’s urine and stool for the presence of blood. In addition bloodwork is typically drawn in order to evaluate blood clotting factors, to rule out anemia and check the baby’s ability to make blood cells. In some cases an ultrasound of the brain and abdomen are needed in order make a diagnosis. (3)

Typical signs of a bleeding disorder include prolonged bleeding from a needle stick (from childhood immunizations or blood test), prolonged bleeding from a laceration, cuts in the mouth that wont heal, frequent nosebleeds, large bruises after a trauma, many bruises (black and blue marks)on the body, prolonged bleeding from the circumcision site (which does not apply to your niece because she is female) and excessive bleeding after dental work in an older child. (2) Prolonged or unusual bleeding in any child needs to be addressed because it can lead to anemia and have serious consequences.

Rh factor incompatibility can cause serious hemolytic or bleeding problems in the newborn (4) “Rh factor” occurs when the mother’s blood type is different from her baby’s. If an Rh positive baby is born to an Rh negative mother, the mother’s body identifies the baby’s blood as foreign. As a result the mother’s body makes antibodies which attack the baby’s blood. This process occurs when the mother’s body is exposed to the baby’s blood, such as during birth, during an abortion or from an ectopic pregnancy. (4) Typically the mother’s sensitization takes some time and this condition is usually not a concern with a first pregnancy. Although, it is possible to occur during a first pregnancy if the mother had a blood transfusion, an amniocentesis or a condition called placenta abruptio. (4) Rh incompatibility and its complications are more of a concern in a second pregnancy and the pregnancies that follow. (3)

Rh factor incompatibility is a serious problem that is typically addressed while the mother is pregnant and when a baby is delivered. For mothers who receive prenatal care, the risk of Rh incompatibility is determined by the Obstetrician. If a mother is at risk, RhoGam, an immunization to prevent this problem is given to the mother in order to reduce the risk to future pregnancies. (4). Since the initiation of this vaccine in the 1960’s the incidence of complications from Rh factor incompatibility has been drastically reduced. (4)

For babies born in a hospital, Rh factor incompatibility can be identified at birth or shortly after birth due to findings on the physical examination and laboratory testing of the infant. The symptoms include a large placenta, jaundice at birth, jaundice that occurs within the first 24 hours after birth or in milder cases jaundice that develops later. (3,4) Early identification and treatment of the baby’s jaundice or hyperbilirubinemia (build up of broken down red blood cells in the baby’ body) results in a better outcome. If a baby is discovered to have severe complications of Rh factor incompatibility after birth, a special type of blood transfusion called an exchange transfusion can be given to the infant in order to save the baby’s life. (4)

Since your niece’s parents do not seem to know the cause of their daughter’s bleeding, they may benefit from the expertise of a Pediatric Hematologist. A Pediatric Hematologist specializes in blood abnormalities and the diagnosis and treatment of childhood bleeding disorders. An evaluation by a Pediatric Hematologist should shed some light on your niece’s situation.

(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 650.
(2)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990: 456-463.
(3)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia, PA: W.B. Saunders Company. 1990:183-185.
(4)Jensen M, Bobak I. Maternity and Gynecologic Care. 3rd ed. St. Louis Missouri: The C.V. Mosby Co. 1985:1125.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Health Questions Answered

Ear Infection in 4 month old

Dear Lisa,

Is it dangerous for a four month old child to have an ear and throat infection? Also the baby is teething.

“Baby with ear and throat infection”

Dear “Baby with ear and throat infection”,

Ear and throat infections are very common in the pediatric population. Ear Infections are so common that they account for 20% of all office visits in the first five years of a child’s life.(1) A child has a 10% chance of developing Otitis Media(a middle ear infection) by 3 months of age and a 62% chance of developing Otitis Media by 1 year old.(l)

Although it is unfortunate, is not unusual or particularly dangerous for a four month old baby to develop an ear infection. As long as your baby is being followed by a Doctor or Nurse Practitioner and is taking an antibiotic as prescribed, your child’s condition should improve. Even though an ear infection itself in a four month old can be successfully treated with an antibiotic it is the complications of an ear infection that I would be more concerned about. Ear pain and dehydration are the two of the complicating factors that you want to try to avoid.

The symptoms of Otitis Media or a middle ear infection include fever, irritability, swollen lymph nodes, ear pain, pulling on the ear, nasal discharge, nasal stuffiness and cough (2) Irritable infants that are in pain many times have difficulty eating and sleeping. If an infant doesn’t ingest the appropriate amount of fluids required in a twenty-four hour period this puts him at risk for dehydration and its complications. This is especially a concern in an infant with an Otitis media who also has a throat infection and is teething. All of these conditions can cause the baby to be very uncomfortable and in pain.

It is very important to address a baby’s pain in order to prevent complications. The pain can be treated with the administration of an analgesic as prescribed by your Doctor. Many Doctor’s and Nurse Practitioners recommend giving Tylenol to infants with pain.(3,4) In particular it is important to control a baby’s pain during feeding so as to ensure that the baby ingests the fluid and calories that are needed. It is a good idea to give the Tylenol 30 minutes before bottle or breastfeeding in order to optimize the amount ingested.

If you find that your baby is having difficulty feeding or has signs of dehydration it would be important to contact his Doctor or Nurse Practitioner. Signs of dehydration in an infant include sunken fontanel (soft spot), dry mucus membranes(inside of the mouth looks dry), sunken appearance of the eyeballs, weak cry, decreased urine output (an infant should urinate at least 6 times in a 24 hour period), listlessness, difficulty waking, sleeping more than normal, weight loss, lack of tear formation, increased heart rate and doughy or dry skin.(5,6) Monitoring for signs early is important because dehydration in an infant can become severe quickly.

Another potential complication of Otitis Media is persistent Middle Ear Effusion or the persistence of fluid in the ear after the infection resolves. Fluid can remain in the ear for 90 days after an acute ear infection resolves. (3) This fluid can interfere with hearing and may affect a child’s learning and language skills. This is a particular concern in children who are developmentally delayed or those with a speech delay.(3)

The symptoms of Middle Ear Effusion include; mild pain, sensation of stuffiness or fullness in the ear, popping or cracking sounds in the ear with chewing or yawning or dizziness. (7) An infant would not be able to tell you that these symptoms exist, therefore a physical examination by your baby’s Doctor or Nurse Practitioner may be necessary in order to make this diagnosis. If a child develops persistent Middle Ear Effusion, he should be monitored on a regualr basis by his Doctor or Nurse Practitioner until it resolves.

An infant with an ear and throat infection should have a diminished fever, decrease in irritability and improvement in eat and sleep patterns within 24 to 48 hours of initiating treatment.(3) If you find that your baby does not show a response to treatment within forty eight hours it would be important to follow up with your baby’s Doctor or Nurse Practitioner. In addition if your baby displays signs of dehydration you should contact your doctor without delay.

Hope your baby feels better soon.

References:
(1)Alper B, Fox G. Acute Otitis Media. The Clinical Advisor. 2005.Apr:78-85.
(2)Kontiodari T, Koivunen P, Niemela M. Symptoms of acute otitis media. Pediatr Infect Dis J. 1998;17:676-679.
(3)Carlson L, Marcy M. Diagnosis and Management of Acute Otitis Media. Summary of the New Clinical Practice Guidelines. Therapeutic Spotlight. 2004.June:4-14.
(4)Berlin L, Pons G, d’Athis P. A randomized, double-blind, multicentre controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children. Fundam Clin Pharmacol 1996;10:387-392.
(5)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 787-788.
(6)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:921-922.
(7)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:363.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents with Sick Infancts

Sweating with Exercise

Hi Lisa,

My son will be 4 this October. He is very, very fair, (I am 100% Irish and he takes after me). I notice that he gets very red in the face and ears and sweats a lot quickly during activities some not so strenuous. I know from my family genes its common for us to become red in the face like that we often get wind burn. But sometimes it concerns me, could it be a sign of something more serious? Thank you.

“Very, Very Fair Skinned Son”

Dear “Very, Very Fair Skinned Son”,

When a child has very fair skin, changes in the color seem more dramatic and are more noticeable. The symptoms that you notice when your son exercises most likely reflect his body’s response to over heating. It is probably more noticeable in your son because he has such light skin. When a person exercises the body’s metabolism increases which results in an elevation of body temperature. When this occurs, the body responds by expelling excess heat in order to regulate the temperature. The body’s regulatory mechanism shunts blood to the skin and releases heat through sweating.(1) This normal response of expelling excess heat is not as well regulated in infants and young children as it is in adults because the control mechanisms have not yet matured. (2)

Sweating many times is a normal response and can be found in children during exercise, crying or in a very warm environment. (3) Sweating in and of itself is not alarming. In conjunction with other symptoms, sweating may represent a more serious condition. Hyperthyroidism is an example of one of the conditions that results in sweating. Sweating is only one of a multitude of possible symptoms of Hyperthyroidism.

Children with Hyperthyroidism suffer from the increase metabolism of all body tissues caused by the increased production of thyroid hormones. The Symptoms include; sweating, nervousness, exophthalmos (bulging eyeballs) increased appetite, emotional liability, weight loss, school problems, sleep disturbances, heat intolerance, fast heart rate, and poor endurance with physical activity.(4) Hyperthyroidism is rare in infants and in young children. The majority of cases of Hyperthyroidism occur in adolescence.(4) The incidence is increased in children with Down’s Syndrome, Rubella Syndrome or a family history of autoimmune diseases.(4)

Sweating may also be one of the many signs of Congenital Heart Disease and Congestive Heart Failure. Signs of Congestive Heart Failure include fatigue, weakness, irritability, difficulty breathing, weak cry, cough, poor feeding, pale color, duskiness, cyanosis (blue color), increased heart rate and sweating during exercise. (3) Childhood syndromes such as Down’s Syndrome, Turner Syndrome, Noonan Syndrome and Fetal Alcohol Syndrome are commonly associated with Congenital Heart Defects.(4,5)

If your child develops other symptoms along with his sweating during exercise you should bring it to your Doctor’s attention. If there is a family history of autoimmune disease, thyroid problems, cardiac defects, or early heart attack or if your child has a childhood syndrome that is commonly associated with cardiac disorders it would be prudent to discuss your concerns with your son’s Doctor.

(1)Gray N.Unusual Case of heat stroke in a young boy. The Clinical Advisor. 2006;Mar50-58.
(2) Bellack J, Bamford P. Nursing Assessment, A multidimensional approach. Belmont, CA:Wadsworth Inc.1984:284-285.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:275,734.
(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1969,1276-1277.
(5)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990:799.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Website

Meningitis

Dear Lisa,

Is viral meningitis contagious if a family member, not in the household has contracted it, and your child has come into contact with them?

“Worried Mother”

Dear “Worried Mother”,

Aseptic or Viral Meningitis is an inflammation of the lining of the spinal cord caused by a virus. The viruses that are common offenders include; Enteroviruses, Coxsackievirus, Echovirus, and Mumps virus. (1) Less likely causes include Arbovirus, Lymphocytic Choriomeningitis virus, Herpes Simplex Virus, Chlamydia, Epstein-Barr virus and Cytomegalovirus. Viral meningitis is typically self limiting and usually resolves within 3 to 14 days. It is not as serious as Bacterial Meningitis which can be life threatening and contagious.

If a child is exposed to someone with Viral Meningitis, it is possible that they will contract the virus that caused the meningitis. It does not mean that they will develop Meningitis. The development of Meningitis depends upon the condition of the host(the person who contracts the virus). If a child has a suppressed immune system, congenital defect of the spinal cord, an absent or non-functioning spleen, is in a debilitated state or is suffering from malnutrition he would be more at risk for developing meningitis

The symptoms of Meningitis include fever, headache, vomiting and stiff neck. In some cases irritability, drowsiness and lethargy may occur. Typically Viral Meningitis does not progress as rapidly as Bacterial Meningitis. Viral Meningitis is less severe than Bacterial Meningitis. (1) The diagnosis of Meningitis is made through the examination of the cerebral spinal fluid which is obtained via a procedure called a “Spinal Tap”.

The treatment for Viral Meningitis is symptomatic, which means only the symptoms are treated. Since the disease is caused by a virus, antibiotics will not treat the condition. Instead a person’s body fights the disease. Many times antibiotics are given to a child with symptoms of meningitis until the results of the spinal tap are available. (2) If the results of the spinal tap reveal that a child has Viral Meningitis the antibiotics are usually discontinued as long as the child does not have a bacterial infection somewhere else in their body.

Close contacts of patients with Bacterial Meningitis, such as Meningococcal Meningitis are at risk for contracting the disease. Outbreaks of Bacterial Meningitis have occurred in child care centers, schools, colleges, and military recruit camps. ( 3) This is not the case for Aseptic or Viral Meningitis. Even though Viral Meningitis is not contagious it is prudent to inform your child’s doctor if your child was a close contact of anyone with Meningitis. In some cases the cause of a patient’s meningitis is not immediately known and precautions are taken until the results of the spinal tap are available. The spinal tap results can take a few days to obtain.

If it turns out that the meningitis was due to a virus, no further precautions will need to be taken. On the other hand if the Meningitis turns out to be bacterial in origin certain measures need to be followed. These include close observation for symptoms and immediate medical attention for contacts that develop a fever. Close contacts with patients with Bacterial Meningitis should receive prophylaxis or medication to prevent them from contracting the disease.

High risk “Close Contacts” include household contacts(especially small children), childcare or nursery school contacts, a person who had direct contact with the Patient’s secretions (kissing, sharing toothbrushes or eating utensils), someone who provided mouth to mouth resuscitation, or a person who frequently eats or sleeps in the same dwelling. Low risk contacts include people who did not have contact with respiratory secretions, schoolmates, co-workers, and indirect contacts (a child who had contact with one of the sick person's high risk contacts). (3) Basically your child’s risk is determined by the type of contact they had with the infected person. Your doctor will be able to tell you if your child is at risk.

In regards to your child’ risk for contracting Meningitis, as long as your child is healthy with no underlying medical conditions he should not be at risk for contracting Viral Meningitis from his relative. He may however be at risk for developing the virus that caused the disease. Even if your relative turned out to have Bacterial Meningitis, your child may not be at risk depending upon the type of interaction your family had with the relative. If there was no exchange of respiratory secretions, if the relative did not eat and sleep at your house and if your son did not have contact with another relative who was a high risk contact he would not be considered as high risk. If your relative turns out to have Bacterial Meningitis, you should discuss the type of contact your family had with your Family Doctor.

(1) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1798-1799.
(2)American Academy of Pediatrics. Pneumococcal Infections. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:414. (3)American Academy of Pediatrics. Meningococcal Infections. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:Redbook 357-360.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Advice About Pediatric Infectious Diseases

Bug Bites

Dear Lisa,

Two years ago April, my daughter was diagnosed with scabies. Unfortunately, my daughter, mother, newborn son, husband, and myself also caught this. We all did the permethrin treatments, several times in the two years because it didn't seem to work, and followed the directions on cleaning everything in our house, which included washing bedding daily and spraying everything possible with a bedding spray. We had been symptom free for almost 8 months but recently my son has been getting "bumps" again all over, not just in the common spots of scabies. He doesn't have them between his fingers like before, but some on his fingers and toes. At first I thought they were small mosquito bites but they look like the scabies bumps we all had the past two years. Some even have a head to them with light yellow or clear fluid. My mother told me she has continued getting a handful of new bumps, big and small, and I just got a handful myself. When we were all diagnosed, we had the bumps in the areas that scabies are known for. The cream seemed to work temporarily, but new bumps seemed to appear all of the time. Now we are all getting new bumps randomly on our bodies and I was wondering if there is something similar to scabies? I am at my wits end because I thought we had this thing finally conquered. I have another newborn baby and I do not want her to have to experience this.

“Please help us!!!”

Dear “Please help us!!!”,

What a couple of years you have had! No wonder you are worried that the new rashes that your family is experiencing are the Scabies too. The Scabies is very communicable which means it is easily spread from one family member to the next. It is common to spread from one person to the next in households. Sometimes just when one person seems to be clear from the problem another family member develops Scabies and it passes back and forth. That is why the recommendation is to treat everyone in the house at the same time. Typically the incubation period, or the time it takes for the infestation to spread from one person to the next, is 4 to 6 weeks. Once a person has Scabies, their body is sensitized to it. Once the body is sensitized, a person can catch Scabies quicker. After the first exposure a person can develop symptoms as quick as 1 to 4 days after repeat exposure to the mite. (1) Typically the second infestation is much milder.

The rash from Scabies is very itchy and favors the skin between the fingers, the belly button area, the belt line, the wrists, underneath the arms, the abdomen, the penis and the breast area. (1). Scabies presents as pink excoriated areas covered with scratch marks. In infants under two years old the rash takes on a different appearance. It presents as vesicles or fluid filled sacks.

Since Scabies is a hypersensitivity reaction to the mite, Sarcoptes scabiei, the rash can persist after the mite is dead. Occasionally 2 to 5 mm red-brown nodules or bumps are present, particularly in the genital area and under the arms. These nodules develop due to the body’s response to the dead mite and can persist for a long time, usually lasting weeks or even months. (1) These may have been the bumps that your family experience during your last episode.

Norwegian Scabies is a rarer form of Scabies that is harder to treat. The rash from Norwegian scabies is more intense and widespread and appears as thick crusted lesions. (1). Scabies infestations that seem resistant to therapy may be due to Norwegian Scabies.

It seems that you were very diligent with the environmental cleaning which should have killed the mites. Although, there is always the chance that your family was repeatedly exposed to the Scabies, possibly from a visitor who slept at the house. Also, the distribution of your son’s rash may be different than the classic “Scabies” rash because of his age. Infants under two years old tend to develop lesions that are distributed more on their head, neck, palms and soles. They also tend to be more vesicular (fluid filled) as compared to adult lesions. (1)

Your description of bumps that looked like bug bites with light yellow or clear fluid could also be a sign of a secondary bacterial skin infection of the Scabies rash. In order to get a definitive answer, you should see a Pediatric Dermatologist. A Dermatologist will be able to tell you if the rash is from Scabies by examining a scraping of your son’s skin under a microscope. If your son has Scabies the Dermatologist should be able to identify the mite. (1)

The Dermatologist will also be able to tell you if there is a secondary bacterial infection or if the rash is due to another cause, such as bug bites. If the rash is due to bug bites, most doctors will not be able to tell you which type of bug is the culprit. Unfortunately, the offending bug usually cannot be identified by the appearance of a child’s rash. (2) The best way to determine which type of bug causes a bite is through an inspection of the home. A house can have an animal or bug infestation without the residents ever knowing it. Houses can be infested with birds, squirrels or bats that could be hidden in the attic or behind the walls. These animals can bring different types of bugs and mites into the home with them. (2)

There has been a recent resurgence of “Bed Bugs” or Cimex Lectularius Cimicidae. “Bed bugs” are flat wingless bugs that tend to be found in people’s mattresses. Their size ranges from the size of a poppy seed to ¼ inch in length. They live off of the blood of warm blooded animals and tend to bite humans in their bed at night when they are sleeping. Their color ranges from nearly white (just after molting) or a light tan to a deep brown or burnt orange. (2) Bed bugs are difficult to find since they live hidden in cracks and crevices such as behind wall paper or the cracks in furniture. They can be found in seams of mattresses, under the box spring, in the headboard, or behind switch plates. Signs that a mattress has bed bugs include black or orange stains on the sheets or mattress and live bugs. (3) Bed bugs are prevalent in hotels, apartments, in household where family members have recently traveled, and in familis who obtained used mattresses or furniture. (3)

A child bit by “Bed Bugs” can develop a hypersensitivity reaction to the bug’s saliva. This allergic response is quite itchy and looks like a flea or mosquito bite. The rash usually occurs 1 ½ days after the bite occurs. The location of the bites from “Bed Bugs” include the parts of the body that are exposed during sleep, as opposed to flea bites which tend to occur on the ankles. (3)

Flea bites are another potential cause of bumps on the skin. They occur in the home where a pet with fleas resides. Whenever family members develop a similar rash it is a good idea to check the pets for fleas. Signs that a pet has fleas include itching and the appearance of “flea dirt” or black specs on the pet’s fur or coat. If you do discover bugs in the home, they can be identified by an Entomologist. Once the bug is identified, the services of an exterminator with experience eliminating that particular bug or animal should be utilized. (3)

It is important to not forget about Chicken Pox. Chicken pox is another childhood illness that presents with an itchy rash. The Chicken pox lesions begin as tear drop shaped fluid filled sacs that initially appear on the torso of unimmunized child. The rash tends to start on the extremities of children who are immunized. New crops of lesions develop each day and the older lesions form a scab when scratched. If you notice a rash consistent with Chicken Pox or a rash with scabbing of the lesions you should contact your son’s Pediatrician or Nurse Practitioner.

I wish you and your family a speedy resolution of this problem and good luck with the new baby.

(1)American Academy of Pediatrics. Scabies. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:468-470.
(2) Harvard School of Public health. Available at: http://www.hsph.harvard.edu/bedbugs/#examined. Accessed September 2006.
(3) University of Kentucky Entomology. Available at:http://www.uky.edu/Ag/Entomology/entfacts/struct/ef636.htm. Accessed September 2006.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Children Healthy

First Pair of Shoes

Dear Lisa,

My baby is 9 months old and I need to know what type of shoes I should get for her. “How can I tell if the shoes I buy fit correctly?”

“Need First Pair of Shoes”

Dear “Need First Pair of Shoes”,

Before babies walk they need their feet covered for warmth and protection. Slippers, slipper socks, booties, moccasins or fabric shoes can be used. These foot coverings may be slippery and are not recommended for children who are walking or learning to walk. When choosing infant shoes or foot coverings you should make sure that they do not fit too tightly. The toes should not curl under when wearing them. (1) “Feetie Pajamas” are also commonly used to keep a baby’s feet warm. These pajamas many times shrink in the wash and fit too tightly which can constrict the movement of your baby’s feet. Many of the children that I took care of developed rashes on their toes and damage to their nails because the “Feetie Pajamas” were too tight. If this occurs, you can still use the pajamas as long as you remove the slipper portion first. When the pajamas are not on your child you can cut off the slipper part of the pajamas. This way your child’s feet can hang out of the bottom of the leg of the pajamas and will not be constricted.

Once a baby begins to walk a shoe with a flexible sole, sufficient to protect the foot should be used. (1) The shoe should be flexible enough so that it permits normal motion and use of the muscles. High top shoes help keep the shoe from falling off and prevent the child from pronating or walking on their toes. (1) Toe walking is not beneficial to the growth and development of a child’s foot or ankle. It is very difficult and almost impossible for a child to put her foot in a position for toe walking when wearing high tops shoes. Because of this many Doctors and Nurse practitioners recommend work boots for children who walk on their toes.

The purpose of shoes for children is to protect their feet from injury. Early walkers tend to walk into things, step on their own feet or scrape their feet on the ground when getting up. For older children, protection is needed during rough play, in case another child steps or jumps on their feet or in case they drop a heavy object on their foot. When shopping for sandals, choose ones with a closed toe area. Open toe sandals are not recommended for children because they do not protect the toes from injury.

When fitting a child in shoes the big toe should be a “thumbs width” from the end of the shoe when your child is in a weight bearing position. (1) The way to measure this is to put the shoe on your child, and then have her stand up. Next place your thumb at the tip of the shoe where the child’s big toe is. When pressing on the top of the shoe over the tip of the shoe you should feel the tip of the child’s big toe. You should not feel your child's toe under your thumb, nor should there be a space between the edge of your thumb and the beginning of the child’s toe. Following this, you should check the width of the shoe. The material over the widest part of the shoe should be supple enough and wide enough to allow a small amount to be pinched. (1) In addition, the shoe should be narrow enough in the heel to fit snugly (1) If the heel slips out of the shoe when the child walks the shoe does not fit correctly. This rubbing of the shoe against the heel with walking can cause blisters on the heel. Other symptoms of ill fitting shoes include the development of corns(which occur due to pressure on the little toe) calluses, and over-riding toes.

Frequently children who come into the doctor’s office with a limp or painful feet are found to have shoes that fit incorrectly. (1) If a child with no history of a fall or injury suddenly develops a limp or complains of foot pain, the first thing to do is to take off the shoes. Make sure there is nothing in the shoe and no bruise or rash on the bottom of the feet. If the limp and foot pain goes away and doesn't reoccur with a different pair of shoes, ill fitting shoes were probably the cause of the problem. If the pain or limp returns you should bring your child to the doctor's office for an evaluation.

(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:847-848.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Infant Development

Sexual Play

Dear Lisa,

I just walked in my ten year old daughter's room finding her letting the dog lick her privates. Is this normal?

“Concerned Mom”

Dear “Concerned Mom”,

It is common for children to engage in sexual play. Younger children, between 5 and 6 years old engage in sex play, such as playing “house” or “doctor” each of which includes close personal contact of a sexual nature. (1) This is why it is recommended to supervise play dates at this age. Children who are a little older, 7 through 9 year olds, become more sophisticated in sexual play. They develop an interest in sex related objects such as clothes and perfume, and may show interest in “peeking” at the bodies of the opposite sex. (1) As children become older, from fourth grade to junior high school, they tend to develop interest in explicit magazines, movies and drawings. Around 11 years old masturbation and stimulation of the genitals often occurs and usually represents normal expressions of sexuality. (1)

As a parent, I would not necessarily worry if you found your child exploring with sexual behavior, especially if it is an isolated incident. What’s more important is how a parent responds to a child's sexual exploration. It is very easy to become excited, confused or angry about this type of behavior, but as adults we should remember children engage in sexual play out of curiosity and because they are discovering how their body works. At a young age, children do not have the mental ability or moral development to completely understand the physical, social, psychological, emotional and medical consequences of sexual activity.

It is also important for parents to be very present and provide guidance and education about sexual maturation and sexual activity. Parents should explain about sex to their child as well as the responsibilities and consequences that go along with it. Because of their developmental age, children may not understand explicit details or long term consequences. Using concepts and terminology that is simple and understandable for a young child is important. Every child is different and each child is ready to learn about their body, sexual development and sexual activity at different ages. Generally, when a child starts to ask questions or seems interested in sexual activity, it is a good time to start. It seems like this is a good time for you to talk to your daughter.

Talking about sexual maturation and sexual activity is a difficult subject for many parents because of the social and religious mores associated with the subject. It may help if the discussion occurs over a period of time as opposed to all at one session. It is important that a parent discusses this information with their child, because it is normal and natural for a child to be interested in the subject. Chances are they they will seek out the infomation from others so it is a good idea to first approach the subject at home. Parents who keep the lines of communication open with their children give them the message that they are approachable and their children can come to them with questions. A very important component in Sexually Transmitted Infection (Sexually Transmitted Disease) prevention is teaching appropriate skills for refusal of unwanted sex, negotiation of safer sex and correct use of condoms. (2) Therefore education may help prevent your child from getting a Sexually Transmitted Disease.

Children tend to be embarrassed so it is important to approach the subject gently with the goal of providing guidance not punishment. For a 10 year old it would be appropriate to start with explaining the proper care of a female’s body, including the subjects of grooming, cleanliness, respect, self discipline and appropriate posture and interactions. Talking about modesty and covering certain parts of their body teaches them how important it is to take care of and respect their body. It may be easier to talk about the subject with the help of printed material. Many of the parent's of the girls that I cared for reported satisfaction with the book, “The Caring and Keeping of You.” It’s a book in the American Girl Series and can be purchased at your local book store or borrowed from the library.

In regards to your daughter’s particular situation with the dog, many times children learn about sex from animals. Your daughter may have allowed the dog to do this to her because she doesn’t fully understand the meaning of her activity. Once you explain to her the functioning and purpose of sexual organs and the transmission of germs she will better understand her actions and shouldn’t be interested in this type of behavior in the future. If you introduce books with illustrations this should satisfy her curiosity and take away her interest in the dog. I can tell you that your are not alone and I have had experience with other girls her age that showed interest in the family dog. An isolated incident does not necessarily mean that there is a problem. If this type of activity became recurrent, then you should be concerned.

At this point it probably would be best to keep the dog out of her bedroom at night and have her wear underwear to bed. If you find that she continues to engage in and is interested in sexual activity it would be important to bring her to the Pediatrician’s office for an evaluation. Sometimes excessive interest in sexual activity at a young age is triggered by exposure to sex in the form of magazines, movies, the internet or conversation. In other cases, excessive interest in sexual activity in a young child may be a sign of another problem.

Children with ADD tend to have trouble with impulsive behavior and because of this they are at a higher risk of having sex earlier than other adolescents. Therefore excess interest in sex in a child with ADD may be a sign that their disorder needs to be addressed and managed differently. (3) Research has shown that adolescent girls who experimented with sex were almost four times as likely to have symptoms of depression.(4) Therefore it would be a good idea to have a child who shows excessive interest in sexual behavior screened for depression by a health care professional. It is important to know that indicators of child sexual abuse include increased interest in sexual behavior in young children and promiscuity, prostitution, drug and alcohol abuse and runnning away in adolescents. (1) Therefore if a young child repeatedly shows interest or engages in sexual activity she should be evaluated by her Physician and sexual abuse should be ruled out.

(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:296-297,1020-1021.
(2)Fortenberry JD. Sexually Transmitted Infections. Pediatric Annals. 2005(34)10:803-810.
(3)Rosenthal M. Evaluate for coexisting morbidities when treating children with ADD. Infectious Diseases in Children. 2006. May:38-39
(4)Waller MW, Halifors DD, Halpern CT. Gender Differences in associations between depressive symptoms and patterns of substance use and risky sexual behavior among a Nationally representative sample of U.S. adolescents. Arch women’s Mental Health. 2006(9):139-150,200.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily

Early Breast Development

Dear Lisa,

My six year old daughter has breast. She started to show around age 5. We have taken her to her Pediatrician but she is puzzled. She has had several tests done but nothing is showing up. She is a very slim child who does not drink a lot of milk. What advise can you give my wife and I?

“Puzzled Parents”

Dear “Puzzled Parents”,

Young girls develop breast enlargement for a many reasons. Some of the possible causes include a benign mass such as a vascular Harmatoma or Hemangioma, swelling from an injury, infection due to Staph, exposure to certain medications, or the ingestion of estrogen containing products. It is extremely rare for breast enlargement or a mass in a child to be due to cancer. Primary breast cancer in the pediatric and adolescent age group is less than 0.2% (1) Sometimes what is thought to be breast tissue is really adipose tissue or fat in an overweight child. (2) Overweight children commonly appear to have increased breast tissue without any real increase in actual glandular tissue. Since you mentioned that your daughter is “very slim” this should not play a part in your situation. You did not report that your daughter is taking any medication, therefore medication side effects in your daughter’s case is also not a factor.

Normal breast development is expected to occur between 8 and 13 years old. A female who presents with breast enlargement before 7 years old should have an evaluation in order to determine its cause.(1) The typical work up for a young girl with breast enlargement typically includes a physical examination, blood work for hormone and thyroid levels, a bone age x-ray and in some instances an MRI. It is good news that your daughter’s physical examination and testing turned out normal because this rules out an organic cause for her early development. Once it is determined that a young girl’s breast enlargement is truly breast tissue and all other disease states have been ruled out she is considered to have Premature Thelarche.

Premature Thelarche is defined as unilateral or bilateral breast development with no other pubertal changes before 7 years old.(1) Premature Thelarche is thought to be caused by an exaggerated response to normal levels of hormones. In other words the body of a child with early breast development responds to normal levels of hormones differently than other children. Usually the size of the breast enlargement in young girls regresses slowly over 6 months to 6 years. In a few cases the breast enlargement may persist into puberty. (1) Once a young girl develops Premature Thelarche, she should be monitored for a condition called Precocious Puberty. In some cases Premature Thelarche is an early sign that Precocious Puberty is developing. One study showed that 14% of girls with Premature Thelarche developed Precocious Puberty.(3)

Precocious Puberty is the development of secondary sexual characteristics before 8 years old in girls and before 9 years old in boys. In this condition a child has elevated sex hormone levels in their blood and displays signs of sexual maturation. The symptoms include development of pubic hair, axillary hair growth, breast enlargement in girls, advancement of bone age, linear growth spurt, increased appetite, and emotional liability. (4) Once a young girl is diagnosed with Premature Thelarche or early development of breast tissue she should be checked every 3 to 6 months by her physician for signs of Precocious Puberty. In addition, parents should watch for the signs of precocious puberty at home and bring it to the doctor’s attention if it occurs. If signs of precocious puberty develop, a child should be referred to a Pediatric Endocrinologist for further work-up and treatment.

During my practice I often came across young girls with Premature Thelarche. Most of the cases were idiopathic, which means not due to an organic cause. Parents were instructed to watch for other signs of sexual maturation, in most cases this did not occur. You and your wife did the right thing by bringing your daughter to her physician for evaluation and testing when you noticed changes in her breast appearance. At this point it is important to monitor your daughter for signs of sexual maturation and contact her Pediatrician if they occur. You can do this by casually observing her when she is changing or bathing without bringing too much attention to the situation.

It would be a good idea to plan supervised play dates, avoiding play that involves dress up or changing clothes in front of her friends. Activities that do not draw attention to her breast development will prevent your daughter from feeling self conscious and feeling different from the other girls. Wearing clothes that are loose fitting and in layers will detract attention away from her breast development. Also, it is important to teach your daughter the concept of privacy, instructing her that dressing should be done behind clothes doors when she is alone. You should also explain to her that no one has the right to look at or touch her body. The good thing is that soon some of her girlfriends will start to develop. Since the normal age for breast development may start as early as 8 years, in a couple of years her friends will not appear so different from her.

(1)Spark R. Unilateral breast enlargement in a 6-year-old-girl. The Clinical Advisor. 2006. March:114-119.
(2) )Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990: 169-172.
(3)Van Winter JT, Noller KL, Zimmerman D, Melton JL. Natural history of premature thelarche in Olmsted County , Minnesota,1945-1984. J Pediatr. 1990;116:278-280.
(4)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:124-126.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Kids Healthy

Infant with Neck Hung to the Side

Dear Lisa,

We recently had a new baby that was delivered with forceps. She is now nearly 4 months old. Her left eye has always appeared smaller that the right one, and she "hung" her neck to the right for quite sometime, almost as if there was some sort of nerve or muscle damage, now we have noticed that her pupil in her right eye does not dilate the same as the left eye. So far the doctors have not been concerned about any of this but I have two other children and have never experienced this before. Sometimes we are not even sure that she is hearing properly, she doesn't seem to really respond to noise as you would expect. What should we be concerned about if anything, and what type of doctor should we have her see?

"Four month old with Neck Hung to the Side",

Dear "Four month old with Neck Hung to the Side",

Many times infants develop a cluster of symptoms that are considered variations of normal. Other symptoms may represent minor alterations that typically resolve on their own or with minimal intervention. Sometimes these symptoms may be related to each other and in others, they may represent individual findings. It is normal for parents to become concerned, especially if these variations differ from the appearance and behavior of a child’s siblings. Open communication with your child’s doctor can help clarify which symptoms are normal and which need further evaluation. Sometimes the time constraints in the doctor’s office limit the amount of time for explanations. I will go over each symptom step by step so that you can direct your discussion and ask pertinent questions at your next doctor’s visit or with a specialist if necessary.

Some of the symptoms that your are describing may be consistent with Plagiocephaly and Torticollis. One of the most common reasons for an infant to prefer one side, have their head “hang” to one side or tilt her head is Torticollis. Torticollis occurs when there is a unilateral (one sided) shortening or contracture of the sternocleidomastoid muscle which results in a restriction of the movement of the neck. (1) This positioning of the neck is usually due to a shortening of the muscle that rotates the head to the opposite side and tilts it towards the involved side. Torticollis may also occur when there is a weakness of the muscles on the opposite side of the neck. (2, 3) In most cases Torticollis is caused by the positioning of the baby in utero before it is delivered or due to positioning of the baby after birth. In rarer cases Torticollis may be due to an injury to the muscle or a mass in the neck. (1)

Ever since 1992, when The American Academy of Pediatrics recommended the ”Back to sleep” positioning for infants there has been an increase in the amount of children with positional molding (misshapen and flat heads) and Torticollis (crooked necks). (2,4) Because babies spend so much time on their backs the bones in the skull develop a flat shape which lends itself to a position of comfort with the neck turned or twisted to one side. (4) Signs of Torticollis may include asymmetric face(one side looks bigger than the other), asymmetry of the skull(the shape of the skull is not even), downward placement of the orbit (bones around the eye), Plagiocephaly, head tilt to one side, decreased range of motion of the neck and resistance to movement of the neck. (1, 2) Infants with Torticollis commonly experience positional molding or Plagiocephaly at the same time. (3) Infants with Plagiocephaly present with a misshapen head, asymmetric placement of the ears, bulging of the forehead and asymmetric appearance of the eyes. (5)

The majority of infants with positional molding and Torticollis improve between 3 to 6 months old, when they begin to sit up more and spend less time lying on their back. (4) In most cases the symptoms can be alleviated and the condition resolved with stretching exercises and repositioning. (1,2) I have found that many babies require interventions including home exercises, frequent position changes, supervised belly time and physical therapy in order treat Torticollis and positional molding. A better outcome is achieved if these treatments are initiated early. (1,2)

In some cases a child with positional molding or Plagiocephaly is referred to a Pediatric Neurosurgeon or a Craniofacial Surgeon for an evaluation. Diagnostic testing may be performed in order to determine the cause of the Plagiocephaly. (2) For resistant or severe cases a helmet or DOC band may be recommended. If a child has severe enough Plagiocephaly that warrants treatment with a helmet, the intervention should be started between 4 and 12 months when the skull is developing. The best results are found when helmet therapy is started early, preferably around 4 months of age. (4)

You should ask your daughter’s Doctor the cause of her symptoms, if they are considered normal variations, the progress of her neck condition and if there are any interventions that can be performed to assist in her development. It would be important to find out if there are any measures you can take at home to monitor her progress or treat her condition.

Although a child with positional molding and Torticollis may present with asymmetry of the eyes, this asymmetry is due to the formation of the bone structure and has nothing to do with the dilation of the eyes. Both eyes should dilate and constrict equally. Anisocoria is the term used to describe the condition of unequal pupil size. This condition many times is present in an infant since birth and may be considered normal. (6) It is not uncommon for a child to have Anisocoria since birth and not be discovered until a later date. Many times the differentiation between the pupil and the iris is very difficult to determine early in infancy, especially if the infant has dark colored eyes. In some cases Anisocoria may be related to central nervous system disease. (6) In order to determine if your daughter has Anisocoria or a problem with her vision you can have her evaluated by a Pediatric Ophthalmologist.

Occasionally pediatric ophthalmologic disorders may present as a head tilt to one side. A child tends to tilt their head in order to see something because they can’t visualize it clearly with the other eye. An infant with a persistent head tilt, despite the institution of stretching exercises, positioning and physical therapy should see a Pediatric Ophthalmologist for an evaluation. A Pediatric Ophthalmologist specializes in pediatric eye conditions and can determine if your child’s symptoms are due to a problem with her eyes. In order to determine if any eye condition is present since birth or if it is a new development, many Pediatric Ophthalmologists request that parents collect serial baby photographs and bring them to the visit.

Typically a newborn’s hearing is evaluated at birth in the hospital before discharge. You can ask your baby’s doctor for the results of your daughter’s hearing test or request records from the hospital where she was born. In general a parent can determine if their infant is hearing at home by watching for a response to noise. An infant should turn its head to the source of a sound. If an infant doesn’t turn her head to the source of a sound this could be because there is a problem with the movement of her neck or because she has a problem hearing.

If at any point during infancy a parent notices that their child is not hearing or responding to noise, a hearing test can be performed in order to rule out a hearing deficit. Hearing tests can be performed in The Speech and Hearing Department of a Children’s Hospital. If you feel that your daughter is not responding to a source of sound you should discuss this with her Doctor who can request a hearing test in order to alleviate your concerns.

It is quite normal for parents to be interested in getting a second opinion regarding their child’s condition by seeing specialist. Many times seeing a specialist helps alleviate a parent’s concerns and gives the situation a new perspective. In order to address all of your concerns, a different specialist for each condition would need to be consulted. A Pediatric Ophthalmologist addresses a child’s vision and rules out eye disorders. A Pediatric Neurosurgeon or Craniofacial Surgeon addresses symptoms consistent with Plagiocephaly and Torticollis. A Physical Therapist addresses and treats a child’s Torticollis. An Audiologist performs hearing tests and evaluates a child’s hearing. Your daughter’s doctor can guide you to the proper specialists in your area.

References:
(1)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:691.
(2)Littlefield T, Reiff J, Rikate H. Diagnosis and Management of Deformational Plagiocephaly. BNI Quarterly. 2001;17(4):1-8.
(3)Kerry G, Beals S, Littlefield T, Pomatto J. Sternocleidomastoid Imbalance Versus Congenital Muscular Torticollis: Their Relationship to Positional Plagiocephaly. The Cleft Palate-Craniofacial Journal. 1999;36(3):256-261.
(4)Komotar R, Zacharia B, Ellis J, Feldstein N. Anderson R. Pitfalls for the Pediatrician: Positional Molding or Craniosynostosis? Pediatric Annals. 2006;35(5):365-374.
(5)Kelly K, Littlefield T, Pomatto J, Ripley C, Beals S, Joganic E. Importance of Early Recognition and Treatment of Deformational Plagiocepahly with Orthotic Cranioplasty. The Cleft Palate-Craniofacial Journal. 1999;36(2):127-130.
(6)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 639.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Infant Development

Toddler Swallowed Paperclips

Dear Lisa,

My 20 month old swallowed two paperclips and I panicked. Did he really need to go to the ER?

“Toddler Swallowed Paperclips”

Dear “Toddler Swallowed Paperclips”,

Kids do the darndest things! Unfortunately, swallowing objects is one of their special talents. Children’s preference for using their mouth to explore puts them at risk for ingesting foreign objects such as coins, pins, tacks, pencil erasers, the tops of pens, wood chips, beads, paper clips and small toys.

Some children who put things into their mouths ingest them and others aspirate the object into their lungs. Although both scenarios are concerning, aspiration can lead to airway obstruction which can interfere with breathing. The anatomy of a child’s small airway in conjunction with their immature protective response lends itself to the aspiration of these small objects into their lungs.(1) The incidence of foreign body aspiration is highest amongst toddlers between 24 and 36 months old.(2)

Luckily when a small round object without sharp edges, such as a coin is ingested and not aspirated, it usually passes right through the bowels without a problem. Typically, swallowed coins can be found in a child’s stool a couple of days after ingestion. It’s just a messy job looking for the object in the child’s stool, and making sure that it passes without complications.

The complication rate of the ingestion of most foreign objects is as low as 1%.(3) On the other hand, sharp objects such as a tack or a group of sharp pins can cause a lot of damage, because they can pierce the bowel and cause bowel perforation, internal bleeding and seepage of stool. The complication rate for a sharp object increases to about 25%.(3) The complications of foreign body ingestion includes ulceration, internal bleeding, perforation of the bowel or obstruction of the bowel.(4) These are all serious conditions that require medical attention and want to be avoided.

The typical treatment for a child who swallows a foreign object is close observation and serial x-rays to follow the path of the object until it is expelled from the body.(4) Unfortunately many times this warrants a trip to the Emergency Room. An Emergency Room visit is also important because sometimes it is difficult to tell whether a child “ingested” (swallowed into the stomach) or “aspirated” (sucked into the lungs) the object. It is common for parents to find their child with an object in his mouth and in some cases the object disappears. Many times the initial assumption is that the child swallowed the object but in some cases the child actually sucked it into his airway.

Foreign body aspiration is especially a concern if an incident is not witnessed by an adult caregiver. A child could have an object in his mouth and then quickly take a deep inspiration and aspirate the object into his lungs without anyone knowing it. Initially the symptoms could include a period of gagging, coughing or wheezing. These symptoms may go away even though there is an object caught in the lungs depending upon the size, location and chemical composition of the object.(5)

A small object could become lodged into a child’s right main stem bronchus for example, leaving the left main bronchus patent and functioning well. As a result the child can be asymptomatic and appear to be breathing normal. (6) It is through a thorough history and physical examination as well as radiologic testing that the placement of foreign body can be determined.

The symptoms of foreign body ingestion and foreign body aspiration can be similar. Signs of foreign body ingestion (swallowed into the stomach) include coughing, choking, pain behind the sternum, and excessive salivation or drooling. (4) Signs that a child aspirated a foreign body (inhaled into the lungs) include cough, wheeze and decreased breath sounds.

In addition, the symptoms of foreign body aspiration can mimic the symptoms of common pediatric respiratory conditions. Symptoms such as coughing, wheezing and decreased breath sounds may also be found in conditions such as Bronchiolitis, Asthma, Pneumonia and Bronchitis. In my practice I have found on more than one occasion that a child was diagnosed with Asthma, when they actually had a foreign body caught in their lungs that their parent didn’t know about. It is not surprising that one study showed that only 15.7% of patients with a foreign body aspiration presented with the clinical triad of concomitant cough, localized wheezing and decreased breath sounds. (2)

It is important for a child with a foreign body ingestion to have an evaluation by a medical professional because of the many potential complications and because of the danger of a foreign body being caught in the airway. A foreign body in a child’s airway can cause airway obstruction, inflammation, infection and respiratory arrest.

Unfortunately a paper clip does have a sharp edge if bent a particular way and should be closely observed because of the potential for complications. In addition, when more than one object is ingested, there is a chance that the objects could become tangled and create a blockage in the intestines. Therefore your trip to the Emergency Room was a good idea and any time spent there was well spent. So I would not be concerned that you "panicked" or "over-reacted" because going to the Emergency room was the right thing to do.

Any child that ingests a foreign body and develops a fever, pain, vomiting, abdominal distention, bloody stools, black stools, constipation, listlessness, lethargy, chronic respiratory symptoms, changes in the sound of his cry or voice, drooling or the inability to eat or swallow should be evaluated by his doctor without delay. The ingestion of a battery or corrosive substance is considered a medical emergency and should be treated accordingly.

I hope everything with your child turns out smoothly.

References:
(1)Johnson DG, Condon VR. Foreign bodies in the pediatric patient. Curr Probl Surg. 1998;35:271-379.
(2)Midulla F. Guide R, Barbato A. Foreign Body Aspiration in Children. Pediatr Int. 2005;47:663-668.
(3)Harrington J, Fareri M. Tack Ingestion. Consultant for Pediatricians. 2006. August:508.
(4) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:393-394.
(5)Tokar B, Ozkan R, Illhan H. Tracheobronchial foreign bodies in children: Importance of accurate history and plain chest radiography in delayed presentation Clin Radiol. 2004;59:609-615.
(6) Madhok M, Jimenez-Vega J. Pin Ingestion. Consultant for Pediatricians. 2006. August:505-506.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Kids Safe

Scarlatina

Dear Lisa,

I was told by my daughter’s Doctor that she has Scarlatina. Is it normal for her rash to look worse and be itchy when she first gets out of the bathtub?

“Daughter with Scarlatina”

Dear “Daughter with Scarlatina”,

“Scarlatina” is a hypersensitivity skin rash that children develop in response to the erythrogenic toxins produced by an infection.(1) The Scarlatina rash is usually caused by Group A beta hemolytic Streptococcus (Strep). In some cases it may be caused by a Staphylococcus infection (Staph). (2) The rash typically appears as red, closely grouped fine papules (tiny bumps) which give a sandpapery feel. It appears 24 to 48 hours after infection with these organisms and lasts 4 to 10 days.(2) The rash first forms in the axillae, groin and neck and then becomes more generalized. (3) It tends to be more prominent in the folds of the skin, such as under a child’s arms. (1) Peeling or desquamation of the skin usually occurs when the rash fades, typically at the end of the first week.

Many parents and children do not notice the rash at all because it is such a fine appearing rash. Unless you look at it in a good light it may be difficult to see, especially in a darker skinned child. Like most rashes, it would be more noticeable when a child bathes. Usually a child first complains of a sore throat which typically brings them into the doctor’s office and then the rash is noticed. Sometimes a child complains that the Scarlatina rash itches which is not surprising because it is a hypersensitivity reaction. Although, itching is usually not the presenting symptom. Those children that complain of itching should be able to control their symptoms with the use of over the counter anti-histamines such as oral Diphenhydramine or Benadryl.

When the Scarlatina rash is caused by strep it usually is accompanied by a strawberry appearing tongue and circumoral pallor or a pale color around the mouth. When the Scarlatina rash is caused by a Staph infection, the rash is often painful and tender. (2) Positive results from a throat culture or culture from a skin lesion confirms the diagnosis of Scarlatina. The treatment includes antibiotic therapy. Sometimes a Scarlatiniform rash may be associated with enteroviral (viral) infections.(1)

If your child’s rash does not respond to over-the-counter antihistamines, increases in intensity, persists, or wakes her at night it would be a good idea to contact her Doctor. If the skin sloughs off prematurely (in only a few days), the rash appears like a burn or involves mucus membranes such as inside the mouth, the eyes or vagina you should also contact your daughter’s doctor. These symptoms may be a sign of the development of another condition.(4)

Hope your daughter is feeling better soon.

(1) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990:472-473.
(2) Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:180-183.
(3) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1686.
(4)Galante R. Cure Worse Than the Disease. Consultant for Pediatricians. 2006. August:495.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents with Sick Kids

Medication Dosages in Metric

Dear Lisa,

When I have to give my baby medication, I find that all of the measurements are in “cc” or “ml”. Can you tell me what these measurements equal? How much is a teaspoon equal to?

“Please Clarify Metric”

Dear “Please Clarify Metric”,

One Tablespoon = 15 ml
One teaspoon = 5 ml
3/4 teaspoon = 3.75 ml
1/2 teaspoon = 2.5 ml
¼ teaspoon = 1.25 ml
1/8 teaspoon = 0.625 ml
One ounce = 30 ml
1 ml = 1 cc (they are interchangeable).
0.5 ml = ½ ml
0.5 teaspoon = ½ teaspoon
0.25 ml = ¼ ml
0.25 teaspoon = ¼ teaspoon

In pediatrics, many times a parent will be asked to give their child “point 5 of a milliliter” or “point 5 of a cc”. Be careful and watch for the word “point” because this means less than one measure. “Point 5 of a milliliter” stands for one half of a milliliter which is less than 1 ml. Many medication errors occur because proper attention is not paid to the word “point”.

Just to give you a visual, any measurement less than 1.0 ml is less than ¼ of a teaspoon. For example when you give your baby a dropperful of Tylenol and you fill the medication up to the 0.8 ml line, this is equivalent to a little more than 1/8 teaspoon.

Now for some fun with mixed amounts:

One and one quarter teaspoon is 5 ml + 1.25 ml = 6.25 ml.
One and one half teaspoon is 5 ml + 2.5 ml = 7.5 ml.

A word of caution, if you are giving your child a medication and the dosage is greater than a normal adult dose, chances are it is too much and you should recheck the dose. If the medication is equal to an adult dose, in most cases this may also be an error and you should also recheck the dose. If you are giving a child a medication with a dropper and you need to go back to the bottle to fill up the dropper again, recheck the dose to make sure it is the correct dosage. If you are ever giving a child a medication using a Tablespoon, recheck the dose, most medications for children are given in teaspoons not Tablespoons.

It is always better to recheck a medication dosage if there is ever a question. If a medication dosage doesn’t seem right, it is better to err on the side of caution and recheck with your child’s Doctor and Pharmacist who can verify that the dosage is correct. If you ever give the wrong amount of medication to your child call your child' s Doctor and Poison Control at
1-800-222-1222.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily

Diaper Rash

Dear Lisa,

My 9 month old baby has a diaper rash that I can’t get rid of. I tried different diaper crèmes, and they didn’t work. Any suggestions? Could there be something else wrong?

“Diaper rash”

Dear “Diaper rash”,

Most diaper rashes are due to the exposure of the child’s skin to urine and stool in the child’s diaper. This exposure in conjunction with the irritation of the diaper itself is the cause of most diaper rashes. (1) The enzymes found in stool irritate the skin and lead to skin break down.

These enzymes tend to have more of an effect on the skin during teething. In addition, teething is commonly associated with diarrhea and looser stools. (2 ) Any childhood condition that results in frequent stooling puts the child at risk for developing diaper dermatitis. (1) Therefore, whenever a child is teething or experiencing frequent stools it is a good idea to be diligent about diapering and skin care.

The best treatment for diaper dermatitis includes frequent diaper changes and exposing the skin to air and light as much as possible. (1) You can expose your child’s bottom to air by putting him to sleep for a nap on top of a waterproof pad with no diaper on. If you open all the shades in the room and expose your child's bottom to light this will also help. Warm baths are helpful for extensive or painful diaper rashes (3). If you put a tablespoon of baking soda in your baby’s bath water this will help soothe the skin.

Applications of emollients such as A& D ointment or Balmex with each diaper change will provide a barrier, so that stool and urine won't come into contact with the skin. You may also use an over the counter antacid liquid and apply it to the area, let it dry and then cover the area with a diaper crème. (1)

It is important to avoid diaper crèmes containing rosins and dyes as an ingredient because these products can irritate the area and exacerbate the condition. Diaper crèmes with lanolin, mineral oil, wax, and olive oil are particularly effective at protecting the skin. (1)

If you follow all of these measures and the rash does not go away, there may be a Candida (yeast) skin infection. A rash that persists for more than three days, and is accompanied by involvement of the skin folds(creases in the skin) and/or Oral Thrush probably represents a secondary yeast infection. (1) An evaluation by your baby’s Doctor or Nurse Practitioner can verify this diagnosis.

Typically, Candida diaper dermatitis appears as a red dry crusty rash with well circumscribed borders covering the diaper area, including the skin folds. Many times satellite lesions or circular lesions can be found. (3) A Candida yeast infection is commonly found in a child with frequent diarrhea or when a child is on a course of antibiotics. It has been found that infants can experience up to a 14 fold increase in the density of Candida Albicans in their diaper area after 10 days of therapy with amoxicillin. (4)

Over the counter products, such as Lotrimin, treat yeast infections on the skin. When applying Lotrimin to the diaper area, it is easier to mix equal parts of your diaper crème, such as Balmex, with the Lotrimin and keep it in a sealed, labeled plastic container. Diapering your child will go a lot smoother if the diaper crèmes are mixed ahead of time.

If a child’s Candida rash persists despite treatment he should be evaluated by his Doctor or Nurse Practitioner. Other skin infections or conditions may need to be ruled out or a switch in the antifungal medication to a prescription brand such as Nystatin may be necessary. (3) Other infections that may be responsible for a prolonged cass of diaper rash include Staph aureus, group A Streptococci (Strep), Coxsackievirus(Hand, Foot, mouth Disease), human papillomavirus (HPV), Herpesvirus and Sarcoptes scabiei(scabies). (1)

In some cases a persistent diaper rash, non-responsive to treatment and with no other signs of infection may represent Contact Dermatitis. Contact dermatitis in the diaper area presents as a redness that spares the skin folds (does not involve the creases in the skin). It is caused by a sensitivity to a product used in the area.

Some common causes of Contact Dermatitis in the diaper area include the colored dyes found in disposable diapers, additives in diaper crèmes and the preservatives and fragrances included in baby wipes. (5) If your child has a persistent diaper rash that doesn’t involve the skin folds you may be able to determine if it is a reaction to a product that you are using by following a few simple steps. First, eliminate all diaper crèmes. Next change the diaper brand to one without colored dyes. After making these changes wait 1 to 2 weeks to if the rash goes away. (1) If the rash disappears, chances are that the rash was due to a sensitivity to one of the products that you were using.

Any diaper rash this is resistant to treatment should be evaluated by your baby’s Doctor or Nurse Practitioner. In some cases a prolonged diaper rash may be a sign of other health conditions. Conditions such as Psoriasis, Zinc deficiencies or Acrodermatitis can present as a chronic diaper rash. (1) These conditions are rare and are only considered if the rash is chronic or lasting for over 4 weeks and resistant to therapy.

References:
(1)Nield L, Kamat D. Diaper Dermatitis: From “A” to “Pee”. Consultant for Pediatricians. 2006;June:373-380.
(2)Grassia T. Talking Teething: Start good oral hygiene early. Infectious Diseases in Children. 2006. August:44.
(3) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 614-615.
(4)Brook I. The effects of amoxicillin therapy on skin flora in infants. Pediatr Dermatol. 2000;17:360-363.
(5)Guin J, Kincannon J, Church F. Baby-wipe dermatitis: preservative-induced hand eczema in parents and persons using moist towelettes. Am J Contact Dermat. 2001;12:189-192.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily

Homework Trouble

Dear Lisa,

With September around the corner, I am dreading the thought of getting back into the homework routine. My son is going into 3rd grade, and homework has always been a chore. He never wants to do his homework and takes forever to finish it. He gets very distracted and uses every trick in the book to get out of doing it. Do you have any suggestions on getting him to do his homework?

“Dreading September”

Dear “Dreading September”,

Homework time tends to be a stressful time for many households. At the end of the day, both parents and children are tired from the activities of the day. Many times it’s hard to fit the homework in between after school activities and dinner preparations.

For children who tend to “put off doing” their homework, it is a good idea to start it when the child first gets home from school, before any other activity. Otherwise, if homework is started later, it may be more difficult for children to stay on track. They become too tired and more easily distracted. (1) There are some measures that you and your son can take in order to help homework time go more smoothly.

First choose a quiet place with minimal distractions. (1) For children who become easily distracted, doing their homework in the kitchen with the telephone ringing and people coming and going is not a good idea. This would cause too much of a distraction and make it difficult for a child to stay on track. Secondly, set up a work station with all of the appropriate supplies in a caddy or box. (1) Have sharpened pencils, erasers, crayons, markers, rulers, paper and paper clips organized and available. Many children use the excuse that they don’t have the right paper, they don’t like a particular eraser or their pencil is not sharp enough so they can get up and stop doing their homework. Before you know it these kids are in another room playing with their toys far from thoughts of doing their homework. By having all of the supplies at arms length this will prevent interruption in the flow of doing their homework.

Next, figure out a homework schedule with the incorporation of breaks. Some children become too overwhelmed if they are faced with a list of homework assignments. If you break up the homework assignment into sections it becomes more approachable. For example, review your child’s homework assignment and decide how difficult each assignment is and how long it should take your child to finish it. Every child is different, each with their own strengths and weaknesses.

Start with an assignment that your child is good at, so that he can get it done with little effort. This way he will be encouraged when he accomplishes the task of finishing a part of his homework. For example, if your child is good at math and hates writing sentences, have him do the math worksheet first and then give him a 10 to 15 minute break before he has to write out his spelling sentences.

Your child may need extra help with difficult assignments that require more than one step, for example writing a story. Sometimes if the parent breaks the steps up for the child he will have more success in completing the task without becoming too overwhelmed. For example if the child has to write a story; have your son first, think of a title and the names of the main characters. Next, discuss how long the story should be, for example two paragraphs or one page. Then have him jot down an outline for the story, making sure there is a beginning, a middle and an end. After this write the story and then proof read it. Lastly fix the errors. You’ll find that if you break up the steps for your child he will get less frustrated and will get the homework done in a timely fashion.

For children with Attention Deficit Disorder (ADD) or those who have difficulty staying on task it may help to use an egg timer. (1) When reviewing the homework, decide how long an assignment should take and put the timer for that amount of time. Many children do well with structure and concrete expectations. It is a good idea to use incentives with the use of the timer. You can tell your son, "If you finish your math in 20 minutes then I’ll let you watch your favorite show on T.V. or play a video game".

It is not recommended to use food as a reward. Instead choose activities that your child likes to do. As a parent you know what works best for your child’s personality. When your child completes a task, make sure you let him know how pleased you are and praise him for doing his homework without interruptions. It is a good idea to praise your child first and before giving him a long list of his errors to be corrected.

Many children have difficulties completing homework. For many it is a matter of discipline or level of maturity. In time and with practice these children improve. For other children, difficulty with homework completion may be a sign of an underlying issue such as Attention Deficit Disorder (ADD), Learning Disability, emotional/behavioral problems or social issues. (2) For example, some children with Attention Deficit Disorder or Learning Disabilities present with distractibility, problems focusing and difficulty staying on task. Therefore, if your child continues to have problems completing his homework and staying on task it would be important to discuss this with his Teacher. It would be important to know if these issues also occur during school hours.

If your child’s problems persist despite your efforts to help his homework time go more smoothly or if your son’s teacher verbalizes any concerns, it would be important to discuss this with his Doctor or Nurse Practitioner. It is important to discuss these concerns so that your son can receive the support that he needs. School systems, as well as Pediatricians are accustomed to addressing these types of issues since approximately 20 % of all school-aged children have academic performance problems. (2) It is important to not ignore these issues because the two major contributors to academic performance problems are learning disabilities and mental retardation. (2)

If your feel that your child is exhibiting signs of ADD or a learning disability, it is important to communicate this to your child’s Teacher and Pediatrician. For more information about learning disabilities log on to:

Learning Disabilities Association of America
www.ldanatl.org

National Center for Learning Disabilities
www.ncld.org

(1)Lambros K, Leslie L. Management f the Child with a Learning Disorder. 2005. 34;4:275-287.
(2) Kelly D, Aylward G. Identifying School Performance Problems in the Pediatric Office. Pediatric Annals. 2005. 34;4:288-298.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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