Carotenemia

Dear Lisa,

My one year old daughter's skin tone is yellow in color. I didn't think much of it because I know it could be due to her eating the orange vegetables (sweet potatoes), but more people are remarking on it and I have shied away from the orange vegetables but her skin tone is still yellow (has been for awhile) and I also noticed lately that her gait is unsteady (not all the time but it is noticeable) almost like she is walking like she is intoxicated. How concerned should I be with these symptoms?

“Sweet Potato Mom”

Dear “Sweet Potato Mom”,

Carotenemia is the condition that commonly occurs in children when they eat too many yellow-orange vegetables. When a child eats too many foods containing carotenoids over a period of time their skin turns an yellow-orange color, but the whites of the eyes stay white.(1) If your daughter eats a lot of orange vegetables such as carrots, sweet potatoes and squash this could be the reason for her yellow-orange discoloration. A child’s orange vegetable intake would have to be cut down to less than three times per week in order to alleviate the symptoms. The orange color should go away gradually and should take a few weeks.

Another condition that can cause the skin to be yellow is Vitamin B 12 deficiency. One of the signs of Vitamin B 12 deficiency is a lemon yellow tinge to the skin.(2) Vitamin B 12 is found in meat, liver, milk, eggs, cheese, fish and soybeans. (3) Although rare in childhood, this condition may occur in children who are strict vegetarians and in those who lack the proper stomach enzymes needed to absorb Vitamin B 12.

Both intrinsic factor and proper Hydrochloric Acid production by the gastric mucosa are necessary for the absorption of Vitamin B 12. Therefore a deficiency in either of these can result in Vitamin B 12 Deficiency. (4) Vitamin B 12 Deficiency is more common in the elderly population because as people age they naturally develop decreased amounts of gastric secretions. (2) There also may be a concern in patients who take medications that block Hydrochloric Acid production in the stomach.

The fish tapeworm, Diphyllobothrium latum is another cause of Vitamin B 12 deficiency, although this is a rare condition. (5) Other consequences of Vitamin B12 deficiency include anemia, gastrointestinal problems, neurologic deterioration and spinal cord degeneration. (3, 4)

If a baby’s eyes are yellow as well as their skin, this represents a more serious condition called Jaundice. Jaundice is caused by Hepatitis (liver infection), Liver Disease, Hemolytic Anemia (the breakdown of red blood cells in the body), medication side effects, prematurity, or bilirubin glucuronyl transferase enzyme deficiency. (2) If the whites of a child’s eyes are yellow this would require immediate medical attention.

In regards to your daughter’s skin color, as long as the whites of her eyes are not yellow there is no need for alarm. You may need to cut down on the sweet potatoes more and wait a little longer before you see a change. If your daughter was breastfed while you maintained a strict vegetarian diet or if she presently is a strict vegetarian then Vitamin B 12 deficiency may need to be considered. If her discoloration does not seem to improve or if it worsens she should be evaluated by her Pediatrician. Other concerning symptoms would include fever, weight loss, diarrhea and fatigue. If these symptoms occurr your daughter should be checked by her Doctor.

Without actually seeing your daughter’s gait it is difficult to tell if it is normal walking behavior or a sign of a problem. Unsteady gait in a one year old can be due to something as simple as ill fitting shoes or as complicated as Congenital Hip Dysplasia, an injury, leg length discrepancy or an infection. Interestingly, painful feet and limps in children are most commonly caused by ill-fitting shoes. (3)

All children who begin to walk generaly have an abnormal appearing gait. When first learning to walk, their feet typically turn outward. Sometimes new walkers will push off with one foot and slightly drag the other. (3) So what looks like abnormal gait to an onlooker, may be normal for a new walker. Since your daughter is only one year old, her gait may be normal for her age. The best way to have her gait evaluated is to bring her to the Pediatrician’s office and have her walk in front of the Doctor. Your daughter’s doctor will be able to tell you if her gait is normal for her age.

There is a concern when a child has pain or limping with walking. If this is the case a more serious disorder may need to be ruled out. Developmental Dysplasia of the Hip also known as Congenital Hip Dysplasia (CHD) is one of the childhood conditions that may present as abnormal gait. Althought this condition is typically discovered in infancy, it may first be noticed when a child begins to walk. It occurs in 1.5 to 20 out of every 1000 live births. (6) Congenital Hip Dysplasia is defined as the abnormal growth or development of the hip.(6)

The exact cause of CHD is unknown, but there are common risk factors noted in babies with this condition. Babies that are large for their age, those who had low amounts of amniotic fluid, those with a family member with CHD, breech presentation, fast delivery and traumatic delivery can all contribute to Congenital Hip Dysplasia. The symptoms of CHD include asymmetric skin folds in the thigh and buttock region, decreased rotation of the hip, laxity of the hip joint, shortening of the leg and abnormal gait. (5, 6) An evaluation by your Pediatrician will be able to rule out this condition, as well as other conditions that cause a baby to limp.

If your child’s abnormal gait is accompanied by other signs such as fever, irritability, a recent illness, weight loss, a recent injury, pain, crying or developmental delays an evaluation by your Doctor is necessary. Otherwise, check your daughter's walking while she is barefoot and with different pairs of shoes and see if the symptoms are consistent. If the abnormal gait is only present with a certain pair of shoes, then the problem is no more than the poor fitting shoes.

If you are interested in reading other Pediatric Advice Stories covering these topics:

First Pair of Shoes

Vitamin B 12 Deficiency

Carotenemia

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 1990:22-23.
(2)Waley L, Wong D. Nursing Care of Infants and Children. 2nd ed. St. Louis, Missouri:The C.V. Mosby Company.1983:468-469,1342.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:748-749,100,848,839.
(4)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:649, 449-450.
(5)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:82-83,682-685.(6) Horn P. A painless limp and leg-length descrepancy in an 18-month-old girl. The Clinical Advisor. 2006.July:121-124.

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

Pediatric Advice About Keeping Kids Healthy

Gastroesophageal Reflux

Hi Lisa,

My 3 month old has been 'snuffly' since birth, her nose has never been never runny but just seems blocked. She has been into hospital as in the early weeks she found it hard to breathe and had a ct scan on her sinuses which showed nothing. I changed her formula to a thickened formula as she used to bring up a lot of her milk after feeds. This has helped and she only spills a little now but her nose even though better seems to always be blocked with thick clear mucus which dries out. Could it still be reflux that’s causing her 'snuffles' and should I investigate it further and get a second opinion from a pediatrician or will she grow out of it?

Thank you,

“snuffles mum”

Dear “Snuffles mum”,

I’m sorry to hear that your little one has had such a difficult time with her nose. The good news is that her CAT scan was normal which rules out any anatomical problems, masses or infections. You did mention that your daughter has Gastroesophageal Reflux (GER), and that the symptoms seem to be improving. Gastroesophageal Reflux certainly can cause infants to have a stuffy, congested nose.

Infants typically have a lot of problems when their nose is stuffy and congested even if they do not suffer from GER. A stuffy nose affects their feeding and breathing dramatically since infants are obligate nose breathers. (1) The best thing that you can do at this point to help her nose is to make sure the house is not too hot, keep your daughter's head elevated, use a cool mist vaporizer and use saline nose drops to keep the nasal secretions loose.

GER is very common in infancy. It affects approximately 50% of infants younger than 2 months old and up to 70% of infants by 4 months old.(2) GER is defined as the retrograde passage of gastric material into the food tube. (3) Infants can develop esophageal symptoms from GER which are caused by inflammation and hypersensitivity to the gastric contents. Infants can also develop symptoms outside of the esophagus which are caused by direct acid-induced injury and stimulation of airway reflexes. (4)

The typical symptoms experienced in infancy include irritability, recurrent and persistent vomiting and regurgitation (reflux into the mouth and swallowed again).(5) Symptoms outside of the esophagus can include; sore throat, hoarseness, wheezing, chronic cough, recurrent pneumonias, Asthma, dental erosions, laryngitis(inflammation of the voice box), Sinusitis, Pharyngitis (throat infection), Otitis media (middle ear infection), failure to thrive, Sandifer’s syndrome and vomit with blood in it. (5,6) When these problems occur, an infant is considered to have Gastroesophageal Reflux Disease (GERD). (5)

The good news is that symptoms of reflux usually resolve spontaneously by age one. (5) In the mean time the measures that can be taken to help your daughter’s reflux include; thickening her formula, elevating the head of her mattress 30 degrees, avoiding position changes for 30 minutes after a feeding, avoid moving your daughter after feedings, plan diapering and play time so that it does not occur after a feeding, avoiding exposure to second-hand cigarette smoke, avoiding allergic foods and feeding her hypoallergenic formula. (4,5) When elevating an infant's head it is importatnt not to use pillows. Instead put a folded blanket under the mattress. Acid blocking medications may be recommended, especially when symptoms outside of the esophagus occur. (5)

By controlling your daughter’s GER symptoms, you may be able to control her nose symptoms. Since GER may cause other problems such as ear infections and respiratory infections it is important that you follow up with your daughter's Doctor if new symptoms develop. As long as she presently doesn’t have other symptoms such as fever, problems moving her bowels, difficulty gaining weight, coughing, change in the quality of her cry, stridor (high pitched inspiratory sound), wheezing or problems breathing, it sounds reasonable to wait it out at this point.

Your daughter’s GER symptoms and nasal symptoms are expected to improve with age. If at any point her condition seems to worsen you should bring her in to see her Pediatrician and a specialist if your Pediatrician feels that it is necessary.

If you are interested in other Pediatric Advice stories covering this topic:

Newborn Congestion

Infant Vomiting

Vomiting and Weight Loss

Baby with Cold Symptoms

I hope your daughter's "snuffles" go away real soon.

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1168-1171.

(2) Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of Gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 1997. 151(6):569-572.

(3)Gold BD. Gastroesophageal reflux disease: could intervention in childhood reduce the risk of later complications? Am J Med. 2004. 117(Suppl 5A):23S-29S.

(4 )Rudolph CD, Mazur LJ, Liptak, GS. North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of Gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001. 32(Suppl 2);S1-31.

(5 )Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006. 35(4):259-266.

(6)Christensen M. Gold B. Clinical Management of Infants and Children with Gastroesophageal Reflux Disease: Disease Recognition and Therapeutic Options. Presented at: The 2002 ASHP Midyear Clinical Meeting; Dec 9, 2002: Atlanta.

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

Pediatric Advice For Infants

Bedwetting

Dear Lisa,

I have a five year old boy. I started night training him when he was not quite four and I was five months pregnant with his little brother. The whole process went perfectly. I would get up two or three times a night and take him to the potty, gradually the number of times I had to get up reduced until about a month later when he began getting himself up to go potty without my assistance. I assumed that when his little brother was born he would regress somewhat. Just because of the emotional stress of having a new baby in the house. I was overjoyed when he didn't regress!!! He went seven whole months without one accident! Then we went to visit some family members out of town and he came down with the flu. He was seriously ill for the better part of a week. He started bedwetting. I thought it was just because he was so sick, and he would be back to getting himself up to go when he felt better.

That has been five months ago. I have tried everything I know to try. I am so frustrated. I have asked so many people and nobody can help me. I am very careful about being gentle and kind with him, I don't want to embarrass him or make him feel like he's done something wrong. But, if I don't get him up to go in the middle of the night, he WILL wet the bed, and sometimes he still wakes up with wet sheets. I asked him once why he started having accidents again and he said "Because I'm just too tired to get up." I'm trying really hard to do things right, but when I'm up changing sheets at two o'clock in the morning because my five year old didn't WANT to get up and go potty, it's almost more than I can take. I just don't understand what could have caused him to regress so completely. Please, please help me!!! This is putting a strain on the whole family.

Thank You,

“Tired and Frustrated”

Dear “Tired and Frustrated”,

It’s interesting how your son did not regress when your new baby was born, but started his bedwetting again after her was ill. Since your son had control of his urine for such a long time and the symptoms returned it would be important to figure out the cause of the return of his bedwetting.

Children with urinary incontinence only at night have Nocturnal Enuresis. Nocturnal Enuresis is a very common childhood condition that affects approximately 13% of all 6 year olds. (1) Children who never gain control of their urine at night have Primary Nocturnal Enuresis. This is the most common type of Nocturnal Enuresis. Children who gain control of their urine at night for at least 3 months and then resume bedwetting are considered to have Secondary Enuresis. (2) Your son’s symptoms fit into the category of Secondary Nocturnal Enuresis. This type of enuresis is usually not caused by a small bladder capacity or immature sleep arousal pattern. (2)

In order to treat your son’s wetting at night, it would be important to first find out the cause. It was very smart of you to ask him why he started wetting at night again. Whenever a child develops a change in behavior it is important to ask him directly about the problem. Since your son replied that he was too tired to get up , this is a good place to start.

It may be a good idea to investigate why your son feels that he is too tired. Has he been sluggish during the day? Is he more tired with exercise as compared to other children his age? Has he not been getting the appropriate amount of sleep? These are some questions that you need to ask yourself. Before we can assume his symptoms are behavioral, it would be a good idea to make sure the symptoms aren’t due to something out of his control.

Since the symptoms began after his prolonged illness, reasons for being tired after an illness should be investigated. Some childhood viruses or infections can cause a child to become temporarily Anemic. (3) A child can have Anemia without their parent knowing it because the signs are typically quite vague and non-specific. Signs of Anemia may include excessive sleepiness, irritability, disinterest in eating, pale skin color, pale mucus membranes, exercise intolerance, short attention span, poor school performance and difficulty eating in infancy. (2,4,5)

Two examples of such infections are the EBV virus and Mycoplasma. (5) Your doctor can evaluate your son for signs of Anemia, or other conditions such as Hypothyroidism that can cause a child to be fatigued. (2) Urinary screening may also be performed in order to look for signs of infection, the kidney’s ability to concentrate the urine, the presence of blood and sugar. (6)

Another very important question to ask is, does your son has any problems with urinary incontinence during the day? This is very important information to know, because children who experience Nocturnal Enuresis along with daytime incontinence may have an organic problem that needs to be ruled out. (2) A child who gains control of their urine during the day for a period of time and then develops incontinence has Secondary Enuresis.

Secondary Enuresis is a type a dysfunctional voiding that develops as a result of constipation or pelvic floor dysfunction. Secondary Enuresis may also occur following a urinary tract infection.(3) Some children who develop a urinary tract infection learn to suppress the need to urinate by controlling the pelvic floor muscles. When this occurs, the muscles of the bladder and the bowel become distended. The urine accumulates and pools in the distended bladder and as a result the child loses the sensation of needing to void. (3)

When this happens it takes months for the bladder to regain its tone. If your son is experiencing day time and night time incontinence, it would be important to bring him to the Doctor for an evaluation so that these factors can be ruled out. In some cases, the expertise of an Uurologist and diagnostic testing such as a bladder ultrasound may be needed.

Once you know that there is no organic cause for your son’s bedwetting, then you can work on the behavior. To start, there is no reason why you should get up in the middle of the night. All that is necessary is that you wake your son and bring him to the bathroom before you go to bed at night and bring him to the bathroom the first thing in the morning. The feeling of being wet and uncomfortable is necessary in order to provide an incentive for your son to change his behavior.

It would be a good idea to purchase a few washable waterproof pads and put one under his body, on top of the sheets before he goes to bed. When he wets himself this waterproof pad will absorb the moisture and prevent the sheets from getting soiled. This way the sheets will not need to be laundered everyday. It is much easier to wash a pad, then to change the whole bed.

Your son should be taught to remove the pad from his bed in the morning and put it in the wash. It is important that this is not viewed as a punishment, but a way of helping him become responsible for himself. It is a good idea to take a matter of fact approach, helping him realize that a mess needs to be cleaned. Understanding that an important step in overcoming bedwetting is having the child have an active role in dealing with their bedwetting should help you relinquish this responsibility. (2) Not only will this approach teach your son responsibility, it will keep you from being overburdened.


You can purchase one of these 34 inch by 26 inch washable pads at a baby supply store such as Babies R Us or Toys R Us. It is also a good idea to limit the amount of fluids that your son drinks in the evening by not letting him drink after 7:30 p.m. (6) Remind him gently before he goes to sleep that he has underwear on and that you expect him to stay dry.

The other thing to consider is a dietary change that may be causing your son’s bedwetting. Has there been a change in his diet since he was ill? Does he now drink soft drinks, caffeine or drinks with sugar-substitutes and he didn’t before? Recent literature has shown that food sensitivities can play a part in enuresis. (6) It has been reported that milk, milk products, caffeine, vitamin C, citrus juices, corn, heavily sugared foods and carbonated beverages may contribute to enuresis. (2,7)

If there has been a change in his diet since he was ill you may want to consider a food sensitivity as a possible cause of his bedwetting. You can eliminate the new products from his present diet for a period of two weeks in order to determine if they are causing a problem. Gradually add the products back, one at a time and take notice which nights your son wets his bed. (6) If the Nocturnal Enuresis consistently occurs when your child ingests a certain food then chances are that item can be contributing to the problem.

Since Constipation contributes to Nocturnal Enuresis it would be important to consider this as factor. It is common for school age children to have firm, infrequent stools. A full rectum can restrict the bladder’s expansion and cause a bladder contraction which leads to urinary incontinence. In addition, constant rubbing of the bladder by the full rectum decreases the sensitivity of the bladder and causes the brain to begin to ignore messages from the area. (3,6) If your son has hard, infrequent stools it would be important to bring this to your Doctor's attention so that this can be addressed before attempting to train your son to stay dry at night.

Bedwetting can be very frustrating, because it is a problem that usually takes some time to resolve. It puts a strain on the family emotionally and physically. It is a very messy problem and the effort that it takes to keep the child’s body and bed clean is not only time consuming, but exhausting. It is also very normal to become frustrated. Children frequently become very embarrassed by the situation and the emotional trauma can many times interfere with a child’s socialization. (8) You have done the correct thing by being gentle and kind with your son. Keeping a non-accusatory tone and having your son involved with his care will help everyone involved.

I wish you dry and restful nights in your near future.

References:
(1)Fergusson DM, Hons BA, Horwood LJ. Factors related to the age of attainment of nocturnal bladder control: an 8 year longitudinal study. Pediatrics. 1986;78:884-890.
(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. 1990:216-217, 440-441, 349,217.
(3)Listernick R. A Thirteen-Year-Old Girl with Anemia. Pediatric Annals. 2003.32(3);139-148.(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1407.
(5)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:495-501.
(6)Mercer R. Dry at Night. Advance for Nurse Practitioners. 2003. February:26-30.
(7)Maizels M, Rosenbaum D, Keating B. Getting to Dry: how to Help your child Overcome Bedwetting. Boston, Mass: The Harvard Common Press; 1999.
(8)Sacharyczuk C. Psychological implications of nocturnal enuresis demand treatment. Infectious Diseases in Children. 2006. April:72.


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

Pediatric Advice For Parents

Green Stools

Dear Lisa,

My 6 week old nephew has been given Mylicon for gas/colic. He is a formula baby and we have given him prune/apple juice for constipation. His poop color is dark green, almost black and a little watery. Why is his poop this color?

“Concerned Aunt”

Dear “Concerned Aunt”,

The stools of bottle-fed infants can vary in color. The colors change according to what the baby eats or due to the medications that he takes. Normal colors include shades of green, brown or yellow depending upon the formula. (1) Some shades of green may appear almost black in color. On the other hand, babies that are exclusively breast fed and not taking iron vitamins are not expected to have green stools. Green stools in this case may be a sign that the baby is not receiving enough milk.(1) Any infant with very light colored stools, grey stools, black stools or stools with visible blood should be evaluated by a Health Care Professional.

Therefore your nephew’s stools sound like they are normal. If you are not sure if the color is black it would be a good idea to bring this the Doctor’s attention. His doctor may need to visually inspect the stool to see if the stools are truly black. Since black colored stools may be a sign that there is blood in the stool, the doctor may want to test the stool.

Blood in the stool turns black when it is not fresh blood. This occurs when the blood enters the system high in the gastrointestinal tract. (2) For example, this can occur if blood enters the stomach or the small intestine. The stool turns black during the transition to the large intestine.

Testing stool for blood can be done with a very simple test called the Hemoccult or Guaiac test. (2) In order to test stool for blood the specimen should be obtained from fresh stool collected on three consecutive days (three days in a row). This is simple when a child is still in diapers. Simply remove the diaper when the infant has a fresh stool and label it with the date. It is important to collect a fresh specimen because the test will not be accurate if the stool is mixed with urine or water. (2)

For older children who no longer wear diapers, the stool can be collected by putting plastic wrap (i.e. Saran Wrap) over the rim of the potty or toilet bowl. The child can have a bowel movement and the plastic wrap will catch the stool and prevent it from mixing with the water in the toilet.
Once the stool specimen is obtained, small specimens collected from two different spots of the stool are smeared onto a guaiac card. A couple of drops of a reagent solution are put on the specimen card and if the window turns blue it means there is blood in the stool. (2)

References:
(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 291.
(2)Kozier B, Erb G. Fundamentals of Nursing. Concepts and Procedures. 2nd Ed. Menlo Park, California: Addison-Wesley Publishing Company.1983:688-700.

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

Pediatric Advice About Keeping Infants Healthy

Chronic Ear Infection

Dear Lisa,

My child has had an ear infection for six weeks now she is four years old. She has been on four different medications. That is a concern but what I have also noticed is that her hair is thinning out and she wakes up complaining about a pain in her leg. Can all this be related somehow?

“Granny”

Dear “Granny”,

Otitis Media is the infection of the middle ear cavity and is commonly referred to as a Middle ear infection. It is a common childhood ailment and accounts for 20% of all visits to the doctor during the first five years of life. (1) The symptoms include earache, sensation of “blockage” of ears, rubbing or pulling ears, hearing loss, fever, irritability, upper respiratory symptoms, vomiting or diarrhea. (1)

Risk factors for developing Otitis Media include daycare attendance, exposure to secondhand cigarette smoke, pacifier use, formula feeding as opposed to breastfeeding, bottle propping practices, having more than one sibling, Native American ancestry, and a family history of Acute Otitis Media. (1) Eighty percent of cases of Acute Otitis Media resolve without antibiotics. When antibiotics are used there is an earlier resolution of pain, reduced risk of developing a middle ear infection in the opposite ear and the reduced risk of developing complications. (1) On the other hand, Antibiotic use may contribute to bacterial resistance. (1)

There are two treatment options for children with Otitis Media; antibiotics or a wait and see approach. The American Academy of Pediatrics recommends antibiotic treatment for children less than 6 months old, children with serious illness, children who cannot be followed up, children with chronic medical conditions, children with a recurrence of Otitis Media in the previous 30 days and children with chronic Otitis media with effusion. (1,2), Children not belonging to these categories can be watched and reassessed in 48-72 hours. If at that point the child is still symptomatic and has Otitis Media upon physical examination, antibiotics are recommended.

Research has shown that children under two years old diagnosed with Otitis Media and treated with an antibiotic have a higher rate of recovering and a decreased rate of recurrence. (3) In addition children in daycare and children with a history of several cases of Otitis Media were found to have higher failure and recurrence rates. (3)

When an antibiotic is prescribed there should be a response to therapy within 48-72 hours. If no improvement is noted after this time the antibiotic typically is changed to a different type. Research studies show that microorganisms that cause refractory cases or severe cases of Otitis Media can be eradicated in 96% of children when high dose amoxicillin-clavulanate is used. (4) Once an inner ear infection is treated, fluid can remain in the ear for 90 days after the acute infection has resolved.(5) This fluid many times resolves on its own and is not considered an infection.

I can see why you are concerned about your child’s ear infections. An ear infection that lasts six weeks and does not respond to 4 different types of antibiotics is not normal. Children who experience an ear infection that does not resolve with repeated antibiotic treatment or those with a high rate of recurrence should be referred to an Otolaryngologist or Ear Nose and Throat Specialist.(6)

Complicating factors such as Eustachian-tube blockage or dysfunction, allergic rhinitis, enlarged or chronically infected adenoids and inefficiency of palatal muscles need to be ruled out.(1,6) Careful evaluation of risk factors should also be evaluated. Depending on your social situation, whatever measures that you can take to eliminate risk factors such as stopping the use of a pacifier or switching to a smaller day care setting may be helpful. (5)

In regards to your question about your child’s hair, hair thinning in a child may reflect normal developmental changes. In some cases the thinning of hair can be due to an underlying problem or condition. Most of the time, normal hair growth patterns are responsible for what appears to be hair thinning.

Hair replacement occurs according to a cyclic pattern alternating between growing and resting phases. Hair on the scalp grows steadily and continuously for 2 to 6 years. Then the hair enters a resting phase in which the hair stops growing. After three months of no hair growth the hair starts to fall out. Following this hair shedding period, the hair rests for an additional 3 months and then new hair growth resumes.

Both this rate of growth and the replacement cycle may be altered by many factors. These factors include; illness, diet, high fever, major illness, surgery, blood loss, drugs, radiation or severe emotional stress. (7) Your child has had an illness and this could be an explanation for the hair thinning that you are seeing. If she had high fevers with her ear infections this could be another explanation.

Diffuse hair loss or hair loss throughout the head can be due to thyroid disease, systemic disease, anorexia nervosa, low ferritin levels and drugs. (8) therefore, if your daughter’s hair thinning is dramatic or doesn’t improve, it would be a good idea to have her checked by her Primary Care Physician. Your doctor will be able to determine if your daughter’s hair changes are due to thinning or from patches of hair that are missing and guide you accordingly.

Children complain or muscle aches for a multitude of reasons. Muscle aches many times accompany an illness or can be a sign of injury or overuse. A child with persistent leg pain associated with fevers presents a particular concern. Children are susceptible to developing Osteomyelitis or a bone infection.(9) Osteomyelitis occurs when germs or microorganisms from the blood deposit into the bone.(9) Children with leg pain and fevers need to be evaluated and Osteomyelitis should be ruled out. Other concerning signs include leg pain that involves a joint, limping, increase in pain intensity and persistence of pain despite palliative treatment. Children with these symptoms should also be evaluated by their Physician.

References:
(1)Alper B, Fox G. Acute Otitis Media. The Clinical Advisor. 2005. April:78-86.
(2)American Academy of Pediatrics/American Academy of Family Physicians Subcommittee on Management of Acute Otitis Media. Clinical practice guideline. Diagnosis and management of acute Otitis media. Pediatrics. 2004;113:1451-1456.
(3)McCormick DP. Watchful waiting in non-severe AOM: How to select cases, and does it work in young children. Session 2600 Update on treatment options for acute Otitis media. Presented at: pediatric Academic societies’ 2006 annual Meeting; April 29- May 2. San Francisco.
(4)Bell E. Acute Otitis media treatment guidelines: Are prescribers using them? Infectious Diseases in Children. 2006. August:14.
(5)Carlson L. What’s New in the Guideline? Therapeutic Spotlight. 2004. June:11-13.
(6)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:489-492.
(7) Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984: 112-113.
(8)Stephenson M. Effective Treatments available for alopecia areata, vitiligo. Infectious Diseases in Children. 2006. May:20.
(9) Bautista S, Gholve P, Pediatric Musculoskeletal Infections: Advances in Diagnosis and Management. Consultant for Pediatricians. 2006.Aug:481-494.

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

Pediatric Advice For Sick Children

Strabismus

Dear Lisa,

My 2 year old child recently had an MRI to make sure that the cause of his Strabismus was strictly the eyes and nothing more. His MRI results revealed white matter on the brain of an unknown cause that could be progressive. He was sent to the lab where blood & urine were taken to check his amino acids, organic acids, and for very long fatty chains. The amino & organic test results have all come back normal. We are just waiting for the other test. My question is, is it possible to have an abnormal MRI revealing this, but it not be anything to worry about? My son has no other medical problems besides the strabismus and has had breath holding spells when he was younger.

“Concerned Mom”

Dear “Concerned Mom”,

Strabismus is the misalignment of the eyes due to the lack of muscle coordination. (1) About 50% of all children with Strabismus have a family member with the condition. (2) Symptoms of Strabismus include difficulty seeing at close range, deviation of the eye, squinting, headache, lack of coordination, double vision, closing one eye, and head tilting. (2) The most common cause of strabismus is imbalance of the muscle alignment of the eyes. Other less common causes include retinoblastoma, loss of vision, myasthenia gravis, cataracts, infection and brain tumor.

In infancy, it is normal for infants to experience intermittent Strabismus due to the immaturity of their eye muscles. (1) This type of Strabismus is called Congenital Infantile Esotropia and is found in approximately 1 – 2% of infants. (1) These infants present with an intermittent inward deviation of one or both eyes. (1) By the age of three months normal ocular movement is usually established. (3) By six months old the infant’s symptoms should be totally resolved. An infant who displays symptoms beyond this point needs an evaluation by a Pediatric Ophthalmologist. Any child with a constant deviation, even if they are under 6 months old, also needs an evaluation by a Pediatric Ophthalmologist. (1)

Congenital Exotropia is a type of Strabismus that is less common. In this condition the eye turns away from the midline. It is usually noticed when a child is fixating on a distant object, daydreaming or fatigued. This condition tends to be associated with an underlying neurological problem such as Periventricular Leukomalacia or other neurological disorders. (1)

Early detection and treatment of Strabismus is essential to prevent Strabismus Amblyopia. (1, 2) Strabismus Amblyopia is the loss of vision in the deviating eye of a child with Strabismus. Visual loss occurs because of the body's attempt to suppress the double vision experienced by the child with Strabismus.

Some childhood disorders are associated with other conditions. When a child is diagnosed with one disorder, diagnostic testing is commonly performed in order to rule out potentially associated findings. Just because a particular condition may be associated with another disorder, does not necessarily mean that every child will develop that problem.

Without knowing your son’s diagnosis, complete history, physical findings or physically seeing your child I cannot offer you any specific information about his condition that may be helpful for you. I can only tell you that generally speaking white matter changes on an MRI of the brain can be associated with neurological conditions. In some conditions, white matter changes are associated with structural brain changes. Cognitive function can be impaired in patients with additional structural brain changes. (4) In general, cognitive function can be normal in children with isolated white matter changes. (4)

The significance of the white matter on your son’s Brain MRI can best be determined by his neurologist who reviewed the films and is familiar with his condition. It is important to remember that a child’s Neurological development with any type of neurologic anomaly can be quite variable and depends upon the extent of the malformation. (5)

Your doctors have performed a comprehensive work-up and in time will be able to give you the answers that you need. It is reassuring to know that the amino acid tests are normal so far. This type of testing typically ascertains the probability of an inborn error of metabolism or genetic syndrome. It is also good news that your son is not presently displaying any abnormal neurologic signs or developmental delays. Although waiting for test results and a diagnosis is extremely stressful, it may be helpful to concentrate on the positive findings that you know so far.

I wish you and your son well.

References:
(1)Wagner R. Understanding Strabismus in the Pediatric Patient. The Diagnosis and Treatment of Ophthalmic Abnormalities in Children: an update. Infectious Diseases In Children. 2002. May:S13-15.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:2048-2051.
(3)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:338-339.
(4)Mercuri E. Longman C. Congenital Muscular Dystrophy. Pediatric Annals. 2005. 34(7):560-568.
(5) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:652.

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

Pediatric Advice For Parents

Growing Pains

Dear Lisa,

My 10 year old son has had muscle twitches for about 1.5 months. They are only painful when he tries to stretch them out. He will be sitting there and suddenly his arm or leg will start jumping and jerking. Are these just regular growing problems or could it be more?

"Son with Muscle Twitches"

Dear "Son with Muscle Twitches",

Growing pains are pains that children experience in their extremities. The pains typically occur in the calves or the shins of both legs and do not include any joints. Commonly the pains occur at night and may even wake a child from his sleep. By the next morning the pain disappears and the child walks, runs and plays normally as if nothing ever happened.

Growing pains are more common in the 3 to 5 year and in 8 to 12 year age groups. (1) Upon inspection of the legs or extremity there should be no abnormal findings; no bruising, no swelling and no deformity. The exact cause of growing pains is unknown but they are thought to be caused by swelling of the muscle bodies within the tight fascial sheaths during periods of activity or overuse. (1) The treatment for growing pains is heat, massage and Acetaminophen (Tylenol). (1)

From the description you gave about your son’s symptoms it does not seem that he is experiencing growing pains. There is no involuntary jumping, twitching or jerking involved with growing pains. It may be possible though, that your son has a growing pain and then moves his leg back and forth voluntarily in response to the pain. If your son is having movements which are out of his control, then the symptoms are not due to growing pains.

Fibromyositis on the other hand can cause local muscle spasms or twitching. Fibromyositis is characterized by pain, tenderness and stiffness in the joints, muscles or surrounding structures. When the thigh is involved it is called a “Charleyhorse”. A Charleyhorse is caused by bruising and tearing of the muscles fibers resulting in a collection of blood. (2)

The pain usually has a sudden onset, is aggravated by motion and muscle spasms are noted. The symptoms disappear with rest, heat and massage. Occasionally Charliehorses can become chronic or recur at frequent intervals. (2) The symptoms you described may be consistent with a Charleyhorse. You stated that your son has muscle twitches and then has pain when he tries to stretch it out. Charleyhorses tend to cause pain with movement.

Tetany is another health condition that causes muscle twitches, spasms and may also cause convulsions. Tetany is caused by a calcium deficiency. The Parathyroid gland is located in the neck and is attached to the thyroid gland. This gland is responsible for the balance of calcium in the body. Children who have had surgery on the thyroid gland, have Parathyroid disease, infection or injury can develop Hypoparathyroidism which causes calcium deficiency. (2) Tetany is not common in childhood, but should be strongly considered if your child has had an operation or injury to his neck or thyroid gland.

Without physically examining your child and witnessing the events it is not possible to determine the cause of your son’s symptoms. The best way to diagnose your son is to have him evaluated by his Primary Care Physician. I recommend keeping a diary of the events, writing down the time and duration of the twitching and pain, the part of the body that is affected, the pain severity, any associated symptoms and what measures relieved the episode. It would also be beneficial to make a video recording of the episode so that your Doctor can witness the event in case it does not occur in the office.

It is important that you seek medical attention because it is not normal for a child’s extremities to involuntarily jump and jerk.

References:
(1)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:566,572.
(2)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984: 219, 416.


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

Pediatric Advice Website -Updated Daily

Sports Injury

Dear Lisa,

I have an eight year old daughter who has begun to love swimming for her swim team. She swims year round and it is hard to get her out of the pool. Recently she has complained of popping and slight pain in her elbow when swimming free and back and knee popping when swimming breast. Is this just a growing thing or should I be concerned. Are there exercises she can do to strengthen these areas?

“Daughter on the Swim Team”

Dear “Daughter on the Swim Team”,

Younger children normally are flexible with the movement of their joints. As children mature they naturally lose this flexibility and their muscular strength increases. (1) Because they are so flexible, children may be able to move their joints in such a manner that it makes a popping sound.

Some children have loose ligaments which also lends itself to popping of the extremity with movement. If the ligaments are too loose and the child has too much laxity, a joint may be subject to injury due to the inadequacy of the supporting structures around bone and muscle. (1) Therefore if you notice popping sounds and/or joint instability it is a good idea to have it evaluated by a Health Care Professional.

In some children, maturity alone is all that is needed to alleviate the symptoms. In others stretching, muscle strengthening exercises or both are needed to rectify the situation. (1) Your daughter’s Primary Care Physician will be able to asses your daughter’s musculoskeletal condition, strength, flexibility and joint stability and determine if she needs further intervention. A referral to a Pediatric Orthopedic Specialist or Physical Therapist for an evaluation may be necessary. In some cases the expertise of a Sports Medicine Doctor is indicated when a child encounters musculoskeletal injuries or complaints during their sport. (1)

What starts out as normal movements in a flexible child can turn into a habit. Some children discover that their body can move in such a manner and continue to force the movement to occur out of habit. You may want to observe your daughter to see if the popping occurs as a result of her purposeful movements, or if the frequency increases during a specific activity or stress. This would be important information to relate to your daughter’s Doctor. It would also be a good idea to ask your daughter if she has control of her movements. If she does you should reinforce the need to stop this activity.

It is wonderful that your daughter has developed such a great interest in a sport. Her continued participation not only will benefit her physically, but the lessons of Camaraderie and working in a team will be carried with her for the rest of her life. As with any sport, it is important to always follow measures that prevent injuries. These measures include; proper warm-up, stretching, conditioning, appropriate protective equipment that is the right size for the athlete and participation at the appropriate level. (2)

By following these measures, keeping open communication with your daughter’s coach and maintaining yearly physical examinations by your Primary Care Physician you can ensure that your daughter experiences a healthy and safe sports environment. Some parents prefer not to have their child participate in organized sports because they are fearful that they will get hurt. It is reassuring to know that statistics show that children younger than 10 years old sustain more fractures and catastrophic injuries in recreational activities than they do in organized sports. (2)

Good luck on the Swim Team!

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. 1990:140.
(2)Setphenson M. Pediatricians play an important role in sports injury prevention, treatment. Infectious Disease in Children. 2006. May:46.


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

Pediatric Advice About Keeping Kids Healthy

Infant with Diarrhea

Dear Lisa,

My daughter is 12 weeks old and has went from one stool a day to many. She was on antibiodics...Zithromax and Flagyl in the last month. Her poops sometimes have mucus in them and she is going up to 10 times a day. I was told to change her formula from Good Start to Nutramigen. She has become extremely irritable since switching her? She used to sleep though the night and is waking up again. Fussy all day long and never used to be.

“Help! Any Suggestions?”

Dear “Help! Any Suggestions?”,

It is very concerning when an infant has such a marked increase in the amount of stools per day, especially when the stool contains mucus. Since your baby’s bowel movement and feeding pattern were previously normal, it would be important to have an evaluation by your Doctor to determine the cause. A common cause for a change in stool pattern as you described can be due to a virus or infection. It is also reasonable to consider your daughter’s antibiotic use as a potential factor. Although Antibiotics are necessary to treat infections, unfortunately they do not come without side effects.

Everyone has intestinal flora or normal germs in their gastrointestinal (GI) tract. These germs serve to fight other microorganisms that enter the GI tract and prevent the new germs from causing an infection. When a patient receives antibiotics, the antibiotics alter the flora in the GI tract by killing the normal flora which is meant to be protective. (1) This makes the patient more susceptible to the invasion or overgrowth of other germs which can lead to infection. Therefore, when a child develops a change in stool pattern after antibiotic use, this alteration in the child’s intestinal flora should be considered.

In treating an infant’s diarrhea, Doctors and Nurse Practitioners may recommend temporarily switching the infant’s formula. Formulas such as Nutramigen are chosen because they are easier to tolerate. The milk proteins are chopped into smaller pieces which makes the formula easier to digest. In some cases a rice based diarrhea formula or soy based formula may be recommended because they tend to bind the stool and slow down the diarrhea. Mothers who are breastfeeding are recommended to continue to do so because the components in breast milk protect the baby.

Lactoferrin, a potent bacteriostatic is abundant in breast milk. This in combination with other antibodies and anti-infective enzymes, found in breast milk helps to destroy the pathogens that cause diarrhea. (2) Lactobacillus bifidus is also naturally present in breast milk. It promotes the growth of beneficial bacteria in the gut and discourages growth of other germs.(2)

Some Health Care Practitioners recommend that children with a diarrhea illness take Probiotics such as Lactobacillus. This recommendation is based on the information from a multitude of studies that show the benefit of supplementing a child’s diet with Probiotics for the treatment of diarrhea.(3) A meta-analysis of nine randomized , controlled studies demonstrated that Lactobacillus is safe and effective in the treatment of children with acute infectious diarrhea, much of which was due to rotavirus.(4)

Because of this evidence that Probiotics are beneficial, scientists are in the process of creating a drink for children who suffer from diarrhea. In order to duplicate the effects of the protective enzymes found in breast milk, scientists have added Lactoferrin and Lysozyme to an oral electrolyte solution. Their research thus far has shown that this new formulation significantly reduced the duration of diarrhea and also reduced the rate of recurrence of diarrhea in children.(5)

Although this information about Probiotics is very promising, it is important to use caution when giving a child Probiotics. The current products on the market today are not approved by the U.S. Food and Drug Administration, which means they are not regulated. Since the manufacturing and labeling is not regulated, a product purchased may not have the ingredients as labeled. In a British study of 13 Probiotic brands, only two contained the ingredients as labeled and the other 11 brands did not contain the listed Lactobacillus acidophilus ingredient, contained extra species, lacked a listed species or included ingredients less than 0ne-tenth of those advertised.(6) Therefore it is important to follow your Doctor’s recommendations regarding Probiotic use.

The Gastrointestinal specialists that I worked with commonly prescribed Probiotics for children with diarrhea. In some cases they recommended them for younger infants if the situation warranted. Even though Priobiotics are considered a good treatment for diarrhea in children, it is important to remember that their long term safety is not known. In addition, Probiotics should not be given to children with diseases that alter their immune system. There have been case reports of immunocompromised children who took Probiotics and became ill with a blood infection.(3)

In regards to your daughter’s condition it is important to have repeat follow up visits with your Doctor in order to monitor her condition. If her symptoms continue, your doctor may need to assess her for dehydration, an electrolyte imbalance or weight loss. In addition, changes in her diet or laboratory testing may be required. In some cases Doctors may order stool cultures, urine testing or bloodwork in order to determine if she has dehydration or an infection. During the follow-up visit it is a good time to discuss the possible effect that the antibiotics may have had on her condition and your Doctor’s opinion of Probiotics.

If your daughter has a fever, vomiting, listlessness, feeding difficulties, is inconsolable, has excessively foul smelling bowel movements, a dry mouth, a sunken soft spot, lacks tears, decreased urine output, blood in her stool, signs of abdominal pain or increased frequency in her bowel movements it would be important to see your doctor without delay.

I hope your daughter has a quick resolution to her symptoms and is back to herself soon.

References:
(1)Rosenthal M. C. difficile is more virulent, more resistant and affecting younger, healthier patients. Infectious Disease in Children. 2006. Aug:35.
(2)Riordan J. A Practical Guide to Breastfeeding. St. Louis Missouri: The C.V. Mosby Company. 1983:36.
(3)Zangwill K. Protecting against rotavirus disease and its complications. Infectious Diseases in Children. The Management and Prevention of Rotavirus. 2006. March:S9-13.
(4)VanNiel CW, Feudtner C, Garrison MM, Christakis DA. Lactobacillus therapy for acute infectious diarrhea in children: a meta-analysis. Pediatrics. 2002.109(4):678-684.
(5)Zavalet N. Abstract #3855.2 Presented at: The Pediatric Academic Societies' Annual Meeting; 2006:San Fransicisco.
(6)Hamilton-Miller JMT, Shah S, Smith CT. “Probiotic” remedies are not what they seem. BMJ. 1996;312:44-60.

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

Pediatric Advice for Infants

Enlarged Testicle

Dear Lisa,

Why would a 3 year old have an enlarged testicle?

“Three year old with an enlarged testicle”

Dear “Three year old with an enlarged testicle”,

A child’s testicle could appear enlarged for a few reasons. A child with Cryptorchidism, can present with the appearance of one testicle being enlarged. Cryptorchidism is the absence of a testicle from the scrotal sac. Therefore the side of the sac that has a testicle would appear larger than the side of the sac without one. Cryptorchidism occurs when a boy has an Undescended testicle or Retractile testes.

An Undescended testicle occurs when the descent of the testicle from the abdomen to the scrotal sac does not occur. A delay in the descent of the testicle from the abdomen can occur in up to 4% of full term newborns and in up to 30 % of premature males. (1) Within the first few months of life about 80% of all undescended testes will be in the scrotum. (1) Spontaneous descent does not usually occur after one year of age. (2). If a testicle does not descend within this time frame medical intervention is indicated.

A testicle may not be able to descend because of a mechanical barrier such as a short spermatic cord or a narrow inguinal canal. Adhesions or fibrous bands may also prevent a testicle from descending. (1,2) In some cases the descent of the testes is diverted to another area in the perineum or femoral area.

Cryptorchidism can also occur due to Retractile testes. Retractile testes can be felt at any level along the line of decent and can be manipulated into the bottom of the scrotum. (1,2) These testes are usually descended, but are pulled back up due to a hyperactive cremasteric reflex. The testes are retracted into the upper part of the scrotum in response to cold, pain, fear or touch.

The appearance of an enlarged testicle may also be due to a Hydrocele or Inguinal hernia. A Hydrocele is a non-tender, fluid filled mass in the scrotal sac. (3) Before a baby is born the testes travel from the abdomen down into the scrotum. The testes descend through a special sac of peritoneal tissue called the processus vaginalis. Once the testes reach the scrotum this sac naturally closes. Freqeuntly at birth some residual peritoneal fluid is left in the scrotal sac after closure of the processus vaginalis. A Hydrocele is the accumulation of this peritoneal fluid in the scrotal sac. The fluid gradually absorbs during the first year of life.

A Hydrocele in a child with a closed processus vaginalis is called a Non-communicating Hydrocele. Non-communicating Hydroceles are full, fluctuant and tense. If a beam of light is directed from behind the scrotum in a dark room, the testicle will transilluminate. This means the light appears as a red glow with clear fluid. No blood or tissue should be seen. (4)

A Communicating Hydrocele occurs when the process vaginalis does not close. If this is the case, fluid in the scrotal sac is not noticed until some time after birth. In this type of Hydrocele, the scrotum appears flat in the morning and increases in size as the day goes on. (4) Since there is an opening between the scrotal cavity and the abdominal cavity communicating hydroceles are frequently associated with Inguinal Hernias. (4)

An Inguinal Hernia occurs when the abdominal contents descend down through the patent process vaginalis and into the scrotum. Inguinal Hernias occur most often during the first 10 months of life. (1) They are painless and tend to increase in size when a baby cries or coughs. (1)

On the other hand an acute onset of painful scrotal swelling may be a sign of a more serious health problem such as epididymitis, acute orchitis , torsion of the spermatic cord or a strangulated inguinal hernia. (3) These conditions require immediate medical attention. If a hernia becomes strangulated or incarcerated the child experiences colicky abdominal pain and the scrotal area becomes more swollen and reddened. When an incarcerated hernia occurs the hernia is not able to be reduced which means that the contents cannot easily slide out of the scrotum and back into the abdomen. (2)

If you notice that your three year old has an enlarged testicle, he should be evaluated by your Doctor so that the proper diagnosis and treatment plan be instituted. Signs such as redness, pain, abdominal pain, increased swelling or limp are concerning. If your son’s scrotal swelling is an acute problem, especially if it is associated with pain or an illness, you should visit your Doctor without delay in order to rule out a more serious condition.

References:
(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:828,790.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1520,1459.
(3)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:380, 376.
(4)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:473-474.

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

Pediatric Advice Updated Daily

Baby with Cold Symptoms

Dear Lisa,

I HAVE A 5 MO OLD SHE HAS RUNNY NOSE, A LITTLE COUGHING, CONGESTED CHEST, SHE JUST STARTED YESTERDAY, NO FEVER, SHE GOT ME SICK TOO. WHAT CAN I GIVE HER OR DO TO MAKE HER FEEL BETTER, CAN I TAKE COLD MEDICINE IF I AM BREASTFEEDING?

“BABY HAS A COLD”

Dear “BABY HAS A COLD”,

The treatment for an infant with an upper respiratory infection is a cool mist vaporizer. (1) The cool mist loosens nasal secretions and shrinks the swelling of the tiny nasal passages. The administration of saline nose drops also loosens nasal secretions. If your baby has a lot of thick nasal discharge, you may need to suction it out of the nostrils with a nasal aspirator or bulb syringe.

When using a nasal aspirator, first support your baby’s head and neck with one hand. Next instill one to two drops of saline into your baby’s nostril. Then deflate the bulb portion of the nasal aspirator by depressing it with your thumb. You should do this before you put the nasal aspirator into your child’s nostril. Once the bulb is deflated, then put the tip of the nasal aspirator into your baby’s nostril. Quickly remove your thumb from the bulb. The suction created will remove the nasal secretions from your baby’s nasal passages.

Since the nasal passages of a baby are sensitive, it is not a good idea to use the bulb syringe too often. The nasal aspirator should be used when you can actually see nasal secretions occluding the opening. A good time to use it is when the baby wakes in the morning, before a feeding or before bedtime. If you use the bulb syringe too often it can irritate the nasal passages.

Over the counter cough and cold preparations are not recommended for infants, especially when they are under 6 months old. (2,3,4) The reason why they are not recommended is because there is no research data that supports their effectiveness. (2,5 ) In addition, cough medications can have serious side effects in children. (2) In particular cough preparations containing codeine or dextromethorphan are not recommended in young children because of their potential to cause breathing difficulties or respiratory arrest. (2,3,4)

It is not a good idea to supress an infant's cough. A cough is a protective mechanism that protects the airway. When an infant coughs, it helps thin secretions and clear them from the airway. By masking a cough you may be falsely reassured that your baby’s condition is improving when he is not. A worsening cough is a sign that a baby needs to be evaluated by a health care professional.

Instead, it is important to monitor your daughter's symptoms. Watch for vomiting with coughing, increased frequency of coughing, rapid breathing, increased work of breathing, listlessness, fever, difficulty with feedings, retractions (the skin over the ribs suck in during breathing), grunting, pale color or irritability. These signs may represent a condition more serious than the common cold and warrant an evaluation by your baby’s Doctor or Nurse Pactitioner.

Yes, women who are breastfeeding do take medications that are necessary. Most medications taken by nursing mothers are found in some degree in breast milk. After the first couple of weeks of life, a full term infant is able to metabolize and excrete drugs. (6) These processes develop much later in infants who were born prematurely.

It is important to remember that most of the information about drugs used by nursing mothers is from anecdotal reports or stories told by those mothers who used the drug while breastfeeding. The information is not based on actual clinical research performed on nursing mothers. There are obvious reasons why this type of research has its limitations. Therefore it is important to measure the risk benefit ratio when considering taking medications while nursing.

The first step is to establish the need for a medication during breastfeeding. Certainly there are mothers with chronic medical conditions that need to take certain medications because without them their health would fail. In other situations, it is a good idea to try natural measures first and resort to medications only if they are necessary.

Some natural measures to treat cold symptoms include gargling with warm salty water, drinking extra fluids which will help loosen respiratory secretions and drinking sugar and lemon drinks which can help soothe the throat. (2) Other helpful measures include irrigating your nasal passages with saline, using steam to treat nasal congestion and sinus pressure and using lozenges and menthol cough drops to soothe an itchy sore throat and reduces cough sensitivity. (2) In addition, the heat from chicken soup and hot tea serves to soothe a sore throat and loosen nasal secretions.

If these natural remedies do not help alleviate your symptoms, an evaluation by your Doctor may be necessary. More serious conditions such as a sinus infection, throat infection or pneumonia may need to be ruled out.

Many over the counter cough and cold preparations contain ingredients that can make your baby irritable or drowsy. Another common side effect of these medications is reduction in the mother’s milk supply. (6) For this reason, these medications are avoided if possible. On the other hand, Acetaminophen (Tylenol) use in breastfeeding women is considered relatively safe. (6)

When both a mother and baby are sick, it is a good time to recruit help from other family members and freinds. Don’t hesitate to ask people for assistance because a helping hand can make a world of a difference. Getting rest can help you regain the strength that is necessary for you to get better.

I hope both you and your baby are feeling better soon.

References:
(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 699.
(2)Pediatric Update. Chronic Cough in Children: New Guidelines Offer New Direction. 2006. Apr:251-256.
(3)Chang AB, Glomb WB. Guidelines for evaluation chronic cough in pediatrics. ACCP evidence-based clinical practice guidelines. Chest 2006;129:260S-283S.
(4) Stephenson M. Be aware of the myriad conditions that trigger chronic cough in children. Infectious Diseases in Children. 2006. March:38.
(5)Taylor JA. Efficacy of cough suppressants in children. J Pediatr. 1993;122:799-802.
(6)Riordan J. A Practical Guide to Breastfeeding. St. Louis Missouri: The C.V. Mosby Company. 1983:138-140.

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

Pediatric Advice Updated Daily

Headaches

Dear Lisa,

My 3 year old son has been suffering from head pain and visual disturbance for about the past 2 months. These "episodes" happen every day up to 6 times a day and last about 5 minutes or so. He complains that his head hurts and that he is "blind". He asks for a washcloth to rub his eyes while he is experiencing the pain. He rubs his forehead, however, favors the right side (temple) and eye. He has had a CAT scan and EEG and an MRI. The CAT scan & EEG appeared normal. The MRI showed increased white matter on the right side of the brain, but I was told that this would not be the cause of his head pain and vision disturbances.

I have now been instructed to have him seen by a psychologist to find out what "stresses" could be causing his symptoms. I'm not sure if I should get a second opinion from a pediatric headache doctor or a more thorough eye exam? I just know my son is not an attention seeker and I firmly believe he is truly having head pain and vision problems. He will rub his head and eyes several times a day everyday, even when he doesn't know I am even looking. I have been reading a little bit on cluster headaches, and thought it might be possible he is having these. What would you suggest I do to look into this further? I am worried every day.

Dear “Worried Mom”,

Your son has had a quite extensive evaluation for his headaches and visual disturbance. The good news is that his MRI and CT scan of the brain is normal which rules out a brain tumor or mass which is most parent’s greatest fear. You did not mention if he had an evaluation by your Primary Care Physician or screening blood work performed.

It would be important to see your son’s Pediatrician for his headaches if you haven’t done this yet. Sometimes headaches are caused by other health conditions outside of the neurologic system. For example cervical spine abnormalities, vascular malformations, medication side effects, dental abnormalities, sinusitis and tick born illnesses can all cause headaches. (1, 2) You did not mention any medication, over the counter products or herbal supplements that your child is taking. In some cases headaches in children can be due to a side effect of a medication or supplement.

A complete evaluation by your son’s Primary Care Physician can review these issues and rule out these conditions as possible causes of your son’s headaches. Assuming that the evaluation by your Pediatrician and blood work was normal, at this point it would be a good idea to see both a Pediatric Ophthalmologist and a Pediatric Neurologist who specializes in headaches.

A Pediatric Ophthalmologist can evaluate your son’s vision, and eye structures, including the retina. In some cases a Retina specialist or Neuroophthalmologist may also be consulted in order to get to the root of a child’s visual disturbance. A second opinion with a pediatric Neurologist who specializes in headaches will be able diagnose the type of headaches that your son has.

Before seeing a specialist it would be a good idea to record your son’s symptoms in a Headache Diary. The Headache Diary should include specific information about the headache such as; the time of day that the headache occurs, the part of the head that hurts, the duration of the pain, the intensity of the pain, a description of the pain (throbbing, sharp), diet, activity, factors that aggravate the headache, accompanying symptoms and location where headache occurred (i.e. sunny room). Knowing this information, your doctors will be able to pinpoint the type of headache that your child is having, determine its cause and subsequent course of treatment. (3,4)

In regards to your question about Cluster headaches, they tend to occur in the adult population. The average age of patients diagnosed with Cluster Headaches is 27 to 31 years old. (5) This type of headache is rarely seen in children less than 10 years old. (3)

Cluster headaches are headaches that occur once to several times per day over the period of several weeks to months. (3) There are headache free periods between the Cluster headaches. The pain is throbbing, severe and unilateral or occurring on one side. Cluster headaches are associated with nasal congestion, a red eye and tearing or the eye. (3). The pain typically lasts 30 minutes to an hour and can occur any time of day. The cause of cluster headaches is unknown, but can be precipitated by alcohol consumption, exercise, hot baths, elevated environmental temperature during an attack period.

The Diagnostic Criteria for Cluster headaches developed by the International Headache Society includes:

At least five headache attacks meeting two criteria:
1. Severe unilateral pain (pain on one side of the head) lasting 15 to 180 minutes
The presence one or more of the following:
a. restlessness
b. conjunctival injection (red eye), tearing, nasal congestion, runny nose, eyelid swelling, sweating, miosis (constriction of the pupils), ptosis (drooping of the upper eyelid).
2. Attack frequency ranges from one to eight headaches per day.
3. Other disorders ruled out. (5)

From your description it doesn’t seem that your son fits the criteria for Cluster headaches. Although, a full history and physical examination performed by a Headache Specialist would be the best person to rule this out and determine the cause of your son’s headaches.

Migraines headaches are the type of headaches that are more prevalent in the pediatric population. Headache specialists agree that the majority of the pediatric patients who seek consultation for recurring, disabling headaches have Migraines. (6) The average age of onset for Migraine headaches in boys is 7.2 years old and in girls is 10.9 years old. (7) Migraine Headaches are characterized by symptoms of intense, recurrent headaches separated by pain-free intervals. They are often associated with other complaints such as nausea or vomiting. Migraine Headaches tend to be exacerbated by exertion and often resolve after vomiting or with sleep. (8) Ninety percent of the pediatric patients diagnosed with migraine headaches have at least one primary relative who also has Migraines. (6)

The main difference between Migraine Headache in adult and in children is that children tend to have shorter episodes of pain. (8) The diagnostic criteria for Migraine headaches in the pediatric population according to the International Headache Society includes:

At list five attacks with the following criteria:
1. Headache lasting 1 to 72 hours
2. Headache has at least two of the following symptoms:
a. location in the frontal or temporal areas (not the back of the head)
b.pulsing quality
c. moderate or severe pain intensity
d. aggravation by or causing avoidance of routine physical activity
3. During the headache at least one of the following:
a. nausea/vomiting
b. photophobia or photophobia
4. The headache is not attributed to another disorder. (9)

You mentioned that your son will be seeing a Psychologist in order to address any “Stressors” in his life which may be causing his symptoms. When the results of the physical examination and test results are normal it is common for Doctors to consider a psychological cause. This reflects their effort to be thorough and investigate all possible avenues. It is common for children to develop somatic complaints such as stomachache or headaches when they are under stress. Therefore investigating this area is many times necessary. Having an evaluation by a Psychologist is a sometimes a necessary step so that a psychological cause can be ruled out and other areas can be considered.

Parents usually know their child best. Parents are the ones who spend the most time caring for their child and they are the ones who know their child’s personality the best. If you believe that your son is not using his headaches to get attention and is truly experiencing pain then other causes of headaches should be investigated.

Your son is very lucky to have a mom who is so concerned about him. I hope you find the answers to all of your questions and your son is pain free soon. Keep up the good work!


References:
(1)Linder S. Understanding the Comprehensive Pediatric Headache Examination. Pediatric Annals. 2005. 34(6):442-446.
(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. 1990:480-481.
(3)Rubin D, Suecoff S, Knupp K. Headaches in Children. Pediatric Annals. 2006. 35(5):345-353.
(4)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:918-919.
(5) Alper B, Passarelli C. Cluster Headaches. The Clinical Advisor. 2006. Aug:85-86.
(6) Perlman EM. Managing migraine in children and adolescents. Prim Care. 2004;31:407-415.
(7) Lewis D, Ashwal S, Hershey A. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004;63(12):2215-2224.
(8)Unger J. Pediatric Migraine: Clinical Pearls in Diagnosis and Therapy. Consultant for Pediatricians. 2006. Sept:545-551.
(9)Olsen J. The international classification of headache disorders. Cephalagia 2004;24(Suppl 1):1-160.


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

Pediatric Advice For Parents with Sick Children

Infant Constipation

Dear Lisa,

My baby is 3months, 2 weeks old (born September 29th) and is having constipation issues. He was born a big baby (11lbs. 8oz.) so pretty much since birth we’ve given him both breast milk and formula, but I have now stopped breastfeeding. We are going on the 3rd week of no breast milk and his constipation has been an issue pretty much ever since.

We were giving him some cereal previously but we thought that was causing the constipation so we stopped and decided to wait until next month to try it again when he can have fruit too. But he’s still constipated on just formula. We’ve been giving him some remedies to help his constipation and they’re working (we’re switching on and off from #1- 2oz water mixed w/ 1 tsp brown sugar and #2- 1oz prune juice mixed w/ 1oz water). The constipation he had on cereal seemed to affect him and bother him. But the constipation since he’s been off cereal isn’t like that. He’s not really agitated by it; it doesn’t seem to hurt him. He’s still a happy smiley baby and sleeping well.

My main concern is why he’s constipated. Is it that his body/digestive system is still adjusting to switching to solely formula? He’s been on the same formula since birth; can he have an issue with the type of formula now all the sudden? He does spit up, but don’t all babies to some degree? I’m concerned that if he’s constipated now on just formula, what’s going to happen when he goes to solid foods in a couple weeks? Could his stools possibly be changing with the only formula diet, meaning less frequently and thicker? Should we just stick with what we’re doing now by trying to thin out his stool withthe remedies mentioned and wait and see?

“Need Help With Constipation!’

Dear “Need Help With Constipation!”,

If your baby is 3 weeks old, born on September 29th, then the only food that is recommended is Breast milk or formula. It is not recommended to introduce food, cereal or fruit until the child is between 4 to 6 months old. (1) The early introduction of food into an infant’s diet can lead to food allergies. (2) I would not worry that you did your baby any harm by giving food early, but from this point on, it would be important to wait until he is at least 4 months old before introducing any solids.

A babies stool pattern normally changes when there is a change in the diet. Babies that are breastfed are expected to have many stools per day for the first month or two. (3) In some cases breastfed babies can have a bowel movement after every feeding. The appearance of the stool is loose, seedy and yellowish in color. As the infant gets older the bowel movements usually slow down to one stool per day or one stool every few days. (3)

Babies that are bottle fed normally have thicker, less frequent stools. They tend to have two to four stools per day in the first month progressing to one to three stools or less per day. (3) The stool is “soft” in nature as compared to the watery stools found in breast fed babies. (3)
The changes in your baby’s stool pattern are most likely related to his dietary intake and transition to formula. In addition, some formulas tend to be more binding than others.

For example, children who ingest soy based formula tend to have thicker stools and may become constipated. Rice cereal also tends to be binding for many babies. Therefore it would be expected that an infant’s bowel movements become thicker when he ingests rice cereal or soy formula.

Just because a baby has thick, infrequent stools does not mean that there is anything wrong or that he is constipated. Constipation is defined as hard, rocklike bowel movements. (3) Frequently constipation is accompanied by straining and difficulty passing stools. Many parents of young infants misinterpret normal straining and grunting as signs of constipation. Infants normally strain and grunt with passage of stools because their abdominal musculature is not developed enough to pass stools easily. This straining does not necessarily mean that the infant is constipated. The frequency of stools also does not determine if a child is constipated or not. The frequency of stools can change in response to a diet change, according to the amount of fluid a child gets and a child’s activity level.

There are a few ways that you can prevent your child from becoming constipated. First make sure the formula is prepared correctly. When preparing baby formula it is very important to accurately follow the directions on the label. (4) If the correct proportions of water are not added to the powder and the mixture does not contain the correct amount of fluid, the baby may become constipated. In addition, many cans of baby formula appear the same. It is easy to confuse “Concentrated Formula” with the “Ready toFeed ” formula.

“Concentrated Formula” requires the addition of water in order to have the proper balance of fluids and nutrients. “Ready to Feed” formula does not require the addition of water. An error in this area can be dangerous to the child and is very easy to make since the writing on the can is typically quite small. This mistake can bring about an osmotic shift leading to dehydration and possibly renal crisis. (4) This is why is very important to follow directions carefully.

It is also very important to prepare the powdered formula with tap water as the formula company recommends. Tap water in the United States is monitored and regulated as opposed to bottled water or spring water which is not. (5) The exact components of bottled water are not known. Therefore the amount of minerals found in bottled water may be too much for an infant. For example, if the bottled water contained an increased amount of aluminum, this could lead to constipation. An excess in Magnesium can lead to diarrhea. (6) Besides the unknown levels of minerals, microorganisms can also be unknowingly present in bottled water.

Lastly, make sure your child is receiving the correct amount of formula per day and the correct amount of fluids. If a baby does not receive enough fluid in his diet, his body will compensate by holding in stool so that fluid can be taken from the stool and absorbed into the body where it is needed. Therefore, not giving enough formula can lead to constipation.

From your description, it seems that your baby is having normal bowel changes due to alterations in his dietary intake. Since he is not agitated or in pain, and his bowel movements aren’t hard balls, it would be a good idea to just monitor him at this time. It is also important to expect a decrease in the number of bowel movements per day as your son gets older. The sugar water and prune juice that you gave your son for his constipation seemed to alleviate the problem. These are both good choices for babies who are constipated. Although feeding your baby these items may no longer be necessary. You should discuss with your your son's Doctor.

Yes, it is true that many babies experience spitting up or Gastroesophageal Reflux (GER) symptoms in infancy. Evidence has shown that spitting up or Gastroesophageal Reflux may occur in up to half of all healthy infants from 0 to 3 months old. (7) As long as the spitting up is not associated with fever, excessive irritability, respiratory symptoms, abdominal distention, difficulty feeding, is not bilious and is not projectile there is no need for concern.

In regards to your son’s present diet, it would be a good idea to leave him on his present formula and let his body get used to it. It also would be important to not introduce any solids until he is older. Since your baby is a large baby, his calorie requirements are higher, so it is expected that he will drink more formula than other babies his age. If your baby’s stools become very firm, consist of hard balls, his abdomen becomes distended, he begins to vomit, becomes listless or has difficulty feeding, you should bring him to the Doctor's for an evaluation. It is also very important to check with your baby’s Doctor before making any dietary changes, especially during the first year of life.

If you are interested in reading more stories on the Pediatric Advice Website about Infant Feeding topic log on to:

The amount of formula a baby should take.

Food Allergies

References:
(1)Grassia T. Pediatricians: Discuss healthy nutrition during well child checks. Infectious Diseases in Children. 2006. Aug:54.
(2)Bassett C. What to do when Foods become allergens. The Clinical Advisor. 2005. Dec:43-47.
(3) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 291, 784.
(4)Riordan J. A Practical Guide to Breastfeeding. St. Louis Missouri: The C.V. Mosby Company. 1983:7.
(5)John Hoptins Bloomberg School of Public Health. Public Health New Center. Researchers Dispel Myth of Dioxins and Plastic Water bottles. Available at: http://www.jhsph.edu/PublicHealthNews/articles/Halden_dioxins.html. Accessed Oct 2006. (6)Brunner L, Suddarth D. Textbook of Medical-Surgical Nursing. 5th ed. Philadelphia, PA: J.B. Lippincott Company.1984:793.
(7)Hassall E. Decisions in diagnosing and managing chronic Gastroesophageal reflux disease in children. J Pediatr. 2005. 146:S3-S12.

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

Pediatric Advice About Keeping Babies Healthy

Influenza Vaccine

Dear Lisa,

Is it necessary to get my five year old the flu shot this year?

“Flu shot?”

Dear “Flu shot?”,

The Advisory Committee on Immunization Practices (ACIP) recommends annual vaccination for healthy children aged 24 to 59 months. (1,2) The ACIP also recommends that household contacts and out- of-home caregivers of children aged 6 months to 6 years receive the influenza vaccine . (1,2) Decisions made by the ACIP influence the pracitce of health care practitioners throughout the country.

Just so you know who is making this recommendation, the ACIP consists of 15 experts in fields associated with immunization. These experts have been selected by the Secretary of the U. S. Department of Health and Human Services. The ACIP provides advice and guidance to the Secretary, the Assistant Secretary for Health, and the Centers for Disease Control and Prevention (CDC) on the most effective means to prevent vaccine-preventable diseases. The overall goals of the ACIP are to provide advice which will assist the Department and the Nation in reducing the incidence of vaccine preventable diseases and to increase the safe usage of vaccines. (3)

In the United States, epidemics of influenza have been associated with an average of approximately 36,000 deaths per year during 1990—1999. (1) Between January and June 2005, 36 pediatric deaths associated with laboratory-confirmed influenza infection were reported to the CDC. (3) The interesting thing is that many of the casualties were otherwise healthy children. (4) This is why there is an interest in vaccinating all children, and not just those with chronic medical conditions.

The rates of serious illness and death from Influenza are highest among persons older than 65 years and children aged less than two years old. Children particularly at risk for developing complications from Influenza infection include those with chronic heart disease, chronic lung disease (Asthma), chronic metabolic disease (Diabetes), chronic Kidney disease, blood disorders (Sickle Cell Anemia) and immunosupression (HIV or cancer). (5) Despite the long standing CDC recommendation that call for annual influenza vaccination of children with Asthma, estimates show that only 1/3 of this high-risk population receives the vaccine.

Efforts in preventing Influenza in children and controlling flu outbreaks stem from the reports that children are more susceptible to complications and serious illness from influenza infection. These complications include respiratory and non-respiratory complications. Respiratory complications include Croup, Bronchiolitis, secondary bacterial Pneumonia, Sinusitis and Otitis media (middle ear infection). Non-respiratory complications include myositis, myocarditis, encephalitis and febrile seizures (4)

In children the symptoms of Influenza include a sudden onset of symptoms. These symptoms include high fever, headache, malaise, muscle aches, runny nose, cough, nausea, vomiting and abdominal pain. (4) Influenza is spread via respiratory secretions, by droplets from sneezing or coughing or by direct contact with articles contaminated with respiratory secretions. (4) Respiratory secretions from persons with influenza are most infectious 24 hour before the onset of symptoms and during the entire symptomatic period. (4) The best ways to prevent spread of the Influenza virus is to vaccinate and practice good hand washing. Frequent cleaning of toys and other contact surfaces should be carried out in daycare centers. (4)

In regards to your question, is it necessary for your five year old to get the flu shot this year? It is highly recommended if your child has a chronic disease or health problem that puts him at risk for complications from the flu. In addition, it would be a good idea to get the flu shot if your child is in day car or school. It is in these situations that children have a greater risk of exposure to the flu.

Basically, the flu shot is a recommendation. It is not mandatory to get the vaccine in order to attend daycare or school. So it is your decision if you want your child to receive the vaccine, knowing the complications and risk of contracting the flu at a young age. In making this decision, I recommend talking to your child’s Doctor or Nurse Practitioner. They are the ones that know your child’s history and social situation best and can discuss your child's risk.

In my practice, I frequently came across parents who preferred not to give their child the Flu vaccine. Most of these parents came to this conclusion because of their child’s low risk of contracting the Flu. Many of these children did not attend daycare or school and the primary care giver did not work outside of the home. If this is the case, I would recommend that the adult who works outside of the home get vaccinated so that they do contract the Flu from their place of employment and spread it to their family.

I hope you and your child stay well this Flu season.

References:
(1)CDC. MMWR Recommendations and Reports. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5510a1.htm?s_cid=rr5510a1_e. Accessed Oct 2006.
(2) CDC. National Immunization Program. Advisory Committee on Immunization Practices. Available at:
http://www.cdc.gov/nip/ACIP/. Accessed Oct 2006.
(3)Centers for Disease Control and Prevention. Update: Influenza activity- United States and world-wide, 2004-2005 season. MMWR.2005;54:631-634.
(4) Nield l, Kamat D. “Flu” Season: Here We Go Again…Consultant for Pediatricians. 2005. Octorber:411.
(5)Cheung M. Lieberman J. Influenza. Contemporary Pediatrics. 2002. 19(10):82-94.


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

Pediatric Advice About Keeping Kids Healthy

Breastfeeding with Strep

Dear Lisa,

Is it safe to be nursing my baby with strep throat?

“Breastfeeding with Strep”’

Dear “Breastfeeding with Strep”,

Yes, it is safe to breastfeed your baby if you have Strep Pharyngitis (Strep Throat). The anti-infective agents found in breast milk offers the newborn protection against diseases.(1) Breast milk contains macrophages, neutrophils and lymphocytes which are all different types of white blood cells that fight infections. These cells surround and destroy harmful bacteria.

Besides the anti-infective benefits of breast milk, the nutritional components provide your baby with the necessary nutrients in the correct proportions in order to promote growth and development. Although formula companies attempt to create a formula that is comparable to breast milk, the exact components of breast milk cannot be duplicated.(1) Your baby was already exposed to you before you were officially diagnosed and treated for Strep Throat. So at this point there is no reason to remove the antibodies that your baby is receiving via breastfeeding from your baby's diet.

Lastly, and just as important, breastfeeding encourages the promotion of maternal infant attachment. (1) Interruption of this attachment is not recommended unless the infant's health is at risk, or if a mother's medication intake is dangerous to the baby. These are some of the reasons that the benefits of breastfeeding your baby through your illness outweighs any risk of transmission of infection.

Strep pharyngitis is transmitted via respiratory secretions. (2) Practicing measures that prevent your child from coming into contact with your respiratory secretions will help protect your baby. These measures include, careful hand washing with warm soapy water before handling the baby’s pacifiers, teething rings or toys, before feeding your baby, before touching or cleaning your baby’s belly button and before preparing food. Other preventative measures include proper disposal of soiled tissues, not kissing baby on the face or hands, avoid putting baby’s hands in your mouth, and covering your mouth during coughing and sneezing.

The most common treatment for Strep Pharyngitis includes Amoxicillin or Penicillin. Both of these antibiotics are considered relatively safe for breastfeeding. (1) Typically once a person with Strep Pharyngitis or Strep Throat is on an antibiotic for 24 hours the risk of transmission is decreased. Close contact should be avoided until after a patient is treated with antibiotics for 24 hours. (2) This close contact includes activities which promote the exchange of respiratory secretions such as kissing, hugging, sharing of utensils and sharing food. (2)

Good luck with your new baby and I hope you are feeling better soon.

References:
(1)Riordan J. A Practical Guide to Breastfeeding. St. Louis Missouri: The C.V. Mosby Company. 1983:34-35, 28, 41-42, 141.
(2) American Academy of Pediatrics. Group A Streptococcal 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; 1997:483-491387-394.


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

Pediatric Advice For Healthy Babies

Dark Circles Under the Eyes

Dear Lisa,

My nephew's skin color just under his eyes shows purple/red. Is this normal for a boy 1 month short of his second birthday? His mother has asked her GP however she was brushed off as if this was normal. It's beginning to worry her (and the family).

“Dark Circles Under the Eyes”

Dear “Dark Circles Under the Eyes”,

It is easier to notice color changes, discolorations and rashes on children with light colored skin. The melanin in dark colored skin masks other pigments, making it difficult to identify the pallor, redness or blue discoloration that is so readily seen in light skinned people.(1) Dark circles underneath the eyes are also more apparent on children with lighter skin. If a child develops a discoloration that is significantly more noticeable than his family members with the same skin tone, then other causes should be considered.

A purple discoloration underneath the eyes not associated with a rash, dryness or crusting may be due to “Allergic Shiners”. Children with Asthma, Allergies or a Sinus infection can develop “Allergic Shiner’s or dark purple circles under the eyes. These dark circles occur due to capillary congestion in the area and have nothing to do with the amount of oxygen that a child is getting.

“Allergic Shiners’ are considered an early warning sign for children with diagnosed Asthma. It is a sign that a child’s Asthmatic condition is worsening. Allergic Shiners are frequently found before a child develops an acute exacerbation of symptoms or an Asthma attack. Parents with Asthmatic children interpret Allergic Shiners as a signal that their child’s Asthma is out of control and that initiation of an Asthma Action Plan is necessary.(2)

Symptoms of Asthma include nocturnal cough, chronic cough, recurrent wheezing, episodic wheezing/cough associated with exercise, airway obstruction in response to a trigger, problems suckling, difficulty finishing a sentence, chest wall retractions, nasal flaring, paleness or cyanosis.(3). Early warning signs of Asthma are symptoms that occur prior to the development of these Ashtma symptoms. Other early warning signs include runny nose, cough, sneezing, change in personality, tightness in the throat and scratching the neck.

Children with Allergies, Eczema, a history of RSV in infancy, exposure to cigarette smoke or a history of recurrent wheezing have a greater chance of developing Asthma. (4,5,6) Major factors that predict the probability that a school age child will develop persistent Asthma include a personal history of Eczema and a parental history of Asthma.(7)

Children with Hay fever or Allergic rhinitis may also develop Allergic Shiners as one of their symptoms.(8) Other symptoms of Allergies include sneezing, itching, runny nose, nasal congestion, headaches, nocturnal cough, nasal itching, nasal rubbing, allergic salute, nasal crease, itchy throat, red eyes, watery eyes, irritability, reduced school performance, fatigue and loss of sleep. (9) Allergic rhinitis is often overlooked and under-treated because it is frequently mistaken for the common cold or recurrent upper respiratory tract infections.(9)

Children with Allergies have a greater risk of developing Sinusitis and recurrent ear infections.(10,11) Sinusitis is the inflammation of the lining of the nasal sinuses.(12) Sinusitis may present with symptoms similar to Allergic rhinitis. The symptoms of Sinusitis include cold symptoms for more than 7 to 10 days, increasing severity of cold symptoms after 5 to 7 days, fatigue, cough, fever, headaches, nasal congestion, eye pain, facial pain, toothache, foul tasting post-nasal drip, loss of sense of smell or taste, bad breath and learning difficulties at school (12,13) The interesting thing is that almost 50% of children with chronic sinusitis have positive skin test to environmental allergens. (13,14)

It is important to remember that skin conditions cannot be diagnosed without having your health care provider actually see and feel the affected area. I can’t tell you how many times I spoke to a parent on the telephone about their child’s rash and when the the child was seen in the office for an evaluation, the condition appeared totally different from what the parent described. This occurs because rashes may change over time and because rashes can be altered due to scratching or the application of medication or crèmes. The interpretation of a rash may vary depending upon the different experience levels of the person evaluating the rash.

It is essential that a Physician or Nurse Practitioner examine your nephew in order to come up with the proper diagnosis. It is important to note that “Allergic Shiners” are many times better appreciated by an Allergist or Pulmonologist who specializes in Asthma and Allergies in children. The education and experience that these specialists receive better prepares them to identify subtle changes found in children with Asthma and Allergies.

If your nephew already has Asthma, the changes around his eyes may be due to an exacerbation of this condition. If this is the case, it would be important to look for signs which show that his Asthma is out of control and report them to his doctor. Signs that a child’s Asthma is not under control include the need for rescue medication (Albuterol) more than twice per week, respiratory symptoms that affect his activity, waking at night due to respiratory symptoms occurring two or more times per month, chronic coughing and persistent night time coughing. (15) If your nephew has not been diagnosed with Asthma, Allergies or Sinusitis and is experiencing these symptoms along with this discoloration under his eyes then he needs medical attention.

Your nephew is very lucky to have a family that is so concerned about his health. It is also refreshing to see a family that can work together and jointly care for their childrens’ health conditions. This is not always the case, because many parents are sensitive about receiving health advice from family members.

It is always important to get a parent's consent to seek information and wise to give advice only when your opinion is sought. This can be very difficult for a family member who is concerned for a child’s health and who may have a more objective view of the whole situation. A caring and helpful approach is more likely to be well received.

References:
(1)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:140.
(2)National Heart, Lung and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma. 1997. Bethesda, MD: National Institute of Health; 1997. NIH Publication 917-4051.
(3)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:265.
(4)Kumar R. The Wheezing Infant: Diagnosis and Treatment. Pediatric Annals. 2003. 32(1):30-36.
(5)Peebles RS. Viral infections, atopy and asthma: is there a causal relationship J Allergy Clin Immunol. 2004;113:S15-18.
(6)Sigurs N, Bjarnason B. Sigurbergsson F, Kjellman B, Bjorksyen B. Asthma and immunoglobulin E antibodies after respiratory syncytial virus bronchiolitis: a prospective cohort study with matched controls. Pediatrics. 1995;95:500-505.
(7)Castro-Rodriguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med. 2000;162:1403-1406.
(8)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 982.
(9)Mahr TA, Sheth K. Update on allergic rhinitis. Pediatr Rev. 2005;26:284-288.
(10)Berger WE. Allergic rhinitis in children: Diagnosis and Management Strategies. Pediatr Drugs. 2004;6:233-250.
(11)Huang S. Nasal Allergy and Sinus Infection: The Link-and Therapeutic Implications. Consultant for Pediatricians. 2006. June:345-352.
(12)Smart B. What you need to Know about Sinusitis. Asthma Magazine. 2002. Sept/Oct:38.
(13)Anon JB Otolaryngol Head Neck Surg. 2004. 130(Suppl): 1-45.
(14)Zacharisen M, Casper R. Pediatric Sinusits. . Immumol Allergy Clinics North Am. 2005;25:313-332.
(15)Hogan M, Wilson N. Asthma in the school-aged child. Pediatric Annals. 2003.32(1)20-25.


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

Pediatric Advice About Children's Health

Scarlet Fever

Dear Lisa,

My 3 year old daughter had this weird looking rash on her entire body. It looked like goose bumps. She was also very pale. She had enlarged lymph nodes on her neck. The doctor said it was probably scarlet fever and did a throat swab. She did not have strep throat, was the result. She was on antibiotics. Could it still have been scarlet fever?

Two days after we completed the meds, she started a new rash, red spots this time. I brought her in and the doctor said she had an ear infection and a cold. She is again on antibiotics. Now, we just discovered 2 small lymph nodes on the back of her neck, just below the hairline. Could these be related to the cold and infection? We have a follow-up to make sure the ear infection is gone. Meanwhile, please reassure me!

“Please reassure me”

Dear “Please reassure me”,

Scarlet Fever is caused by Group A beta-hemolytic Streptococcal infections. It presents with an abrupt onset of high fever, abdominal pain, vomiting, sore throat, headache and malaise. A fine, sandpaper-like rash occurs 12 to 48 hours later. This rash first appears under the arms, around the neck and in the groin area before it becomes generalized. The rash which is referred to as Scarlatina is caused by exotoxins produced by one of the strains of Group A Streptococcal bacteria. (1). Strep infections can also cause middle ear infections, Sinusitis, Peritonsillar abscess, Cervical Adenitis and skin infections. (1)

Although Strep is the most common cause of a Scarlatina rash, an infection with certain strains of Staphylococcus may also cause Scarlet Fever. When Scarlatina is caused by a Staph infection the rash is usually tender or painful which is not the case for Strep Scarlet Fever. (2)

The test used to determine if your child has a Strep infection is a throat culture. Health professionals use the throat culture to diagnose Strep infections because it is difficult to differentiate a viral throat infection from a Strep infection simply through visual inspection. (1, 3) The specimen is obtained from vigorous swabbing of the tonsils and the back of the throat with a cotton tipped swab. If the swab and testing is performed correctly, a symptomatic person infected with group A beta hemolytic strep will have a positive result.

False negative cultures can occur in less than 10% of symptomatic patients.(1) In other words a child could have a Strep infection and not have it show on a throat culture test in less than 10% of the time. In general, health professionals rely on the results of the throat culture and only consider a false negative if the child’s history and physical examination strongly support a Strep infection. If this is the case a Doctor or Nurse Practitioner may opt to treat a child with antibiotics. Since untreated Strep infections have potential serious complications and long term effects, this is very reasonable and many times a necessary approach.

From my experiences there have been patients that demonstrate the classic presentation of Strep and have negative Strep results. Once treated with antibiotics the Strep symptoms did go away. By no means is this the norm and in most cases the throat swab is accurate. Occasionally throat culture results may not be accurate due to improper technique or lack of patient cooperation. It is fairly common for a child to resist the throat swab and move so much that it is practically impossible to get a good specimen.

Children diagnosed with Strep may have a reoccurrence of Strep Pharyngitis shortly after completing a 10 day course of recommended oral antibiotics. Studies show that 24 % of children treated with Penicillin and 18% of those children treated with Amoxicillin are back in the clinician’s office within three weeks. (4) This may be contributed to missed dosages of medication, re-infection or medication failure. If this occurs a child should be treated with an alternative antibiotic such as a cephalosporin, amoxicillin-clavulanate or dicloxacillin. (1)

In regards to your child becoming ill again after finishing her course of antibiotics, this can sometimes happen. Children with Strep can pass the infection to someone else in the household. The child can become re-exposed and develop Strep again. It is also possible that a child develops a new infection because their body is run down.

It is expected that a child’s cervical lymph nodes (lymph nodes in the neck area) will enlarge during an infection. This reflects the body’s normal response to infections such as Strep or an inner ear infection. As long as you keep on following up with your Doctor, your daughter’s lymph nodes and infection can be monitored and adjustments to her recovery plan made if necessary.

Some of the measures that you can take to help your daughter recover include good hand washing (especially when you are exposed to her secretions) and avoiding the sharing of food, drinks or eating utensils. Refrain from kissing on the mouth when family members are sick, properly dispose tissues that come into contact with saliva or nasal discharge and keep away from other children with known Strep infections.

In addition it is important that your daughter gets the appropriate amount of sleep which ranges from 11 to 13 hours per day for her age. (5) Even though it’s difficult to feed a child when they are sick, try to give her nutritious foods such as fruit, fruit pops, 100% fruit juice, and soup with vegetables.

Your daughter is very fortunate to have a mom who is so concerned about her. Caring for your daughter during her illness, bringing her to see the Doctor, giving her the medication prescribed and keeping follow-up appointments with the Doctor takes a lot of time, patience and strength. It is this patience and strength that will help your daughter get through this illness.

I wish your daughter a speedy recovery.

For more information about topics discussed you can read the following stories on the Pediatric Advice website:

Scarlatina

Strep Throat

References:
(1)American Academy of Pediatrics. Group A Streptococcal 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; 1997:483-494.
(2)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:180.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:710.
(4)Newsline. The Clinical Advisor. 2006. Feb:17.
(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. 1990:70.


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

Pediatric Advice for Sick Children

Decreased Breast Milk Production

Dear Lisa,

I recently realized that my breast milk has decreased to less than 2 ozs per time. I pump 35 minutes. I was exclusively breastfeeding by recommendation of my doctor. No bottles used. Now my 10 month old will not take any type of milk - breast or formula from any type of sippie cup, bottle or regular cup. I'm trying to mix in with her food and nurse what I can - but she has dropped 2 lbs the past 2 months. I am feeding well balanced diet and giving Poly Vi Sol with Iron vitamin - and she is a good eater. Any ideas how to make up the missing calories and nutrients? She does not even consume 5 ozs of milk per day. Thank you!

“Worried Sick Momma”

Dear “Worried Sick Momma”,

Sometimes babies wean themselves from the breast or bottle on their own and seem to prefer solids. In other instances, a child may want to continue to breast-feed but the mother’s milk supply is diminished and the amount of milk produced does not satisfy the child. When this occurs the child usually refuses milk from a cup because they prefer to breast-feed.

A mother’s milk production can slow down for many reasons. Factors that interfere with milk let-down include hormonal problems, fatigue, excessive amounts of coffee or soft drinks high in caffeine, smoking and some drugs. (1) In many cases, a reduction of milk supply can be caused by maternal stress. A mother’s hormonal response and let-down are vulnerable to brief periods of stress. The stress can be due to either a physical cause such as pain or emotional disturbance. (1) Situations such as divorce, loss of a loved one, moving or worry over a sick child can all temporarily affect the mother’s ability to lactate for a short while. The return of milk supply is possible with continued sucking or pumping of the breasts providing that the mother is motivated to continue to breastfeed. (1)

This first step in trying to remedy the situation is to figure out the cause of your child’s decreased breast milk intake. Is your baby not interested in breastfeeding because she prefers to eat solid food? Or is she interested in breastfeeding but there just is not enough milk. If your daughter continues to give you cues that she wants to breast-feed, by pushing her face into your breast and then crying after breast feeding for only a few minutes, this would be a sign that she wants to continue to breast-feed. If this is the case, and you wish to continue breast feeding, there are a few measures that you can take to regain your milk supply.

First, determine if there are possible stressors in your life that could be affecting your milk supply. Address these issues and discuss them with a health care professional if necessary. You may also want to discuss with your doctor other factors that could be affecting your milk supply, such as your diet, any medications that you may taking or possible hormonal abnormalities.

Secondly, remove potentially disrupting factors from the feeding environment. Irritations in the area where the baby is fed may also affect a mother’s ability to breastfeed. There have been reports of mother’s who identified irritating factors in the home that caused difficulties with breastfeeding. For example, one mom discovered that barking dogs disturbed her every time she sat down to breastfeed her infant. Once the environment was changed the problem with breastfeeding went away. (1)

The next step in trying to regain your milk supply includes stimulation of your breasts. Suckling on each breast every 2 to 3 hours is the most effective means of stimulating breasts to produce milk. (1) As long as suckling occurs 8 to 10 times in a 24 hour period it is okay to spread the suckling out at night for 5 to 6 hours. You can accomplish this by bringing your baby to the breast or by using a breast pump to stimulate lactation when it is not feasible to breastfeed. Massaging of the breast before and during pumping in motions similar to a breast self exam has been shown to enhance prolactin secretion. (1) Therefore incorporating massaging into the pumping routine may help milk production.

On the other hand, if your baby is not interested in breastfeeding, turning her head away and resisting your attempts to put her to the breast, she could be trying to wean herself. If this occurs and she prefers to eat food instead, then you can adjust her diet so that she receives the proper amount of calories. In order to determine if her intake is sufficient, perform a 24 hour food diary.

The food diary should include everything that your daughter eats and drinks and the amount of calories in each item. Baby formula typically contains 20 calories per ounce. Infants require 80 to 125 Kcal per Kg of body weight per day during the first year of life. (2) If your daughter’s calorie intake falls short from what is expected you should bring the food diary into your Pediatrician’s office so that you can discuss ways to increase calories in her diet.

If your daughter needs more calories you will need to adjust her diet. A few suggestions include eliminating water intake, avoiding low fat food and adding formula to the solids that she takes. You can add formula to cereal, oatmeal, pastina, farina, mashed potatoes, vegetables and macaroni. In addition, you can choose foods that are nutritious and high in calories. 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), eggs (72 calories per medium size egg) and cheddar cheese (120 calories per ounce). Although your daughter may not like some of these foods, you can puree them and add them to her meals in order to hide the taste while adding calories at the same time.

Just remember, you should wait 3 to 5 days before introducing a new food into an infant’s diet. This time is needed to determine if there is a reaction to the new food. If two new foods are given at the same time and a child develops a reaction, you will not be able to tell which food caused the problem.(3) Also be careful to give only soft items that are cut into small pieces. Avoid foods that are round in shape or large pieces because these types of food can pose a choking hazard. (3) For example, your daughter should not eat whole olives because she can choke on them. But you can add a tablespoon of olive oil to her pasta or vegetables in order to add calories to her meals.

Whenever a child loses weight and becomes disinterested in a certain type of food it is a good idea to rule out a food sensitivity, a food intolerance or malabsorption problem. Infants with malabsorption problems tend to have difficulty gaining weight because their body is not able to properly digest a certain type of food. For example, both cow’s milk allergy and wheat intolerance , also known as Celiac Disease can lead to problems gaining weight.

Babies with a Cow’s milk allergy develop symptoms including crying, irritability, colic, feeding refusal, failure to thrive, vomiting, regurgitation, wheezing, and sleep disturbances. (4) 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.(5)

You mentioned that your baby’s symptoms began two months ago, when she 8 months old. If this happened to coincide with the introduction of new food you may want to consider the possibility of a food intolerance or malabsorption. It would be a good idea to take note of any changes in your daughter’s stool, the presence of signs of abdominal discomfort or delays in development. If your daughter is having bulky stools, greasy stools, blood or mucus with the stool, loose stools, gray stools, excessively foul smelling stools, vomiting or signs of abdominal pain you should bring this to your doctor’s attention. These symptoms may be a sign of a food sensitivity, Malabsorption or more serious health condition.

It can be very frustrating for a mother when her child doesn’t gain weight. Know that sometimes babies go through phases of refusing a certain food or drink and then go back to eating it again. In some cases the cause can be something as simple as mouth pain due to teething. It is important to follow up with your Pediatrician during this difficult time so that your daughter’s growth and development can be properly monitored and you can receive the support that you need.

I wish you and your daughter well.

For more information about topics discussed you can read related stories on the Pediatric Advice website:

Celiac Disease
Failure to Thrive

References:
(1)Riordan J. A Practical Guide to Breastfeeding. St. Louis Missouri: The C.V. Mosby Company.1983: 163, 221-289.
(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. 1990:230.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 305-306.
(4)Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapuetic Spotlight. 2005. August:4-12.
(5)Gelfond D. Fassano A. Celiac Disease in the Pediatric Population. Pediatric Annals. 2006.35:4:275-279.


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

Pediatric Advice About Infant Nutrition

Cardiac Abnormality

Dear Lisa,

What is elevated right atrial pressure in a 4 month old infant and how dangerous is it?

"Baby with elevated right atrial pressure"

Dear "Baby with elevated right atrial pressure",

The heart has four heart chambers, two atria and two ventricles. The right atrium is the upper chamber on the right side of the heart. It receives unoxygenated blood from the body via the superior vena cava and inferior vena cava. Blood from the right atrium is pumped into the right ventricle below it. The blood then flows from the right ventricle to the lungs via the pulmonary artery to get oxygen. (1) The term atrial pressure represents the pressure in the atria or upper chambers.

The two things that affect the pressure in a heart chamber is the size of the chamber and the amount of blood in the chamber. (2) The pressure of a heart chamber changes as the amount of blood in the chamber changes. Through the different phases of the heart beat, blood is moved in and out of the heart chambers. The opening and closing of the valves between the chambers and the contraction and relaxation of the heart muscle is what controls the movement of the blood through the chambers. (2) This opening and closing of the valves is controlled by normal pressure changes in each heart chamber.

The pressure in the chambers of the heart changes according to phase of the heartbeat.
When the muscle of the right atrium is relaxed or not contracting, the pressure steadily increases due to the continual flow of blood from the body into the chamber. As the ventricle stops contracting and goes into the relaxation phase, ventricular pressure drops below atrial pressure. This change in pressure causes the valve between two chambers to open and the blood from the right atrium drains into the right ventricle. When atrial pressure builds up, the right atrium contracts and sends the remaining blood rushing into the right ventricle.

Therefore elevated atrial pressure is not a diagnosis but one of the hemodynamic changes in the heart that may be normal depending upon the phase of contraction. If the right atrial pressure is consistently elevated above the pressure that is expected this may be considered abnormal. A single abnormal finding is not a diagnosis of a heart condition. Typically one abnormality in the heart affects the functioning and dynamics of the other parts of the heart. Therefore the condition and functioning of the whole heart needs to be evaluated in order to diagnose a cardiac condition.

Through Echocardiography a pediatric cardiologist can tell you the position, size and motion of the chambers of the heart, the condition of the internal structures of the heart and the pressure on each side of the heart valves. (3) This additional information along with your child’s history and physical examination is needed in order know the significance and long term effects of elevated right atrial pressure.

Increased atrial pressure is one of a group of changes that may be found in certain heart conditions, but alone is not diagnostic of a particular condition. Heart defects resulting in abnormal or insufficient functioning of the valve, a malformation of the chambers or an abnormal opening between chambers can lead to increased blood volume in the right atrium and subsequent elevated right atrial pressure.

For example, a child with Pulmonary Stenosis has a malformation of the cusps of the pulmonic valve, which controls the flow of blood from the right ventricle. If the condition is severe, the right ventricular pressure increases and thickening of the right ventricular wall occurs also known as right ventricular hypertrophy. If the right ventricular hypertrophy is severe enough, right atrial pressure can increase. (3) Upon reviewing an Echocardiogram of a child with Pulmonary Stenosis all of these findings would be noted.

A consultation with a Pediatric Cardiologist can give you the information that you need about the status of your child’s heart as well as the “danger” of these findings. It is also important to remember the cardiac defects have different levels of severity. The expertise of a Pediatric Cardiologist is needed in order to interpret Echocardiogram results, to determine the significance of any findings, discuss long term effects and answer your questions.

I wish you and your 4 month old baby well and hope you find some clarification of your child's condition.

References:
(1)Waley L, Wong D. Nursing Care of Infants and Children. 2nd ed. St. Louis Missouri:The C.V. Mosby Company.1983:1279.
(2)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:468.
(3)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company.1994: 1310,1349.


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

Advice About Pediatric Health Conditions

Vitamin B 12 Deficiency

Dear Lisa,

My husband is 47 years old and has just been diagnosed with long term B12 deficiency. He has severe symptoms including dementia. He was also just diagnosed with diabetes about 2 months later. He also has spinal cord compression in several areas of his neck and back.

My question is this. My husband was an Rh factor baby born in 1959. The doctor thought transfusion was too dangerous and thought to put him on B-12 shots until he was about 6 years old. He ate lamb chops for breakfast for that time too.

Would his Rh problem affect him today? We just found out about this problem and we’ll tell his neurologist and internal med doctor this as soon as we see them again. I am just interested to know if there is a connection here or not.

Thank you in advance for any opinion you may have.

“B 12 Deficiency in Oklahoma”

Dear “B 12 deficiency in Oklahoma”,

I am sorry to hear about your husband’s B12 deficiency, Diabetes, Dementia and spinal cord compression. As you may already know, the Vitamin B 12 is essential for normal bone marrow function and has an indirect effect on the formation of Red Blood Cells. (1,2) The Vitamin B 12 also is necessary for the formation of the amino acid methionine, the formation of folacin and for the manufacture of choline.(1,3) Deficiency in Vitamin B 12 can lead to Pernicious anemia, malfunction of the nervous system due to degeneration of axons of the spinal cord, Gastrointestinal problems and neurologic deterioration.(1,3)

Pernicious Anemia develops when the lining of the stomach fails to secrete sufficient amounts of intrinsic factor which is needed for the absorption of Vitamin B 12. This type of anemia is more common in the elderly because of their decreased amount of gastric secretion. When the body is deprived of Vitamin B 12 the bone marrow produces less Red blood cells, but the Red blood cells that are produced are larger in size. The red cells that are produced are usually immature and fragile which makes them more susceptible to being destroyed during circulation.(2) This is the process that leads to anemia.

The Vitamin B 12 can be found in liver, organ meats, milk, eggs, cheese meat, fish and soybeans(1) Vitamin B 12 is not found in vegetables and this is why Vitamin B 12 deficiency is a risk for people who follow a strict vegetarian diet. (4) In order to prevent B 12 deficiency, you should eat foods that contain Vitamin B 12. Even if an adequate amount of Vitamin B 12 is ingested from the diet, B 12 deficiency can still occur. The absorption of Vitamin B 12 is dependent upon the secretion of Hydrochloric Acid and intrinsic factor by gastric mucosa. (3) If a person has a deficit in his gastrointestinal mucosa he can develop Vitamin B 12 deficiency regardless of the type of diet that he is on.

On the other hand, the anemia that results from Rh factor has a different cause. The Rh factor occurs when a pregnant mother’s blood is Rh negative and the baby’s blood is Rh positive. If some of the fetus’s blood leaks into the mother’s blood stream, such as during an amniocentesis, an abortion or during birth, the mother’s body makes cells that attack the baby’s blood. This occurs because the mother's body identifies the baby's Red Blood cells as foreign. As a result the Rh positive baby or subsequent babies suffer due to blood hemolysis. Hemolysis is the swelling and rupture of the Red blood cells. If this occurs the baby can develop Erythroblastosis fetalis or Hemolytic Disease of the newborn.(3)

Before the vaccine RhoGAM became available in the late 1960’s Hemolytic Disease of the newborn due to Rh incompatibility occurred in 0.5% to 1% of all mature pregnancies in North America.(5) Many babies died or became seriously ill from this disease. Exchange transfusions as well as replacement transfusions saved many lives.(5) If severe Hemolytic Disease of the newborn is left untreated about 10% are expected to develop kernicterus. (5) Kernicterus is a type of encephalopathy caused by increasing bilirubin(a product of broken Red Blood cells) levels. Complete recovery is expected in most infants who do not develop kernicterus.(5)

It is very fortunate that your husband survived his Rh factor incompatibility at birth, since many babies from that era did die. In regards to your question about your husband's new diagnosis of B 12 deficiency and Rh factor at birth, it is not likely that they are related. Pernicious anemia and hemolytic Disease of the newborn fall into two separate categories of anemia. Each type of anemia has a different cause.

Your husband's Internist would be the best person to ask about the cause of his B 12 deficiency. It would also be a good idea to inquire about Pernicious Anemia and any treatments that may be needed to help his condition. Unfortunately my area of practice is limited to the pediatric population and I do not have enough experience regarding alterations in the health conditions of adults. My experience with Vitamin B12 deficiency is limited to breastfeeding infants whose mothers are on a strict vegetarian diet, or in teenagers who have insufficient Vitamin B12 intake due to their diet.(4)

The good thing is, now that B 12 deficiency has been identified, you can better understand your husband’s health problems and he can receive the treatment that he needs. I hope this information helped and I wish you and your husband well.

References:
(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 100.
(2)Waley L, Wong D. Nursing Care of Infants and Children. 2nd ed. St. Louis Missouri:The C.V. Mosby Company.1983:468,1342.
(3)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:649, 449-450.
(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:574.
(5)Jensen M, Bobak I. Maternity and Gynecologic Care. 3rd ed. St. Louis Missouri: The C.V. Mosby Co. 1985:1125-1128.


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

Advice About Pediatric Health Conditions

Toilet Training

Dear Lisa,

My 3 year old will not be potty trained. The school she attends is also trying but in a 4 hour period she will not go on the toilet but will wet her clothes up to six times. There is no increase in fluid intake. Urinalysis and cultures are negative, blood sugars are normal. She has been on low dose abx for urinary reflux for @ 2 years. Are there any other things that she should be tested for?

“Mother of Three”

Dear “Mother of Three”,

There is a broad range in age that a child is expected to potty train, from 2 years old to almost 4 years old. There are some developmental milestones that need to be reached before a child is ready to use the potty. First of all a child should have the gross and fine motor skills needed to pull down their pants and physically sit on a potty. A child with motor delays or insufficient abdominal strength, which is found in children with Cerebral Palsy, may have problems learning to toilet train. (1) A child also needs the verbal skills to communicate to their caregiver that they need to go to the bathroom. (2) A certain level of Intellectual ability or cognitive awareness is also necessary in order for a child to understand what it means to go potty and to understand what a potty is for. (2) Lastly, attention to sensation is necessary for a child to feel the sensation that they “have to go”. Children with Attention Deficit Disorder have higher rates of wetting themselves because they may not possess the concentration level or attention to sensation at a level that is needed in order to potty train. (1)

Once a child is developmentally able to potty train, a parent must then consider the child’s readiness. A child that is ready to toilet train shows interest in going on the potty, likes to watch others use the potty and shows a desire to please their parents. (3) If your child is not showing interest in these areas then an evaluation of the home and school environment may be necessary. The questions that should be explored include: Is my child refusing to make this step because she is seeking attention? Has there been a change in the family such as a new sibling or new home that is upsetting her? Is my child holding on to the diaper because she likes the individual attention that she gets during diapering? Is my child refusing to potty train because there is a fear of the toilet? These issues may need to be addressed, before potty training can be mastered. If this is the case, your child may need you to spend time with her to explain what is expected and to help alleviate her fears.

Other signs of readiness include a child that holds the urine for more than 1 1/2 hours, a child that wakes from a nap dry, a child who finds a special place to go and a child who is uncomfortable in a dirty diaper. (3) If a mother notices signs of readiness it is a good idea to become a little more assertive with a schedule and level of expectation. A child that falls within the normal age for potty training, and developmentally able may need a little encouragement and direction from mom.

In some cases a baby is ready to potty train but the caretakers are not. To some mothers potty training “the baby of the family” is a sign that their child is growing up and the end of the baby years. To many mothers this transition may be difficult to accept. In other cases, moms with experience realize how much time and energy is takes to potty train a child. Potty training may be put off because of other household commitments or commitments outside of the home that would interfere with the process. Not only does a child need to be ready, but a Mom needs to be ready to potty train too. It is better for a child to potty train when they are ready because it will prevent them from becoming confused or developing habits that will be hard to break when they are older.

For families that are ready to potty train there are a few steps that can be taken to help the process run more smoothly. The first step is to help your child become aware of the sensation that she has to go to the bathroom. The best way to do this is to discontinue the use of diapers or Pull-ups and put underwear on your child. Underwear does not absorb moisture and will keep the cold wet feeling of urine and stool close to the skin. This way the child will associate a negative sensation with going to the bathroom in their pants. This negative feeling will encourage the child to use the potty in order to feel warm, comfortable and dry. If a child continues to wear diapers they will not experience this discomfort because the diaper absorbs the moisture and keeps the urine and stool away from the skin. A child wearing a diaper has no incentive to stop playing to go on the potty if they can just go in their diaper and stay comfortable.

When a child wearing underwear has an accident it is more noticeable to the caregiver, who should interrupt the child’s play and make her get changed when she soils. This is especially helpful in a child who has difficulty sensing the need to use the toilet. If the caregiver brings it to the child’s attention right away, the child will learn to pay attention to the wetness or coldness of the underwear. The child will learn that they will have to stop playing anyway and that it is quicker and easier to use the potty then clean and change into new clothes.

It is also a good idea to pick up on the gestures and cues that a child displays when a child needs to go to the bathroom. When a caregiver notices these clues of wiggling, sitting in the chair differently, rocking back and forth or touching the private area she can bring it to the child’s attention. The child should stop what she is doing and sit on the toilet. By brining these cues to the child’s attention it teaches them to become more in tuned to their body and its feelings. This is sometimes difficult in a daycare setting when a caregiver doesn’t have the time to give one child individual attention. This may better be accomplished in the home setting during a vacation or with the help of a relative or friend if the mom has to work.

In addition to picking up on early cues and putting a child in underwear, a child should be put on a bathroom schedule. Since a child that is not potty trained is expected to urinate every 1 /12 to 2 hours, they should sit on the potty automatically every 1 /12 to 2 hours during the day. This should start in the morning when a child wakes and the child should sit whether they feel if they have to go to the bathroom or not. It is very important to praise the child for sitting, even if they do not urinate or have a stool.

Once potty training begins, it takes a lot of time, a lot of effort and a lot of patience. It is normal for children to have accidents which can be very frustrating for the caregivers. A parent can help their child by having a “you can do it” expectant attitude, rather than a “when are you ever going to learn” attitude. A very matter of fact attitude towards potty training with the avoidance of punishment will prevent the child from using potty training as a tool to get their parent’s attention. A positive attitude will help a child who is having difficulty and will give them the encouragement that they need. (2)It is important to remember that it can take up to 6 months to potty train a child, and many times children take a few steps forward and then a step backwards.

If you have given potty training a concentrated effort and are still finding no success it would be important to evaluate what is going on when your daughter is at school. You mentioned that your daughter will not go on the toilet at school. Does the staff bring her to the bathroom every 1 ½ to 2 hours on a schedule? If she goes on the toilet at home and not at school, is there something that she is afraid of or uncomfortable with at school? Is she afraid of the toilet at school because it is different or makes noises? Or is it that she is just too busy playing that she doesn’t want to stop to go on the toilet. How does the staff handle it when she has an accident? It would be a good idea to figure out what the issue is at school by talking to the staff and your daughter. You can ask your daughter to show you how she goes to the bathroom at school by using a doll or puppet. You may get more information from her this way.

If you give your child sufficient time and she still can’t seem to master the task of potty training then other areas may need to be explored. It is a good idea to discuss your concern with your daughter’s Pediatrician. Your Doctor may want to evaluate your daughter to make sure there are no anatomical reasons or complicating factors that are contributing to her inability to control her urine and stool. Testing the urine for a urinary tract infection and the blood for diabetes is part of the work-up which was reported normal in your daughter’s case.

Other areas may also need to be investigated, such as her ability to hold her urine and her ability to sense the need to urinate. A physical examination including a complete neurological evaluation by your daughter’s pediatrician will be able to tell you if there is an issue in this area. The evaluation typically includes a visual inspection of the genital and rectal area to make sure there are no anomalies that prevent a child from controlling their bladder and or bowels. The skin on the lower back, sacrum and gluteal cleft should be inspected for signs of an occult problem. Findings such as a port wine stains, tufts of hair, congenital nevi (moles), gluteal cleft deviation(asymmetry of the but crack) or deep sacral dimples may be a sign of an underlying problem which may affect sensation. (4) In addition the Pediatrician may evaluate your child’s stooling pattern because children with constipation have more problems with controlling their urine. The hard stools can cause pain, interfere with feelings or sensation of having to void and cause the child to withhold the stool because of the fear of painful defecation. (4)

Since you mentioned that your daughter has vesicoureteral reflux (urinary reflux) she may already have seen an urologist and had testing of her kidney and her bladder. In some cases a Pediatrician may recruit the expertise of a Urologist and request further testing if a child has difficulty controlling her urine. Typical testing includes an ultrasound of the bladder. This test can tell you if your daughter’s inability to potty training is due to a problem with her bladder. A post-voiding residual volume can be checked by doing an ultrasound of the bladder. It can tell you if the bladder is large, distended and unable to be emptied or if it is very small, leading to overflow incontinence. (4) In cases where a child has persistent problems controlling her urine as well as her stool an MRI may be needed. An MRI examines the lower spine for abnormalities which may interfere with bowel and bladder control. (4)

If your daughter is approaching four years old, it is better to discuss your concerns with your pediatrician sooner rather than later. Instead of assuming that your daughter is just not ready, it is better to have her evaluated for confounding factors. Institution of behavior modification early on for dysfunctional voiding can result in the reversal of symptoms which is not necessarily the case if you wait too long. (4)

I wish you luck and your daughter success in this difficult endeavor!

References:
(1)Howard BJ. Toileting Problems of Young Children. Audio-Digest Pediatrics. 2000.46(02).
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:219-221.
(3)Rosenthal M. Suggestions to help parents change their toddler’s behavior outlined. Infectious Diseases in Children. 2006. Mar:44.
(4)Listernick R. AThirteen-Year-Old Girl with Anemia. Pediatric Annals. 2003. 32(3):139-145.

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

Pediatric Advice For Parents

Lump in the Groin

Hi,

Hope you could send me some advice on what to do about a lump on my 5 year old son's right neck, and on the right groin. He says no pain when I touched them, but concern. Seems the one in the groin is slowly getting bigger. Is there any physical risk? Any treatment?

“My Beautiful Son!”

Dear “My Beautiful Son!”,

Many parents report seeing small lumps underneath the skin on the side of their child’s neck. This tends to become more noticeable when a child turns his head. Parents also notice bumps under the skin in the groin area when they change their child’s diaper. These are the same areas that normal lymph nodes are found. Typically lymph nodes are round or oval shaped, rubbery, non-tender, painless nodules located under the skin. The size depends upon the location, but in general normal lymph nodes in the pediatric population are less than 2 cm. (1)

The lumps you are seeing on your beautiful boy may be normal lymph nodes, but the only way to be sure is to have an examination by a Physician or Nurse Practitioner. They will be able to tell you if the lumps are lymph nodes and if they are within normal limits for your child’s age.

Basically, the lymphatic system is a vascular network that drains fluid from the body tissues. The fluid is filtered through lymph nodes which serve to rid the body of old cells and toxins and make antibodies. Lymph nodes are dispersed throughout the body and only the superficial ones can be seen or felt. Superficial lymph nodes can be found in the cervical area (neck), underneath the arms and in the arms and legs. (1)

Typically lymph nodes enlarge when a child is fighting an infection. Therefore the body around the area of an enlarging lymph node should be examined. An enlarging lymph node in the inguinal area could represent a rash or an infection around the penis, lower abdomen or buttock area, or a cut or injury below the site on the child’s leg. (1) A bug bite or a tick bite in this area, is one example why an inguinal node would enlarge. Ticks tend to embed under the skin in the warmer parts of the body such as on the scalp, underneath the arms and in the groin area.

Since you noticed that the lump on your son’s right groin area is enlarging it would be a good idea to get it checked by your physician. If the lump is a lymph node your Doctor may want to check your son for an infection. In some cases the lymph node itself can become infected when it can’t filter the dead cells and toxins quick enough.

Adenitis is the term used for lymph nodes that becomes infected (2) In the pediatric population, the cervical nodes or the nodes around the neck area are the ones that tend to become infected. The symptoms of Adenitis include a red, warm and enlarging lymph node, pain and limitation of movement of the area. (2) If a child has signs of Adenitis, he should be evaluated by his physician so that the condition can be diagnosed and treated accordingly. An enlarging lymph node becomes a particular concern if a child develops a fever, weight loss, or if the node becomes painful, or hard. (1) If these symptoms occur your child should have an evaluation by his Pediatrician without delay.

Not every lump noticed on a on a child is a normal lymph node. It depends where the lump is located, the child’s state of health and other associated symptoms or physical findings. That is why it is important to have a child checked by his doctor who can inspect and evaluate the child’s whole body. A lump in the inguinal area may represent many conditions, one of these conditions being an Inguinal Hernia.

An Inguinal Hernia is the protrusion of the intestines through a defect in the abdominal wall. It presents as a bulging or protrusion of the skin in the groin area. In children most inguinal hernias are due to a congenital defect in which the hernia is detected in the scrotum. (3) During normal neonatal development the testes descend from the abdomen down to the scrotal sac. After the descent of the testes the tube should naturally close. An inguinal hernia develops when this tube remains open and the abdominal contents slide down the tract into the scrotal area. (4)

The symptoms of an inguinal hernia include a bulge in the groin area, an enlarged testicle and a dull ache. (3) Most children with reducible hernias have little or no pain at all. There have been many occasions that I discovered an inguinal hernia during a physical examination of a child and the child and parent never noticed it.

Direct hernias usually occur in the older population and are due to a weakness in the abdominal wall. This type of hernia rarely enters the scrotum and appears as a bulge in the groin area. (3) Both types of hernias become more noticeable or enlarged when a person engages in activities that increase intra-abdominal pressure such as coughing, crying constipation, straining with stools and obesity. (3, 5) If your child has symptoms that are consistent with a hernia he should be evaluated by his Physician.

I would not be alarmed about your son’s lumps because they may be normal physical findings. It would be a good idea to check the area for a rash or signs of an infection and inform your doctor about his condition. This is especially important because the lump in your son’s groin area is enlarging. An examination by your doctor can diagnose the lumps and put your mind at ease.

I wish your beautiful little boy good health and speedy resolution of these physical findings.

References:
(1) Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:438-439, 592.
(2)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984: 538.
(3)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:422.
(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1458.
(5)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:790.

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

Pediatric Advice About Keeping Kids Healthy

Immunization Reaction

Dear Lisa,

My daughter got her 4 month vaccines the other day and the next day she had hard bumps at the site of the injections. Was I supposed to rub the area after she got the vaccines? At this point I can't rub them because she cried but at least I will know for next time.

I assumed if I needed to rub it out her doctor would have told me but now I'm questioning myself. Please help!

“Bumps at the site of Injection”

Dear “Bumps at the site of Injection”,

Tenderness and swelling at the site of an injection is a common side effect from vaccine administration. (1) This reaction can occur whenever a child receives any injection, whether it be a vaccine or a medication. There is nothing that you as a parent could have done to prevent this common side effect. To answer your question, parents are not supposed to rub or massage the injection site after a vaccine is administered. In some cases a nurse may put pressure on an injection site after an injection is administered. The purpose of this is to stop the brief bleeding that normally occurs after an injection. Bleeding at an injection site is treated with gentle pressure to the area for a few minutes. (2) The best thing that a parent can do after your baby gets a shot is to pick her up and hug her!

The DPT vaccine, which is a routinely given at the 4 month visit, may cause a localized reaction. (3) Signs of a localized reaction include redness, induration or nodule formation at the injection site. (4). Many times this nodule formation can be felt under the skin for a few weeks or even months after an immunization is given. This nodule will gradually disappear on its own. (5)

In some cases redness and swelling occurs at a vaccine injection site because of a Hypersensitivity reaction or allergy to a hidden ingredient in the vaccine. Some vaccines have trace amounts of antibiotics which may cause a reaction in susceptible individuals. The Polio vaccine, which is routinely given at the 4 month visit may contain trace amounts of the antibiotics; Streptomycin, Neomycin and Polymyxin B. (2)

Some children allergic to Neomycin may experience a delayed-type, local reaction reaction 48 to 96 hours after administration of the Polio Vaccine (IPV), MMR or Varicella. The signs of this type of reaction include a raised red and itchy area on the skin. (2) This type of reaction is not a contraindication for future immunizations. Other vaccine components, such as gelatin may also cause a reaction in a sensitive child.

If your child develops signs of a hypersensitivity reaction to a vaccine, you should contact your Doctor. At the time of vaccine administration the staff at the doctor’s office documents the site of injection for each vaccine. It is a good idea to take note which vaccine was given at the site where a reaction occurs. Knowing this information, your doctor can monitor your child during future immunization administration. If your child develops a minor reaction, this does not prevent her from receiving the vaccine in the future. (2) These minor hypersensitivity reactions are commonly treated with an anti-histamine such as Benadryl.

On the other hand if a child has a history of an Anaphylactic reaction to Neomycin; Neomycin –containing vaccines should not be used. An immediate severe allergic reaction or anaphylaxis to a vaccine is a contraindication to future immunizations with that product. (2)

Serious complications of Intramuscular injections are rare. (2) Some of these rare reactions include cellulitis (skin infection), sterile abscess, bacterial abscess and skin pigmentation. Sterile abscesses or bacterial abscesses are estimated to occur once per 100,000 to 166,000 doses of DPT.(2) Signs of an abscess include redness, warmth, induration, pain, and fever. If a child develops signs of an abscess she should be evaluated by her Pediatrician so that treatment can be initiated with an antibiotic if necessary.

The description of your daughter’s symptoms sound like normal swelling that occurs after an injection. The only way to be sure what type of reaction your daughter is having is to have her evaluated by your Physician. Whenever there is a reaction to an immunization, no matter how mild, it is a good idea to contact your Pediatrician’s office so that the information can be documented.

Many times the pain reliever Tylenol is recommended to treat the discomfort from vaccine administration. I found that in most cases the discomfort subsides within 48 hours. During this time it is a good idea to watch the injection site for signs of an infection. This can be best done by keeping the site clear from bandages or band-aides. A band-aide can mask signs of an infection. This is the reason why band-aides are typically not used after giving an immunization. If a band-aide is used it should be left on the site for no more than 1 to 2 hours. (2) Signs to watch for include increased swelling at the injection site, redness that spreads, induration, warmth at the injection site, discoloration at the injection site, limitation in movement, prolonged crying or excessive irritability and fever. If any of these signs occur your child should be evaluated by your Physician.


For more information about Vaccines and the potential side effects log onto:

The Children’s Hospital of Philadelphia

References:
(1)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:403.
(2)American Academy of Pediatrics. Active and Passive Immunization. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:15,32-34.
(3)The Children’s Hospital of Philadelphia Website. A Look at each vaccine: Diphtheria, Tetanus, Pertussis Vaccines. Available at: http://www.chop.edu/consumer/jsp/division/generic.jsp?id=75701. Accessed Oct 2006.
(4) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 58.
(5)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:403.

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

Pediatric Advice About Keeping Children Healthy

Mumps

Dear Lisa,

I have a question for you. My daughter who is away at college in Pennsylvania called me and told me that she has intense jaw pain and a large cold sore on her top and bottom lips. She went to the school dispensary and they told her that she had a swollen lymph node in her neck. They just gave her Motrin and told her to come back. They also mentioned that she should have the dentist take a look to see if the problem is with her teeth. She told me she has no pain in her gums and doesn’t think that's the problem. She is going back to the dispensary today. Any idea what might be causing the pain in her jaw?

“Daughter with Jaw Pain”

Dear “Daughter with Jaw Pain”,

Jaw pain may be due to a multitude of reasons. Dental abnormalities such as gum abscess, TMJ or Wisdom Teeth eruption are some possible causes. If your daughter’s symptoms persist it would be a good idea to consult a dentist as the infirmary suggested in order to rule out these potential problems. A teenager with an upper respiratory infection or throat infection may develop swollen lymph nodes in her cervical area which can cause pain in the neck area and under the jaw line. If your daughter continues to experience symptoms it would be important to follow up with a Physician.

Swelling of the parotid gland which is located in the jaw area also causes jaw pain. When swelling of the Parotid gland or Parotitis occurs, it extends above and below the jaw bone. (1) Parotitis has many causes including infection with Parainfluenza virus, Influenza virus, Coxsackie virus, Echovirus, Lymphocytic choriomeningitis virus, HIV, immunologic disorders, side effects to medication (iodides or guanethidine) or tumor. (2) One of the most common causes of Parotitis in children and adolescence is the Mumps virus. (1)

The Mumps is caused by a Paramyxovirus and was considered a common childhood illness until the introduction of the Vaccine in l967. ( 3). In 2005, the first outbreak of the Mumps in more than 20 years began in the United States. (4) The majority of the cases occurred in the Midwest, in young adults from 18 to 25 years old. Most of them were vaccinated for the Mumps. (4) Health officials have identified the strain that is circulating in the Midwest to be the same strain that is responsible for an outbreak in the United Kingdom. (4). There have been 70,000 cases of Mumps in the United Kingdom since 2004.

More than 4,600 people contracted the Mumps this year in the Midwest area of the United States. (5) This recent outbreak primarily involved young adult college students. (5) The states involved include Iowa, South Dakota, Nebraska, Missouri, Kansas, Pennsylvania, Illinois and Wisconsin. (5) In the past, the Mumps was a concern in the late winter and early spring, but an outbreak in a camp in Upstate New York extended to the late summer months.(3,6)

The symptoms of the Mumps include swelling of the parotid salivary gland accompanied by muscle aches, decreased appetite, headache and low grade fever. (4, 7) Many times a child develops swelling of the cheeks and neck. (7) The disease is transmitted via spread of respiratory secretions or from exposure to saliva. The spread of the virus occurs through sneezing, coughing and sharing of utensils, cups and other items contaminated with saliva. (4) The symptoms typically appear two to three weeks after a person is exposed. (4)

Since your daughter has a few risk factors including her age, her residence in Pennsylvania, living on campus at a College, and jaw pain you may want to consider seeing a doctor and discussing this possibility. It would be a good idea to ask her about her recent exposures. Has her roommates or friends recently been ill with the mumps or an undiagnosed illness? Has she had close contact with someone with the Mumps or a viral illness? Unfortunately patients that contract the Mumps may not be able to identify the source. This occurs because many patients with the Mumps develop non-specific symptoms or sometimes no symptoms at all. Because of this they can spread the germ unknowingly. (7)

If your daughter’s symptoms worsen or persist, or if she develops new symptoms such as swelling around her neck, face or jaw area, muscle aches, fever or decrease appetite she should have an evaluation by a Physician. Your daughter did report cold sores in her mouth which is typical of a virus. Coxsackie virus causes lesions around the lips and may also cause Parotitis. The physician that your daughter sees will be able to exam her cold sores and rule out Mumps and or Coxsackie virus.

I hope she's feeling better soon.

References:
(1)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company.1991:592.
(2)Centers for Disease Control and Prevention. Mumps-Technical Q & A. Available at http://www.cdc.gov/nip/diseases/mumps/mumps-tech-faqa.htm. Accessed Oct 2006.
(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. 1990:474.
(4 )Brunell P. Health Officials investigate mumps outbreak. Infectious Diseases in Children. 2006. May:8.
(5)Rusk J. Mumps Outbreak in the Midwest Persists. Infectious Diseases in Children. 2006. August:9-10.
(6)Mumps Outbreak at a summer camp-New York, 2005. MMWR. 2005;55:175-177.
(7)Pediatrics Update. Mumps: Making Headline News. Consultant for Pediatricians. 2006. July:412-414.


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

Pediatric Advice About Infectious Diseases

Ear Piercing

Dear Lisa,

I am planning on bringing my 10 year old daughter to pierce her ears. When I brought my older daughter she screamed because it hurt so much. I am dreading this. Is there anything I can do to help my daughter with the pain?

“Planning to Pierce”- N.J.

Dear “Planning to Pierce”,

There is a prescription called EMLA crème which is commonly used for painful procedures in children. It is used in children for ear piercing so the child won’t feel the pain. EMLA crème is similar to the Lidocaine that the dentist rubs on your gums before dental work. This medication numbs the area and if used correctly the child will not feel pain during the procedure. You can ask your Doctor or Nurse Practitioner if your child is a candidate for EMLA crème. This medication is typically not used on infants, especially under three months old because of the risk of side effects.(1) It is intended to be used on clean, dry intact skin. EMLA crème should not be applied to skin with an open wound or a rash. (2).

It is very important to closely follow all directions when applying EMLA crème in order to prevent side effects and to make sure that the medication works properly. When applying EMLA crème, make sure the area is clean and dry. Move all hair away from the ears by using a clip or barrette. Next, apply a small dot of crème (the size of a small pea) on both sides of each ear lobe. Instruct your daughter not to touch the area. Following this, cut 2 small rectangles (one for each ear lobe) approximately ¾ inch in length by ½ inch width of plastic wrap (i.e. Saran wrap). Apply this piece of Saran Wrap on the skin, over the dots of crème so that the plastic rectangle flaps over the ear lobe and covers the front and back. One end of the rectangle should cover the front of the ear lobe and the other end of the rectangle should cover the back side of the ear lobe. The moisture from the medication will make the plastic wrap stick.

The medication should stay under occlusion for at least 60 minutes in order for it to work properly. (1,2) The depth and duration of pain relief depends upon how long the crème remains on the skin under occlusion (2) Therefore, if the medication is wiped off by accident after 20 minutes, the analgesic effect would not be as good as crème which remained on for an hour. It is important to remember that the medication will not work if the area is not under occlusion or not wrapped with plastic.

When you are ready to have your daughter’s ears pierced, remove the wrap and wipe the excess medication off with a tissue. Discard the tissue right away and wash your hands. If you get the medication on your hands at any point wash your hands immediately. It is possible to develop a headache if you accidentally touch your head with your fingers if medication is left on them. The ear lobe should stay numb for approximately 1 hour after removing the plastic.

EMLA is also commonly used for needle sticks and blood work. (1,2) If this is the case, ask your Doctor or Nurse Practitioner where to put the medication before applying the crème to a spot. You need to apply the EMLA crème the same way, but the saran wrap should be wrapped around the area (for example around the elbow) otherwise it will fall off. In some cases the prescription will come with an occlusive dressing in the shape of a rectangle. If this is the case there is no need to use saran wrap and only use the dressing provided. It is a good idea to put the EMLA crème on two sites because sometimes the first needle stick is not successful. If both sites are not used make sure you remove the medication from the unused area. If the creme is left for a longer time than recommended the medication can be absorbed into the body and lead to side effects. (2)

It is important to explain to your child how the medication works and to support her during the painful procedure. (1,2) If a child is very anxious about a painful procedure she may still cry and scream even though she doesn't feel the pain. Studies of children under 7 years old who used EMLA crème had less overall benefit. (2) Therefore the importance of education and support should not be overlooked. A mother's loving touch and encouragement is paramount and better than any medication!

EMLA crème should not be used in children who are allergic to the ingredients or in those children with the rare condition called Congenital or Idiopathic Methemoglobinemia. Children taking drugs such as acetaminophen (Tylenol), sulfa drugs, chloroquine, dapsone, nitrates, nitroglycerin, nitrofuratonin, phenobarbital, phenytoin, are also at a greater risk for developing Methemoglobinemia. (2) If you child is taking any medication make sure you discuss this with your Doctor before using the EMLA crème.

When using EMLA creme make sure you follow the directions carefully and do not apply more than is directed. There have been reports of side effects in infants whose parents applied the medication in larger doses than recommended on a large part of their body. (2)

Good luck with your new earrings!

References:
(1) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 849,866.
(2)Physician’s Desk Reference. 2004. Montville, NJ. Thomson PDR at Montville.605-608.

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

Pediatric Advice for Parents

Crying at Night

Dear Lisa,

I HAVE A 9 MONTH OLD BABY, WHEN SHE IS SLEEPING SHE WILL ALL OF A SUDDEN WAKE UP SCREAMING. I HAVE TRIED EVERYTHING TO Calm HER DOWN BUT FOR 30 MIN. TO AN HOUR SHE SCREAMS LIKE SHE IS IN PAIN. SHE BECOMES WET AND CLAMMY, I WILL GIVE HER SOME TYLENOL, WHEN SHE DOES SETTLE DOWN SHE JUST LAYS THERE LOOKING AROUND, THIS HAS BEEN GOING ON FOR ABOUT TWO WEEKS NOW. IT IS NOT EVERY TIME SHE GOES TO SLEEP, BUT EVERY NOW AND THEN. IS SHE HAVING NIGHTMARES THIS YOUNG OR COULD SOMETHING BE WRONG WITH HER?

"WAKING AT NIGHT CRYING",

Dear “WAKING AT NIGHT CRYING”,

A 9 month old who wakes at night screaming is most likely in pain. The pain could be from a multitude of sources, with ear infections being on top of the list. Children with Otitis Media (a middle ear infection) have a lot of ear pain at night and tend to wake up crying. Other signs of an inner ear infection include runny nose, nasal stuffiness, cough, pulling at the ear or fever. (1) If your daughter is exhibiting any of these signs I would be suspicious of an ear infection. An examination by your daughter’s Doctor or Nurse Practitioner can tell you if this is the problem.

Infants may also cry and wake at night because they are teething. Nine months old is a common age for teething. When a tooth is about to erupt the gums become swollen and painful. Children that are teething tend to be irritable, drool, gnaw a lot and wake at night. (2) While sleeping some babies bite down hard on their swollen gums by accident which causes a lot of pain and can wake them from their sleep. This is especially a concern when there is a new sharp tooth in the lower gum that irritates the swollen gum above. This commonly occurs since the lower central incisors (bottom middle teeth) are typically the first to erupt followed by the upper central incisors (top middle teeth). (2) You can look inside your baby’s mouth to see if the gums are red or swollen. If it is too hard to see inside your baby’s mouth, a Doctor or Nurse Practitioner can do this for you. Giving a pain medication at bedtime such as Tylenol can help a child who is teething.

Abdominal pain is also a cause of infant pain and waking at night. Nine months old is the age when new foods are typically introduced into a child’s diet. Many children are first introduced to eggs or dairy at this time. If a baby develops a sensitivity to new foods they can experience abdominal pain and in some cases vomiting. (3) Signs of abdominal pain in a baby include crying, grimacing, pulling knees up to the chest and refusal to eat. (4) In some cases the abdominal pain can be due to gas. Certain foods such as oatmeal, beans, corn and certain vegetables tend to make babies gassy. If your baby has burbing and expels a lot of gas when she wakes at night crying this may indicate that she is having difficulty adjusting to a new food.

Many times abdominal pain in children is intermittent and not continuous. In cases where a child is sensitive to a food, the symptoms may come and go if the child is not eating the offending food everyday. For a child with intermittent abdominal pain, it is a good idea to keep a food diary in order to see if there is a relation between certain foods and symptoms. Babies with abdominal pain should be evaluated by their Physician and the abdominal pain diary should be brought to the Pediatrician’s office for the evaluation. If a baby experiences signs of constant abdominal pain that are continuous or seem to be worsening, this may represent a more serious problem and your baby’s physician should be contacted.

Another cause of intermittent abdominal pain in a child is Gastroesophageal Reflux (GER). Gastroesophageal Reflux symptoms are more predominant after eating and at night. Children with GERD tend to vomit, regurgitate, arch their back, have excess hiccoughing, irritability, nasal congestion, coughing or wheezing. (5) If your baby is exhibiting any of these signs or if she has a history of GERD, this diagnosis should be considered. An evaluation by your baby’s Doctor or Nurse Practitioner can help clarify the situation.

Whenever a baby wakes suddenly crying at night it is a good idea to do a head to toe check. You want to make sure that your child is not injured. Some babies can accidentally get their arm or leg caught in a slat of the crib. It is also very important to inspect each finger and toe while the lights are on. There have been cases where a long strand of hair or string accidentally wrapped around a baby’s finger or toe and cut off the circulation. This can cause a lot of pain and if it is not detected can be very harmful.

Dreams that scare and wake a child are more predominant in older children when a child’s imagination struggles with what is real and what fantasy is. Dreams are also means of expressing anxiety or fear. (4). Developmentally at nine months old, the psyche is not developed enough to experience enough turmoil or anxiety that would result in waking and crying from a dream. Night Terrors also occur in older children. They are repetitive in nature and usually occur at the same time each night. Children with night Terrors typically assume a crouching position in their bed while they are crying or screaming . They appear to be staring at something that is scary. During a Night Terror the child does not respond to an adult who tries to soothe them. The child falls back to sleep and has no memory of the episode in the morning. (4)

I hope you find the source of your baby’s crying soon so that everyone can get a good night’s sleep.

References:
(1)Niemela M, Uhari M, Junio-Ervasti K. Lack of specific symptomatology in children with acute otitis media. Pediatr Infec Dis J. 1994;13765-768.
(2)Grassia T. Talking teething: Start good oral hygiene early. Infectious Diseases in Children. 2006:44.
(3)Grassia T. Children’s allergy to cow’s milk lasts longer than previously thought. Infectious Diseases in Children. 2006;19(1):43.
(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1418, 254-255.
(5)Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapeutic Spotlight. 2005:3-14.

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

Pediatric Advice Updated Daily

Sexual Abuse

Dear Lisa,

Can a female abuse victim receive blisters inside her vagina from possibly fondling?

“Hope"

Dear “Hope”,

In most cases it is difficult to tell if a victim was sexually abused based solely on the findings of a physical examination. There are a few reasons for this. Generally a perpetrator who abuses a child does not intend to harm the child physically because of the desire to reengage the child in activities over time. (1) In addition, injuries to the genital area resulting from sexual assault heal very quickly. (2) To complicate matters even more, children tend to not report the abuse immediately because many times they are threatened by the perpetrator or embarrassed and ashamed by the abuse. (1) As a result, abnormalities are typically not found when the child is examined. Research studies have shown that when sexually abused children victims were examined, many of them had normal physical findings. (3)

On the other hand, suspicious physical findings on the examination of a child’s genital area many times turns out to be normal findings for the child’s age. (1) The appearance of the vaginal in the child changes according to their age. In infants the hymen may appear thicker and redundant. These changes are due to maternal hormones which affect the appearance of the vagina for the first few months of life. (4) These findings reappear when a child approaches puberty. In prepubertal girls, the hymen tends to appear more vascular and reddened. (5) In addition, the appearance of the hymen is very variable from one person to the next. All of these normal changes may appear to be abnormal. Because of the many potential variations in appearance, it is necessary for a child who is suspected to have been sexually abused to see a doctor who specializes in this area of medicine. (1)

The victim’s report of the story about what happened is many times the only evidence that can be examined and the most important part of the investigation. It is important to remember that when children report abuse they describe their experience from the developmental perspective of a child who does not have a complete understanding of what is going on. Because of this, they may not report the event as accurately as adults would like them to. (1) Children commonly report that someone “put something inside of them”. This may be interpreted as vaginal penetration to an adult, but to a child this may include contact which is limited to placing “something” in the vaginal area without true penetration. (1) Any type of genital contact is inappropriate, regardless of the degree of penetration, but from a legal standpoint these details become very important.

Children can contract Sexually Transmitted Infections as a result of inappropriate sexual contact. (1) The spread of sexually transmitted diseases occurs when a child comes into contact with infected genital secretions or sexual organs. (1) Therefore the presence of a sexually transmitted infection tells you that the child came into contact with the germ, but it does not tell you exactly what type of contact occurred. For example a child can catch a Sexually Transmitted Disease when they are fondled by a perpetrator whose hands have infected secretions on them. The only scenario where a sexually transmitted infection in a child may not be caused by sexual abuse is in the case of an infant. An infant can catch a Sexually Transmitted Infection from its mother during birth. (6) Sexually transmitted infections can present themselves as lesions, sores, wart like growths, or with pain with urination. In most cases Sexually Transmitted infections are asymptomatic which means that the person does not develop any symptoms at all. (7)

So to answer you question specifically, in most cases no physical evidence of sexual assault is found and a lot of weight falls upon the child’s story and witness accounts. If physical evidence of abuse is found, a child should be examined and the results documented by a doctor who specializes in the area. Since suspicious findings on physical examination of the genital area many times end up being normal, it would be important to have your child examined by a health care professional with experience in that area. What may appear to be blisters to you, may be a normal finding. If the lesions truly are blisters, then screening for Sexually Transmitted Diseases (STD) should be performed. If a child is determined to have an STD this tells you that the child was in contact with the germ, but this does not tell you exactly which type of contact occurred, whether it be fondling or penetration.

All sexual contact with a child, regardless of which type, is considered sexual abuse. Even if there was no physical contact, children exposed to sexual activities via photographs or inappropriate exposure potentially can develops significant psychological problems. (1) These types of activities should be taken very seriously because they may be the perpetrator’s way of preparing a child for future sexual abuse. (1)

The American Academy of Pediatrics recommends the collection of forensic evidence within 72 hours of the sexual abuse. (1) Therefore, if you think your child has been abused, it would be important to contact your Pediatrician for an evaluation and referral to a doctor who specializes in this area. Child Protective Services should be contacted if sexual abuse is suspected. The Child Protective Services case workers are trained to deal with this very sensitive subject and can provide a family with the necessary social support services that are needed.

References:
(1)Giardino A. Finkel M. Evaluating Child Sexual Abuse. Pediatric Annals. 2005. 34(5):382-393.
(2)McCann J, Voris j. Simon M. Genital injuries resulting from sexual abuse; a longitudinal study. Pediatrics. 1992;89(2):307-317.
(3)Muram D. Medical evaluation of Child victims of sexual abuse. Curr Opin Obstet Gynecol. 1989;1(2):250-258.
(4)Berenson A, heger A, Andrews S. Appearance of the hymen in newborn. Pediatric. 1991;87(4):458-465.
(5)Huffman JW. The Gynecology of Childhood and Adolescence. Philadelphia, PA:WB Saunder; 1969.
(6)Davidson M. Sexually Transmitted Infections. Screening and Counseling. Clinician Reviews. 2006;14(6):56-60.
(7)Fortenberry J. Sexually Transmitted Infections. Pediatric Annals. 2005. 34(10):803-810.


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

Pediatric Advice About Keeping Kids Safe.

Chronic Headache

Dear Lisa,

I need your professional opinion. I have a little daughter (13 years old), with a lot of medical problems. She has Hydrocephalus(fourth entrapped ventricle-slit ventricle syndrome), Cerebral Palsy, spastic diplegia, etc. We went to our Neurosurgeon for e check up since she was having a lot of headaches(3 years until now). He said her physical exam was normal and the shunts are ok.(pumping them/without a CT scan). She is double shunted,(programmable valve shunts).His opinion was that headaches caused by her situation of the slit ventricle syndrome and advised to take by her a little dose of acetazolamide(Diamox). If it’s not work he will change the program of the shunts (both shunts). As he said and I have read, when the patient with slit ventricle syndrome lying down he feels better. That doesn’t work in my daughter’s headaches(even she is sleeping with her hand in the front place of her head). When she have a sneeze, or a suddenly movement she touch the front place of her head. Is it really the problem now, the slit ventricle syndrome, or is there a new problem with the fourth entrapped ventricle? Is any relationship between her situation and her oral hydration?(her hydration is about 1350-1500 ml daily winter or summer/her weight is 22kg). Is it possible her headaches caused by the other medical problems?(cerebral palsy-they are not seizures-,osteoarthritis, bad vision, bad and longtime position on the wheelchair).

Thank you for your time.

“Worried about My Daughter’s Headache”,

Dear “Worried About My Daughter’s Headache”,

I hate to hear about anyone who is suffering and in pain, especially when it is a child. It sounds like you have invested a lot of time and energy taking care of her and it must be very frustrating knowing that she’s in pain and not having a answer. Unfortunately children with Hydrocephalus and Slit Ventricle Syndrome tend to experience headaches. As with most chronic medical conditions, children experience symptoms differently. Children with Slit Ventricle Syndrome can present with variations in the type of headaches. Yes there are some that find relief with change of positioning, but others may experience a more cyclical pattern.(1) In general the common symptoms found in Slit Ventricle Syndrome include headache, vomiting and drowsiness.

Just to make things more confusing, these same symptoms occur when there is a shunt malfunction. Shunt malfunction may occur because of chronic or acute inflammation, accumulation of cellular debris or blood, or blockage of one of the ends of the shunt.(2) A child’s growth may also affect the functioning of the shunt. Unfortunately the need for shunt revision occurs at some point in almost all children treated for Hydrocephalus from infancy (2) Therefore, whenever a child experiences symptoms it is important to make sure the shunt is functioning properly.

Many times the functioning of a shunt is checked by measuring the pressure in the skull through Intracranial Pressure ICP monitoring. (1) As you already know the functioning of a shunt is also checked through imaging studies such as a Scan of the head. You mentioned that your Neurosurgeon checked the shunts by pumping them, said they were okay and reported that your daughter's physical examination was normal. These are all good signs. It would be important to follow up with your Doctor if your daughter’s symptoms persist or worsen, in case he may want to order further studies such as a Cat Scan or MRI.

Your daughter’s complaints of pain at night and with movement or activity are typically considered warning signs for a problem that originates in the brain. Headache that awaken a child or present when the child first awakes in the morning are classic symptoms of increased intracranial pressure. (3) In particular pain in the occipital area (back of head) and the inability of the patient to describe the quality of the head pain are associated with problems inside the skull such as a shunt malfunction.(3)

Your daughter's Neurosurgeon knows her medical history, findings from her physical examination and results of tests done so far. He is in the best position to advise you regarding the most beneficial course of treatment. It seems that your child’s Neurosurgeon has pin pointed Ventricular Slit Syndrome as the cause of your child’s headaches. Accepting a chronic condition as the reason for a longstanding painful symptom in your child is very difficult and normally results in a lot of questioning and doubt. It is also very common to want to rule out other causes of a headache since headaches can be caused by many factors. This is a very thorough and reasonable approach, especially when it comes to the health of your child.

Whenever a parent has a chronically ill child, so much time is spent at specialist’s office that sometimes the value of the primary care physician or Pediatrician is overlooked. It is through your daughter’s Pediatrician that other causes for a headache can be investigated. This is not only a very essential part of her overall care, but it will reassure you all areas were investigated. Headaches in children have many causes and an evaluation by your daughter’s Pediatrician can guide you in the right direction.

Cervical spine abnormalities can present with musculoskeletal headaches and also with headaches compatible with migraines.(4) You mentioned that your daughter has Cerebral Palsy, Osteoarthritis and is wheelchair bound. All three of these conditions may cause or contribute to an abnormality in her cervical spine which could lead to chronic headaches. This may be an area that you want to investigate.

Chronic Sinusitis is another condition that is commonly associated with headaches. (4) Your pediatrician will be able to ascertain if your daughter’s symptoms are caused s by chronic Sinusitis. Sometimes a child can have a chronic headache and Sinusitis at the same time. If this occurs, the Sinus infection can make the chronic headaches worse and more difficult to control. Once a Sinus infection is treated, the chronic headaches are much easier to treat. (4)

Another consideration is Temporomandibular Joint problems or TMJ which can also present with a chronic daily headache. TMJ is often associated with clicking or popping and problems moving the jaw. Other dental conditions such as malocclusion or an uneven bite, chronic gum infections and abscesses can lead to chronic headaches.(4) An evaluation by a dentist can identify and address these issues if necessary.

You mentioned that your daughter has bad vision. Bad vision is usually not the cause of the type of chronic headaches that you are describing. But your daughter’s health condition can affect her vision. Eye problems are often found when a child is initially diagnosed with Hydrocephalus, as well as in children with functioning shunts and controlled Hydrocephalus. (2) The increased intracranial pressure that children develop with Hydrocephalus can causes changes in their eye examination. Because of this yearly visits with a Pediatric Ophthalmologist are typically recommended.(2)

Your child’s evaluation at the Pediatrician’s Office can rule out any other possible causes headaches that may apply to your daughter. Many times a head ache evaluation includes blood work and a headache diary. The Headache diary is a record that is taken over the span of 1 to 2 weeks and includes information such as the intensity of pain on a scale of 1 to 10, the location of the pain, other associated symptoms such as vomiting or visual disturbances, the time of day that the pain occurs, the duration of the pain, any association between the pain and activities, its relation to food and the time of the month. I’m not sure if your daughter is able to eat food or if the fluids she is taking is a nutritional supplement. It would be important to report any changes in her dietary intake and use of medications and herbal supplements. In some cases certain foods or herbal remedies cause headaches.(5)

I wish you and your daughter a speedy resolution to this problem. If she continues to have pain you should bring her back to the Neurosurgeon’s office in order to discuss other treatment options. In some cases an adjustment in the medication or the addition of a new type of medication is all that is needed.

For more information about Split Ventricle Syndrome; log on to:
The International Federation for Spina Bifida and Hydrocephalus.

References:
(1)The International Federation for Spina Bifida and Hydrocephalus. Split Ventricle Syndrome. Available at: http://www.ifglobal.org/hydrocephalus.asp?lang=1&main=7&sub=1#Slit_Ventricle_Syndrome. Accessed September 2006.
(2)Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis Missouri: Mosby –Yearbook, Inc. 1992:304-305.
(3)Rubin D, Suecoff S, Knupp K. Headaches in Children. Pediatric Annals. 2006;35(5)345-354.
(4)Linder S .Understanding the Comprehensive Pediatric Headache Examination. Pediatric Annals. 2005;34(6):442-446.
(5)Lewis D, Yonker M, Winner P, Sowell M. The Treatment of Pediatric Migraine. 2005;34(6):449-460.

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

Pediatric Advice About Sick Kids