Chest Pain

Dear Lisa,

My son is 9 years old and has been complaining of pains in his chest. They are not continuous or everyday. They come and go and happen at different times of the day. He can be in the middle of an activity or doing something calm. He also has dark circles under his eyes and his coloring in his face has been a little pale lately. Is this something that could be serious or is it possibly growing pains?

“Son with Chest Pain”

Dear “Son with Chest Pain”,

Growing Pains are the pains that children experience in their arms and legs, not in the chest. Pains in the joints or the chest are due to other conditions. Growing pains usually occur in the calves or shins of both legs.(1) Children typically complain of pain in the evening or in the middle of the night. The story of a child who has Growing Pains goes like this; the child goes to sleep at night and suddenly awakes due to pain in the calf. After applying warm compresses or administering a pain medication the child goes back to sleep. By the next morning the child is absolutely fine with no complaint of pain, no limp and no rash. The child proceeds to run and jump on the leg all day with no noticeable problems.

On the other hand, pain in the chest can be due to a variety of reasons. Most people become alarmed when a child complains of Chest Pain, associating this symptom with a heart problem. In reality, cardiac defects are rarely the cause of chest pain in children. Only 4 to 6% of childhood complaints of chest pain are attributed to cardiovascular lesions.(2)

Acute Pericarditis is one of the potential cardiac causes for Chest Pain. Pericarditis occurs when the lining of the heart or the pericardium becomes inflamed. This inflammation is usually caused by an infection. The signs of Pericarditis include a stabbing, sharp chest pain that occurs when a patient lies down. The symptoms improve when the patient sits up.

Hypertrophic Obstructive Cardiomyopathy is a life threatening cardiac condition that occurs in children. adolescents and young adults. The symptoms include angina like chest pain, fatigue, shortness of breath, palpitations or passing out; usually occurring during exercise.(3) It is a familial condition and a known cause of sudden cardiac death.(3) Many times there is a history of a family member who had a sudden unexplained death.

Luckily, musculoskeletal conditions are the most common cause of Chest Pain in the pediatric population.(4) Muscles strains or injuries to the pectoral, shoulder or back muscles due to trauma or physical activity are the leading cause of Chest Pain in children. Costochondritis is a common childhood musculoskeletal disorder. It occurs when the cartilage between the ribs becomes inflammed. The point of inflammation occurs at the point where the sternum (breastbone) meets the ribs on a chid's anterior chest.

The symptoms of Costochondritis include a chronic sharp pain of the anterior chest wall that typically radiates to the back or abdomen. The pain can be worsened by deep breathing and physical activity. Application of pressure to the area where the ribs meet the sternum elicits chest pain in patients with Costochondritis.(5) The pain from Costochondritis can last for months. The children that tend to develop Costochondritis are those who participate in sports that involve swinging of the arms; such as tennis or swimming.

Conditions of the upper gastrointestinal tract such as gastritis, esophagitis or Gastroesophageal reflux can also present with chest pain. The pain from gastritis usually occurs behind the breastbone and is aggravated when the child leans forward. Children taking oral steroids or Non steroidal anti-inflammatory drugs such as Ibuprofen are at greater risk for developing gastritis.

Gastroesophageal Reflux Disease (GERD) is a common gastrointestinal disorder experienced by both children and adults. Signs and symptoms of GERD in an older child include heartburn, vomiting, difficulty swallowing, and chronic cough. GERD symptoms occur more frequently after meals and at night.(6) The older children that I cared for with GERD often complained of a bad taste in their mouth or a feeling like food was coming up their throat. It is important that GERD is diagnosed and treated because untreated GERD can lead to Esophagitis, throat disease and Barrett’s esophagus.(7)

Chest pain due to a respiratory origin is also a common finding in children. A respiratory infection can cause acute chest pain due to Pleurisy. Pleurisy occurs when the pleural membrane or the lining of the lungs becomes inflamed. Certain respiratory infections can cause this membrane to become inflamed. When the pleural membrane becomes inflamed it causes friction during breathing which can be quite painful. A patient with Pleurisy experiences such sharp pain that it causes him to catch his breath. Pleuritic pain can also refer to the abdomen and shoulder due to a common sensory nerve supply.(5)

Chest pain is also a common finding in children with Asthma.(5) Asthma is the most common chronic disorder in childhood. It affects approximately 5 million children in the United States.(8) Because the symptoms vary from child to child and different triggers affect different children, Asthma tends to be a challenge to diagnose. There is no one diagnostic test that determines whether a child has Asthma or not.(8) The diagnosis is made through a careful evaluation of a child’s clinical history as well as his family history.(8)

Airway inflammation is the hallmark of Asthma. This inflammation can remain “silent” and not cause any noticeable symptoms. The emergence of Asthma symptoms develops long after the inflammatory cascade causes changes in the airway.(8) By the time a child develops symptoms their disease is out of control. Therefore, many times the diagnosis of Asthma is more of a subjective decision rather than a measure of objective findings. That is why a detailed history of symptoms is necessary in order to make the diagnosis.

Children with Asthma can go undetected or undiagnosed for months or years before a diagnosis is made. Many Asthma related Emergency Department visits and hospitalizations can be attributed to the Doctor’s failure to recognize and correctly classify the severity of disease in a timely manner.(9) It takes an astute practitioner with extensive experience to identify Asthma in the early stages.

The most common symptoms of Asthma include recurring cough, wheeze, shortness of breath and chest tightness or pain. Symptoms that are elicited with triggers, symptoms that worsen at night and waking at night due to respiratory symptoms are key indicators for Asthma.(10) Other more subtle signs of Asthma include exercise intolerance, allergic shiners(dark circles under the eyes) and prolonged expiratory phase during breathing. From my experience I found that many children with Asthma triggered by exercise experienced chest pain as their presenting symptom.

A viral infection can also cause Chest Pain in children. Pleurodynia also known as “The devil’s grip” can cause intense chest pain. Coxsackievirus Group B is usually the offending organism that causes the condition. The chest pain from Pleurodynia occurs in spasms and is intensified by breathing and coughing. Other symptoms include fever, sore throat and diarrhea.(11)

Psychogenic Chest Pain accounts for 5 to 17% of the cases of Chest Pain in the pediatric population. (2) Psychogenic Chest Pain is usually seen in children over 12 years old and more often found in females.(12) This diagnosis is a diagnosis of exclusion and is a only a consideration when all other causes have been ruled out. Psychosocial or social pressures in a child’s life can contribute to Psychogenic Chest Pain. Stressors including a death in the family or divorce are potential causes of Psychogenic Chest Pain.

As you can see, the causes of Chest Pain in children are many. An accurate diagnosis can only be made through a complete history and physical examination performed by a health care professional. To aide in the diagnosis it would be a good idea to keep a symptom diary. The symptom diary should include the location of the pain, its affect on activity, the time of day, relation to food intake, environmental conditions and activities (ex. coloring with markers), weather, medication use and activity level. It would also be important to record the duration of symptoms, associated findings (for example a runny nose) and measures that improve the symptoms. A symptom diary can help you determine if there are triggers that elicit the Chest Pain.

Since your child is experiencing intermittent chest pain, sometimes associated with exercise, dark circles under the eyes and pale skin color a respiratory cause should be investigated. It would be unlikely that his symptoms are due to a respiratory infection or virus because you did not mention a recent illness or fever. Instead, Asthma should be considered because it is a very common childhood disorder and because his symptoms are commonly found in children with Asthma.

If there is a family history of Asthma, Allergies or Eczema, then Asthma would be a strong consideration. It would be a good idea to have your son evaluated by a practitioner who specializes in treating childhood Asthma. An in depth review of your child’s personal history of symptoms, such as Allergies and Eczema as well as a review of the family history regarding these conditions should be investigated. This is essential because the presence of Allergies and Eczema puts a child at risk for the development of Asthma. (13,14)

If your child is presently engaged in sports, has heartburn or has a relative who experienced an unexplained sudded death you should discuss this with your doctor. These findings may represent one of the other conditions discussed.

I wish your son well.

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

Growing Pains

Asthma Treatment

Asthma Triggers

Allergic Shiners

Gastroesophageal Reflux in Infancy

Gastroesophageal Reflux

References:
(1)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:566,572.
(2)Fyfe DA, Moodie DS.Chest pain in pediatric patients presenting to cardiac clinic. Clin Pediatr (Phila). 1984. 23:321-340.
(3) Walsh CA. Syncope and sudden death in the adolescent. Adolesc Med. 2001.(12)105-132.
(4)Kocis KC. Chest pain in pediatrics. Pediatr Clin North Am. 1999;46:189-203.
(5)Kundra M, Mahajan P. Pediatric Chest Pain: Key to the Diagnosis. Consultant for Pediatricians. 2006. August:460-466.
(6) Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. (35)4:259-266.
(7)Rudolph CD, Mazur, 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:S1-S31.
(8)Mahr T, Crisalida T, Hollingsworth J, Ortiz G, Senske B, Calvin M, Waldrop J. Attaining the Inside Track on Asthma Control. The Clinical Advisor. 2006. Dec:S 3-S14.
(9)Wolfenden LL, Diette GB, Krishnan JA,. Lower physician estimate of underlying asthma severity leads to under treatment. Arch Intern Med. 2003. 163:231-236.
(10)National Asthma Education And Prevention Program. Guidelines for the diagnosis and management of asthma: expert panel report 2. Bethesda, Md; US Department of Health and Human Services. Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute. 1997. NIH publication no. 97-4051.
(11)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:345-346.
(12) Selbst SM. Chest pain in children. Pediatrics. 1985. (75):1068-1070.
(13)Kumar R. The Wheezing Infant: Diagnosis and Treatment.Pediatric Annals. 2003. (32)1:30-36.
(14 ) 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 Health Questions Answered

Omnicef Side Effects

Hi,

My 2yr old daughter was prescribed Omnicef for Strep throat. This is day five and yesterday evening we started noticing a significant change in behavior. She's screaming and crying not wanting to take a bath and not wanting to go to bed (both unusual). She appears okay during the day. Could this excessive irritability be due to the Omnicef?

“? Side effect to Omnicef "

Dear “? Side effect to Omnicef”,

Irritability is not a side effect listed in the Physician’s Desk Reference as an adverse reaction to Omnicef. Omnicef is an antibiotic that is commonly prescribed in the pediatric population and I personally have never heard this complaint from any of my patients. The side effects that may occur in the pediatric population (> or = 1 %)include diarrhea, rash and vomiting. Other less frequent side effects(Less than 1%) include abdominal pain, vaginal yeast infection, vaginitis, upset stomach, rash, nausea and abnormal stools.(1)

Brick red colored stools is a side effect that occurs when Omnicef is taken with foods rich in iron or with iron supplements. The iron in the food binds with the Omnicef to form a nonabsorbable complex in the gastrointestinal tract. This nonabsorbable complex causes the stool to turn brick red in color.(1) I have seen this side effect in children taking Omnicef. The brick colored stools return to their normal color after the antibiotic course is finished. In order to prevent this change of stool color from occurring, iron supplements should not be giving within two hours of receiving Omnicef. Iron supplements can be given 2 hours before the Omnicef dosage or two hours after the dosage.

A two year old child typically does not have the cognitive ability or communication skills to decipher and communicate pain, abdominal discomfort, vaginal itchiness or nausea effectively. If your daughter’s irritability continues, these potential side effect to Omnicef should be considered as a possible cause. Irritability and crying at night can also represent another problem such as an ear infection or a behavioral issue. Therefore an evaluation by your Doctor may be necessary in order to decipher the cause of her symptoms.

Many children receive extra loving care when they are sick. During an illness, routines change and special privileges may be granted. For example a child may be allowed to stay up later at night or sleep in their parent’s bed when they are sick. They also tend to get more individual attention from their parents when they are not feeling well. When a child’s condition improves it is normal for them to find displeasure and misbehave when old routines are re-introduced.

If your daughter had a change in her bedtime routine when she was ill, there is always the possibility that she may be acting out because she doesn’t want to go back to the old routine. For example if she was allowed to sleep in your bed when she was sick, it would be expected that she would become upset when she was put in her bed alone.

If you feel this is the case, explain to your daughter that she was allowed to stay up late or sleep in mommy’s bed when she was sick but now that she’s better, she has to sleep in her own bed again. Be assured that children understand hundreds of words before they actually speak and she will understand what you are trying to tell her. At the same time it would be a good idea to emphasize what she can do now that she is feeing better; for example go to the store or visit with friends.

Lastly, I would like to mention that a Strep infection can develop complications. In most cases, once a child receives Antibiotics the infection is eradicated and the child does not experience any complications or long term effects. Although there is a possibility that a child can develop complications whether she is treated with an Antibiotic or not.(2,3) These potential complications include Otitis Media(middle ear infection), Sinusitis, peritonsillar abscess, Tonsillitis, Cervical Adenitis, Glomerulonephritis, Scarlet fever, Arthritis and Bacteremia (infection in the blood).(2,3)

Therefore a child diagnosed with a Strep infection that fails to show a positive response to Antibiotic therapy or a child who develops new symptoms shortly after being diagnosed with Strep needs to be re-evaluated by a Physician. Concerning signs include a persistent fever, inability to swallow, swelling in the neck area, shortness of breath, change in urinary pattern or rash.

I hope your daughter is feeling better soon.

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

Strep Throat

Scarlatina

Scarlet Fever

Acute Otitis Media

Chronic Otitis Media

Cervical Adenitis

References:
(1) Physician’s Desk Reference. 2007. Montvale, NJ. Thomson PDR at Montvale.
(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; 1997:483-494.
(3)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1600-1602,1592,1686.

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

Pediatric Advice- Your Questions Answered

Parvovirus

Dear Lisa,

My son had Fifths disease about a month ago. He now has it again. Most of the children at the daycare have it or has had it. What can be done besides washing hands to get it out of the daycare? Is it likely for a child to get it more than once in that time period?

“Child with Fifth Disease”

Dear “Child with Fifth Disease”,

Fifth Disease also known as Erythema Infectious is caused by the virus Parvovirus B 19. The infection develops in stages. First an afflicted child develops a low grade fever, general malaise, muscle aches and headache.(1) Sometimes these symptoms are so mild that they go undetected. (1) Following this stage a symptom free period occurs which lasts 1 to 7 days. Next the characteristic “slapped cheek” rash develops on the face which is accompanied by a pale color noticed around the lips. The important thing to know is that once the rash develops the child is no longer contagious.

Following the appearance of red cheeks a body rash develops. This rash is diffuse, lacey, flat and pink in color. It appears on the torso, extremities and buttocks. The palms and soles are spared. The rash may become pruritic in some with fifteen percent of the children affected complaining of itching.(1)

During the third stage of the disease the rash appears to come and go. There are certain triggers associated with the reappearance of the rash. These triggers include exercise, emotional stress, hot tubs and sunlight.(2) This waxing and waning of the rash can go on for weeks and in some cases months. (2) Therefore a reoccurrence of the rash does not mean that a child developed Fifth Disease again, it just means that they are in the third stage of the disease which can be quite prolonged.

Young adults may develop a less common presentation called the “gloves-and socks” syndrome. This condition includes an itchy, eruption on the hands and feet that consists of small pink bumps. The rash causes some mild pain and swelling and is frequently followed by a body rash that consists of tiny broken blood vessels.(3)

In regards to your question about your son getting Fifth Disease again, Fifth Disease is a virus that children only get once. It is likely that the recurrence of the rash is the continuation of the original infection contracted one month ago. He probably is in the third stage of the disease, the time that the rash comes and goes.

Your other question about getting Fifth Disease out of your son’s daycare is a common question that parents ask. Typically outbreaks occur during the winter and spring months. Fifth Disease is a very difficult virus to contain. The transmission of the disease occurs before the eruption of the rash and therefore it is not determined that a child has Fifth disease until the contagious part of the disease has passed. Since many children have such mild symptoms during the first stage of the disease and because there is an asymptomatic period immediately before the development of the rash there is no way to know that a child is contagious until it is too late. In addition the virus is formed in such a way that it is resistant to heat, cold and detergents which are the typical conditions that kill most other viruses.(4)

The transmission of Fifth Disease occurs via respiratory droplets, which means the disease is spread when a child coughs, sneezes or comes into contact with another child’s nasal discharge. The infection can also be spread from exposure to an infected person’s blood or blood products and from a pregnant mother to her fetus.(5) The incubation period or the time it takes a person to become infected once exposed is 4 to 21 days.(6)

Although it may seem alarming because Fifth Disease is difficult to contain, this is not a significant concern because in the majority of cases, Fifth Disease is a mild, and self limiting condition.(1) The best way to prevent the spread of infection is to practice good hand washing at all times, even when children do not appear to be ill. It is also a good idea to teach children to cover their mouths and noses when they cough and sneeze and to properly dispose of soiled tissues.

It is important to note that Fifth’s Disease is not the only medical condition that causes a child’s cheeks to become red. I have had children who experienced recurrences of red cheeks accompanied by a body rash and it turned out that these children did not have Fifth Disease but had food allergies.

The condition “Popsicle Panniculitis” is another condition that can cause red cheeks in young children. This rash develops three days after a young child is exposed to cold from sucking on ice pops, the use of a cold pack or exposure to cold air. It appears as red, painless, swollen nodules or plaques on the cheeks. No treatment is necessary except avoidance of the cold and the rash will subside on its own.(7) Other potential causes of red cheeks in a child includes skin abscesses and Lupus erythematosus.(7)

The diagnosis of Fifth Disease is usually made through history and Physical Examination. If necessary a blood test for antibodies to Parvovirus B19 may be performed in order to confirm the diagnosis.(1) The development of a new rash in a child should be examined by a health care professional so that the correct diagnosis can be made and proper treatment recommended.

For more information about topics discussed, read other Pediatric Advice Stories:


Fifth Disease

Skin Abscesses

Food Allergies

References:
(1)Leung A, Robinson WM. What’s Your Diagnosis? Consultant for Pediatricians. 2006. June:366-370.(
2)Leach CT., Jenson HB. Erythema infectiosum (fifth disease). In: Jenson HB, Baltimore RS. Pediatric Infectious Disease. Principles and Practice. Philadelphia: WB Saunders Company;2002:325-330.
(3)Harrington J. Parvovirus B19 Infection. Consultant for Pediatricians. 2006. April:234-235.(4)Koch WC. Fifth(human parvovirus B 19) and sixth (Herpesvirus 6) diseases. Curr Opin Infect Dis. 2001.14:343-356.
(5)Frydenberg A, Starr M. Slapped cheek disease. How it affects children and pregnant women. Aust Fam Physician. 2003. 32:589-592.
(6)Weir E. Parvovirus B 19 infections: fifth disease and more. CMAJ. 2005. 172:743.
(7)Kamat D. “Popsicle” Panniculitis. Consultant for Pediatricians. 2006. Nov:729.

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

Pediatric Advice About Childhood Infectious Diseases

Salmonella

Dear Lisa,

My baby is due this April. My 15 yr old son has a ball python. I've read that reptiles carry Salmonella and that this can be deadly to a newborn and children up to age 5. Would you recommend I remove the pet from my household or are there things I can do to limit any exposure to the baby. Also, am I at risk during my pregnancy? We have had the snake for 4 years.

“Salmonella Concerns”

Dear “Salmonella Concerns”,

Yes, it is true that reptiles can become infected with and carry Salmonella. Other pets such as dogs and cats can also become carriers.(1) The interesting thing is that when animals are infected with Salmonella they usually are asymptomatic or have no visible symptoms. Therefore an owner would never know that their pet is harboring the germ.(1)

Salmonella is responsible for a broad spectrum of illnesses. Salmonella infection can cause Gastroenteritis, Enteric fever, Bacteremia(blood infection), Meningitis, Osteomyelitis(bone infection) and Abscesses. The way that the disease manifests itself depends upon the serotype or type of Salmonella exposure and the health condition and age of the person exposed.

Gastroenteritis is the most common condition caused by Salmonella. The symptoms of Gastroenteritis caused by Salmonella develop abruptly and include nausea, vomiting and crampy abdominal pain followed by loose watery stools. Diarrhea caused by Salmonella may contain mucus and visible blood. (1,2) Fever is a common symptom that is noted in 70% of patients.(1)

In normal healthy adults, the symptoms subside within 2 to 5 days. Those at risk for systemic disease or complications include children under 5 years old, the elderly, those with Sickle Cell Disease, patients taking antibiotics or steroids and those with compromised immune systems. (1,2) Infants in particular have a higher risk of developing Septicemia(overwhelming infection), Bacteremia(blood infection), Meningitis and Osteomyelitis (bone infection). Salmonella can be fatal in infants , especially in those under 3 months old, and in the elderly. (2)

The good thing is that there are measures that can be taken to prevent the transmission of the disease. Salmonella is transmitted via the fecal oral route. This means you can catch Salmonella from contact with an infected person’s stool. Microscopic amounts of stool can become caught underneath the fingernails or left on the hands from inadequate cleansing. The germ can be spread if an infected person handles food that other people eat.

Transmission can become an issue because Salmonella can be shed from a patient’s stool for weeks and sometimes months after the infection has resolved. Surprisingly 1% of patients continue to excrete Salmonella for more than one year after their acute infection!(2) The problem with such a long transmission period is that a patient can unknowingly spread the disease not realizing that they still harbor the germ.

Another mode of transmission is through undercooked food. Poultry, cattle and livestock are common reservoirs for Salmonella. Thoroughly cooking meat and eggs kills Salmonella and prevents people from becoming infected. The problem is that other items that come into contact with the raw meat or eggs during food preparation can become contaminated with the microorganism. Fruits and vegetables can also transmit the disease because once contaminated they are typically not cooked but eaten raw allowing the germ to infect the host.

Other sources of transmission include ingestion of contaminated water or unpasteurized milk and contact with contaminated medications, dyes and medical instruments. Contact with infected animals, especially pets is a common source of infection. Animals such as turtles, iguanas and other reptiles are known carriers of Salmonella. (2)

In order to prevent yourself from becoming infected during your pregnancy you should avoid handling your son’s snake, feeding it or cleaning its cage. It also would be a good idea to have your older son clean his own bedroom, washing his hands carefully afterwards. Whenever preparing food, careful cleansing of food surfaces and diligent hand washing is necessary in order to prevent the transmission of Salmonella. A person that is known to have a Salmonella infection should not handle or prepare food.(2)

From my experience, the infants that contracted Salmonella did so when their parents touched their pacifier or bottle with infected hands. In many of the cases, a caretaker touched an infant’s pacifier or bottle while they were preparing a meal made from chicken or eggs. Many of these parents reported that they put the pacifier in the baby’s mouth out of habit, forgetting to wash their hands first.

In order to keep a newborn baby from catching Salmonella it is necessary that each family member washes their hands before feeding the baby, touching the pacifier, touching the baby’s hands or cleaning the baby's belly button. When preparing meals remember to clean all cooking surfaces before putting the baby's food on them and to wash your hands before touching the baby or any baby items.

The addition of a new baby into the home will affect the dynamics of your whole family. This adjustment may be more difficult for some family members because of change in routine, change in family dynamics and shift of responsibilities. These changes can be difficult for a teenage sibling, especially if they affect his lifestyle. Removing your son’s pet from the home during this time may cause him a lot of grief.

It would be a good idea to sit down and talk with your son about where he stands. If the initial novelty of the snake has worn off and your son is no longer interested in caring for his pet it may be easier to find the snake a new home. I would not be surprised though, if your son is resistant to giving the snake away. Most people are unwilling to remove their pet from the home.(3) Many people view pets as part of the family and refuse to move a pet out of their bedroom, not to mention out of the home .(3)

There are a lot of positive aspects to pet ownership. Studies on the elderly have shown that interacting with animals causes a decrease in blood pressure.(4) Having a pet is a very good learning experience for a child too. Taking care of a pet teaches a child the value of life and the responsibility of taking care of someone other than themselves. Pet ownership has also been shown to have positive psychological effects. So there will be some benefits if the snake remains in the home.

Whether or not you keep the snake or not is your decision. You know your son the best, how mature and responsible he is and how likely it is that he will follow measures to prevent the spread of infection. If you decide to keep the snake it is important that your son understands the steps that he needs to take in order to keep your family free from infection.

You should explain to him that after he handles his ball python, feeds it or cleans its cage that he needs to thoroughly wash his hands with warm soapy water. Before handling the new baby’s food or pacifier he also needs to wash his hands. If your son lets the snake out of the cage and onto the floor it would be a good idea to keep the snake confined to his bedroom and to keep the new baby out of his bedroom when she learns to crawl.

Congratulations on your pregnancy. I wish you and your family well and you a happy and healthy pregnancy.

References:
(1)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:330.
(2)American Academy of Pediatrics. Salmonella 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; 1997:462-465.
(3)Phipatanakul, W. Environmental Indoor Allergens. Pediatric Annals. 2003. 32(1):40-48.
(4)Stephenson M. Spreading disease from pets to people. Infectious Diseases in Children. 2006. September:101-102.


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

Pediatric Advice About Infectious Diseases In Children

Pneumonia

Dear Lisa,

My 19 month old has a mucus filled cough followed by mucus filled vomiting she has no fever, no appetite, but she is very tired and groggy what should I do?

“Child with mucus filled Cough”

Dear “Child with mucus filled Cough”,

A child can develop mucus in her airway due to a respiratory infection. When a germ enters the airway the immune system responds by making antibodies and mucus in order to combat the germ. In some cases the mucus drips down the back of the throat and causes a post-nasal drip. This post nasal drip can cause a child to gag and vomit.

Mucus can also develop in the lower airways or in the lungs. Potential causes of mucus production in the lower airway in young child include Pneumonia, Bronchiolitis or Asthma. Signs of Pneumonia typically include a fever, fast breathing, lethargy(tiredness), shortness of breath, coughing, wheezing, decreased appetite, vomiting and abdominal pain. A child does not need to have all of these symptoms in order to be diagnosed with Pneumonia. Fever and fast breathing may be the only sign found in a young infant or toddler.(1)

Even though fever is usually present when a child has Pneumonia it does not have to be present. There are certain types of Pneumonia referred to as “Atypical Pneumonia” that present with minimal fever or no fever at all. (1) Even though Atypical Pneumonias are considered to be more prevalent in 5 to 10 year old children, preschool children are also at risk. A study performed by Michelow showed that preschool aged children experienced as many episodes of Atypical Pneumonia as older children.(2)

Bronchiolitis is one of the most common and serious viral infections that affects the lower respiratory tract in young children.(3) Almost 85% of cases are caused by RSV. Other potential pathogens include Parainfluenza Virus, Adenovirus, Influenza Virus and Rhinovirus. The symptoms of Bronchiolitis include a several day history of clear nasal discharge and nasal congestion followed by cough, fever, wheezing, retractions, poor feeding and in some cases respiratory distress.(4) Signs and symptoms of Bronchiolitis last for 10 to 14 days with the most intense symptoms occurring by the fifth day.(4)

Bronchiolitis is usually a mild and self limiting disorder, but in some cases it can become quite serious. It is the most common cause of hospitalization among infants. In the United States, 2 out of every 100,00 infants affected dies due to complications related to Bronchiolitis.(4) Those children at risk for developing severe disease include the very young, premature and those who are chronically ill.(5) All young children with symptoms consistent with Bronchiolitis should be evaluated and closely followed by a health care professional.

Asthma has many presentations, the most common in young children being chronic chough, nighttime cough, exercise intolerance, increased work of breathing, wheezing in a child with eczema and difficulty breathing.(6,7) Asthma is a chronic inflammatory disease that involves airflow limitation, bronchoconstriction, airway edema, mucus plug formation, airway hyperresponsiveness and airway wall remodeling. Excess mucus production, coughing up mucus and vomiting mucus are frequently found in children with Asthma.

Asthma is the most common chronic illness of childhood. It affects approximately 5 million children in the United States. Those at risk for developing Asthma include children with allergies and those with a family history of Asthma.(8) A Viral respiratory tract infection is one of the major triggers for an exacerbation of Asthma.(9) Therefore if a child with Asthma develops a respiratory infection, she should be evaluated by her Physician and have an action plan implemented in order to prevent deterioration of her health.

Since a mucusy cough can represent a wide range of disorders, a child presenting with this symptom needs to be evaluated by a Health Care Professional so that the correct diagnosis and treatment plan can be initiated. Young children are at a particular risk for developing complications from respiratory tract infections. Therefore, children under 3 years old with respiratory symptoms should be examined by a Physician or Nurse Practitioner.

Since your child is only 19 months old it would be important to have her seen by her Physician. Her decreased appetite and lethargy may be signs of worsening of her respiratory condition or they may represent a complication such as dehydration. Young children can easily become dehydrated when they are ill. Changes in diet and insensible water loss due to coughing and increased respiratory rate can quickly lead to dehydration in a young child. Sign of dehydration include dry tacky mucus membranes (inside of the mouth looks dry), poor skin turgor(non-elastic skin), decreased urine production, sunken fontanelle (soft spot), sunken eyeballs, reduction in amount of tears, increased heart rate, thirst, weight loss and listlessness.(10)

It is not a good idea to treat a young child suffering from respiratory symptoms with over-the-counter products. Over-the-counter products can cause side effects, fail to treat the cause of a cough and can mask symptoms of an underlying problem. There are many over-the-counter medications that are labeled to be used for cough. Many of these products are marketed as expectorants or a treatment for thinning mucusy secretions. Guaifenesin is a common component in many of these products.

At very high doses, Guaifenesin has mucokinetic effects and can thin respiratory secretions. The problem is at these high doses, significant side effects can occur. (11) In addition, controlled studies have shown that Guaifenesin has no benefit in the treatment of children with cough. It did not change volume or quantity of sputum, nor did it reduce cough frequency.(11)

The officials with the American College of Chest Physicians published Evidence–based Clinical Practice Guidelines regarding the treatment of a cough. These guidelines stressed that most over-the-counter syrups do not treat the underlying cause of the cough. The Guidelines’ authors do not recommend giving over-the-counter cough syrups to children under 14 years old.

Cough suppressants such as codeine and dextromethorphan can also cause significant side effects in children and are not recommended. They have the potential to cause breathing difficulties or respiratory arrest.(12) In addition no clinically evidence from controlled studies has documented their efficacy in the pediatric population.(13)

When a child has a mucusy cough the best thing that you can do is let the child cough and not give over-the-counter cough preparations. A cough is the body’s natural mechanism to protect and clear the airway. The force of a cough moves secretions in the respiratory tree upwards and thins the mucus. If a chid has excessive coughing, she should be evaluated by a Physician.

A natural way to help thin a child’s respiratory secretions is to increase the amount of fluids that your child drinks. This includes solids that melt to a liquid state at room temperature such as ice pops, Jell-O and sherbet. The application of saline nasal spray to the nasal passages can help liquefy and remove mucus from a child’s nose. Gargling with warm salt water can be performed in an older child. This can also aid in liquefying mucus that drips down the throat.

Concerning signs in a child with a respiratory symptoms include; difficulty breathing, pale or blue skin color, listlessness, irritability, accessory muscle use(the skin in between the ribs sucks inwards during breathing or the shoulders rise and fall), nasal flaring (the nostrils flare open with breathing), increased respiratory rate, clipped speech (the child cannot say the ABC’s without pausing to take breaths), back pain, chest pain, leaning forward and drooling or fever. These symptoms can represent worsening of a child’s condition or another serious health condition. If any of these symptoms occur when a child is suffering from symptoms of a respiratory infection, medical attention should be sought without delay.

I hope this information helps and that your daughter recovers quickly.

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

Nasal Congestion

Chronic Cough

Baby with Cold symptoms

Asthma Treatment

Asthma Triggers

Adenovirus

References:
(1)Nield L. Pneumonia: Update on Causes-and Treatment Options. Consultant for Pediatricians. 2005.Sept:365-370.
(2)Michelow IC, Olsen, Lozano J. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004; 113:701-707.
(3)Linzer JF, Guthrie CG. Managing a winter season risk: bronchiolitis in Children. Pediat Emerg Med Rep. 2003.8:13—24.
(4)Bradin SA. Croup and Bronchiolitis: Classic Childhood Maladies Still Pack a Punch. Consultant for Pediatricians. 2006. Jan:23-30.
(5)Gorelick MH, Singh SB. Respiratory emergencies. In; Selbst SM, Cronan K. Pediatric Emergency Medicine Secrets. Philadelphia, PA: Hanley & Belfus. 2001. 241-252.
(6)Stephenson M. Be aware of the myriad conditions that trigger chronic cough in children. Infectious Disease in Children. 2006. March:38.
(7)Castro-Rodriguez JA, Holberg GJ, Wright AL, Martinex 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)Kumar R. The Wheezing Infant: Diagnosis and Treatment. Pediatric Annals. 2003. 32(1):30-36.
(9)Johnson NW. Viral Infections Increase Asthma Hospitalizations. Journal of Allergy and Clinical Immunology. 2006. 117:557-562.
(10)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:921.
(11)Franco ME. Evaluation of chronic cough in children. Presented at: Miami Children’s Hospital’s 41st Annual Postgraduate Course “Perspectives in Pediatrics. Feb 6-9 2006:Miami Beach, Fla.
(12)Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics. ACCP evidence based clinical practice guidelines. Chest. 2006.129:260S-283S.
(13)Bell E. Is codeine a useful medication in pediatrics? Infectious Diseases in Children. 2006. July:12.

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

Pediatric Advice For Parents with Sick Children

Chiari Malformation

Dear Lisa,

My 8 yr old daughter had brain surgery three yrs ago for a Chiari Malformation. She is now having the same symptoms but they have become more severe and persistent. My question is, can a Chiari malformation return? If not what could mimic the exact same symptoms of a Chiari?(severe headaches, fatigue, pain in neck radiating down arm, shock like feeling going down arm, depression, she can't sleep, VERY agitated, blurred vision, ringing in ears, constant blinking. The list goes on and on, but I know you are busy, I can't get her neurosurgeon or neurologist to listen. I really need help, and I don't know where to get it.

“Worried Sick”

Dear “Worried Sick”,

It sounds like you and your daughter have been through a lot over the last 8 years. As you already know, Chiari Malformation (also referred to as Arnold-Chiari Malformation) occurs when the part of a child’s brain called the posterior fossa is downwardly displaced towards the spinal cord. This downward displacement causes compression and elongation of the tissues and the cranial nerves which leads to the resulting signs and symptoms known to the disorder. Although children with Chiari Malformation are born with the condition, only about 1/3 of these children develop symptoms in infancy. (1)

The common symptoms include neck stiffness, neck pain, headache, nystagmus (involuntary periodic movement of the eyes from side to side or from up to down), difficulty swallowing, drooling, vomiting, inspiratory stridor, and in some cases apnea. (1,2) A poor gag and swallow reflex can also develop due to the compression of the cranial nerves. This often leads to aspiration of food and liquids during eating and recurrent Pneumonias. (1) In older children decreased strength in the upper extremities with increased muscle tone and exaggerated deep tendon reflexes may also be present. (1)

Chiari Malformation is diagnosed through imaging studies such as x-rays and/or an MRI of the brain. In cases of milder disease the symptoms may stabilize and the child outgrows the symptoms. In more severe cases, especially when apnea or recurrent pneumonia is involved, surgery may be necessary. The surgical procedure that is typically performed to treat Chiari malformation is a posterior fossa decompression. This decompression alleviates the pressure on the fourth ventricle and the affected cranial nerves which hopefully prevents worsening of symptoms.

Since your daughter is developing the same symptoms that she experienced before her surgery it would be important to have her re-evaluated. You mentioned that you informed your daughter’s Neurosurgeon and Neurologist about her symptoms, but they did not seem to listen. You did not mention if your daughter had an evaluation, a scan of her Brain or what the specialist’s impression of the findings was.

In some cases it may seem that a Doctor is not listening, but what they may be doing is monitoring symptoms to see if they progress. In other cases the Doctor may be deciding what treatment approach to take. Sometimes a child’s complicated condition goes beyond the expertise of a certain specialist and a second opinion is necessary.

I suggest that you write down all of your concerns and questions and schedule a consultation with your daughter’s specialists. At the consultation your Doctor should be able to tell you if your daughter's symptoms are due to her Chiari Malformation or due to another cause. Don’t be afraid to ask your Doctor what his impression is, what his plan is and what pain control measures can be instituted in order to alleviate your daughter’s discomfort. Pain medications may initially be withheld because they can mask symptoms and prevent an accurate diagnosis. If your daughter’s symptoms have been persistent and the disease course has been determined the institution of pain medication for comfort should be a viable option.

When a child has a chronic or complicated medical condition it is a good idea to seek a second opinion. A second opinion can help you gain additional insight into your daughter’s condition, offer you new alternatives or reassure you that you are already on the right course. Some people are afraid to get a second opinion because they do not want their Doctor to become insulted or because they are affraid that their Doctor will think that they do not trust him. A good Doctor will not take this personally and understand that you are trying to do the best that you can for your daughter.

Just like every other profession, there are some Doctors that have a stronger background, more expertise or more experience in a particular area of medicine as compared to others. By getting a second opinion you can explore all of your options and get a different perspective on your daughter’s condition.

When seeking a second opinion, it is a good idea to search out a Neurosurgeon associated with a major Children’s Hospital or associated with a major university in a large city. Your daughter’s pediatrician is a very good resource and should be able to refer you to a specialist that can answer your questions. A Nurse at your insurance company should also be able to direct you where to find a second opinion.

You will need to get a copy of your daughter’s operative report from the hospital where she had surgery and copies of all diagnostic testing as well as films from x-rays or MRI scans performed. The specialist that you see for a second opinion will need to review this information.

Many times very practical, useful and informative suggestions come from other parents experiencing the same situation. You can meet other parents with children diagnosed with Chiari Malformation by joining a support group. In order to find a support group you can contact a children’s rehabilitation hospital, children’s hospital or the Board of Health in your area.

Chiari Malformations are very commonly associated with spinal cord defects such as Spina Bifida. Spina Bifida is more common than Chiari Malformations and it may be easier to find a Spina Bifida support group close to your home. You can find information about Spina Bifida support groups on the Spina Bifida Association Website. Within the Spina Bifida Association and support groups you should be able to find other parents with children diagnosed with Chiari Malformation.

I hope this information helped and I wish you and your daughter well.

Spina Bifida Association

Spina Bifida Support Groups

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1789-1791.
(2)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:438.650-651.


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

Your Pediatric Health Questions Answered

Constipation

Dear Lisa,

My son is 12 months old and has had constipation problems since he was about six weeks despite the fact that he is a breastfed baby. His doctor is completely unconcerned and simply advised giving him juice with no further inquiries. Now my son is eating three complete meals a day along with breast milk and the food seems to come out quite a few days later. Now not only is he constipated but he is also beginning to pass stools that are hard, dry and black with a fine sandy texture surrounding them. I don’t believe it is anything I am feeding him but I am not sure. Am I overreacting or should I be worried?

“Worried about Constipation”,

Dear “Worried about Constipation”,

The term Constipation is often defined differently by parents and Physicians. (1) Some parents believe their child is constipated if a bowel movement does not occur in an expected timeframe. The frequency of bowel movements alone does not necessarily define constipation. Normal patterns can range from having several bowel movements per day to having one bowel movement every few days.(2)

The amount of time that stool takes to travel through the bowels and out the rectum is called the transit time. Every person’s body has a different colonic motility pattern which dictates their transit time. Some people’s transit time is slower than others. For people with slow transit time, it takes longer for the stool to travel through the intestinal tract. The longer it takes for the stool to travel through the digestive tract; more water is reabsorbed from the stool and put back into the body. Therefore if a child has a long transit time their bowel movements are expected to be infrequent and their stool is expected to be firm.

Colonic motility can be variable and influenced by other factors such as; sleep, meals, physical activity and emotional stress.(3) Therefore at times a child’s pattern can change dependent upon these variables. Children who have an abnormally slow transit time can develop Constipation. Symptoms of this type of Constipation include an infrequent urge to defecate, infrequent stools, bloating and abdominal discomfort.(4) Children with slow transit Constipation can benefit from the addition of fiber to their diet. Adding fiber to the diet increases stool weight and water content.

Actually, Constipation is defined as difficulty passing hard stools, pain with defecation and a decrease in the frequency of bowel movements. Streaks of red blood are also a common finding in children who are constipated because the passage of hard stools can cause a fissure or a small cut. This fissure bleeds and as a result streaks of red blood can be found on the outside of formed stool.(2)

Perhaps your Doctor seemed unconcerned about the infrequency of your son’s bowel movements because this could be normal for him and because he had no other symptoms. It is common for some children to have infrequent stools. As long as the stool comes out soft and there is no pain or straining it is not considered to be a problem. Now that your son is developing new symptoms such as hardness in texture and a black color this needs to be addressed.

In most cases, Constipation in childhood is acquired and due to changes in diet.(2) There are certain foods that can bind a child’s stool and other foods that may loosen a child’s stool. Every child is different and has a different response to the addition to a new type of food. For many children rice, soy and bananas are binding and can lead to hard stools. On the other hand fruits, fibrous vegetables, bran flakes and oatmeal can loosen a child’s stool. If your child’s stool consistency has changed since the introduction of solids you may want to keep a diary in order to determine if a certain type of food is changing the texture in his bowel movements.

In some cases Constipation can be due to a secondary cause. In other words a different condition can cause a child to develop Constipation. Constipation can be caused by a metabolic or endocrine disorder such as Hypothyroidism, due to a neurologic cause such as Muscular Dystrophy or because of a gastrointestinal disorder such as Celiac disease.(5) Other potential causes in childhood include central nervous system disorders, muscle disorders, mechanical obstruction or side effects to medication.(5)

Hirschsprung disease may be a consideration in a child who has had constipation since birth.(2) Hirschsprung disease is a condition that occurs due to the absence of ganglion cells in a child’s distal intestine.(6) This leads to ineffective colonic motility, constipation and obstruction. About 50 to 90% of cases are detected in the neonatal period.(6) Symptoms demonstrated in the newborn period include feeding intolerance, bilious vomiting and delayed passage of meconium.(7)

Typically 95% of full term infants pass meconium (first stool which is black and tarry in nature) within the first 24 hours of life. Fewer than 10% of children with Hirschsprung disease pass meconium within this timeframe.(6) Just because an infant has normal bowel movements during the neonatal period does not exclude the possibility of Hirschsprung disease. There certainly are a number of children who have a normal history of neonatal bowel movements who ultimately are found to have Hirschsprung disease.(8)

In some cases Hirschsprung disease is diagnosed at a later age.(8) In particular, breastfed infants with Hirschsprung disease have been found to be diagnosed later in the first year of life.(8) Other signs of Hirschsprung disease in an older child include; a history of intermittent abdominal distention and failure to have a bowel movement without the aid of an enema or laxative.(2) If this is the case it would be important to discuss this possibility with your Physician.

If your son is having straining or pain with his stooling, the stool consistency remains hard after dietary manipulation or he has black stools he should be evaluated by his Physician. If this is the case, it would be a good idea to bring a stool sample to the doctor’s office so that he can see the consistency and test it for blood. If it is determined that your son has Constipation this would be a good time to discuss dietary management and the possibility of secondary causes. In some cases a child with Constipation not responsive to dietary manipulation may need to be prescribed medication or referred to a Gastroenterologist for an evaluation.

If you are interested in reading other Pediatric Advice stories covering topics discussed:

Infant Constipation

Treatment for Constipation

Stool Color

Celiac Disease

Stool Withholding

References:
(1)Pare P, Ferrazzi S, Thompson WG, Irvine EJ, Rance L. An epidemiological survey of constipation in Canada; definitions, rates, demographics and predictors of health care seeking. Am J Gstroenterol. 2001.96:3130-3137.
(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. 1990:179-180.
(3)Rao SSC. Constipation evaluation and treatment. Gastroenterol Clin North Am. 2003.32:659-683.
(4)Lembo A, Camilleri M. Chronic constipation. N Engl J Med. 2003.349:1360-1368.
(5)Borum ML. Constipation; evaluation and management. Prim Care. 2001.28:577-590.
(6)Dasgupta R, Langer JC. Hirschsprung disease. Curr Probl Surg. 204;41:942-988.
(7)Kamat D. Hirschsprung Disease. Consultant for Pediatricians. 2006. March:190-191.
(8)Listernick R. A 4-month-old Girl with Bilious Emesis. Pediatric Annals. 2006. 35(7):470-477.


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

Pediatric Advice-Your Questions Answered

Migraine Headache

Dear Lisa,

I am a 19 year old nursing student and I need your help! Since I was about 5, I have suffered from some form of migraines. They have gotten worse as I have gotten older. I have worked with my pediatrician and two neurologists and over about 10 years, we diagnosed me with pseudotumor and dura-sinus thrombosis (b/c a blood clot was found in one of the veins in my brain). I have been put on an uncountable number of meds, and most didn't seem to help, or I had horrible reactions too. Currently I am taking a diuretic twice a day (500mg) and using the medicine called "Amerge" for when I do get a headache. I was doing really well for the past two or so years and then in this last six months I seem to have fallen again. I met with my neurologist last week and had another spinal tap done to see if my pressure was still high. It was 165, which as I was told, was low and normal, thus suggesting that the Diamox was working, and/or that I no longer had a problem with pseudotumor. I should probably say as well, that the psuedotumor diagnosis is a very odd one for me b/c I am not obese or in bad shape, but rather tall, thin and I try to stay active.

Anyways, for the past six months, I have experienced a horrible pulsing sound in my ears when I sleep and I feel like my head just throbs with each pulse. It doesn’t happen every night, but often. I woke up this morning with horrible pounding in my head, and I heard the "swooshing" sound as well. I began to get horribly nauseated as it got worse. It was 4am and I have a roommate and I couldn't just get up. The other thing is that my right eye begins to hurt terribly as well when this happens. I don't have double vision, or blurriness, it just hurts, aches, and throbs. Getting up and out of bed tends to help a little. But today the headache, nausea and eye sensitivity lasted most of the day and this is not unusual. I don't have a kink in my neck, and no other part of my body feels odd. I have done food diets and kept journals and have never found anything.

Sincerely,

“Nursing Student with killer pain”

Dear “Nursing Student with killer Pain”,

WOW! The one thing that I can say is, all of your experience with your own health conditions, medical specialists, diagnostic testing, coping with pain and navigating the health care system, you sure are going to be a great Nurse. I’m sure it has been extremely difficult dealing with your pain and medical problems from such a young age and find it very admirable that you have chosen a career dedicated to helping others. Your future patients will benefit from all of your life experiences.

Asking questions also makes a good Nurse and a well informed patient. When it comes to your health, there are never too many questions, especially when the situation is not clear. The first issue I would like to address is your diagnosis of Pseudotumor cerebri. I am sure you already know that Pseudotumor cerebri is a condition that is caused by increased intracranial pressure. This increased pressure can lead to cerebral edema (swelling) or subarachnoid fluid accumulation.(1) Typically the reason for the increased pressure is unknown.

The symptoms of Pseudotumor cerebri include a headache that occurs first thing in the morning or wakes a person at night, nighttime or early morning vomiting, visual field deficits and problems with lateral deviation of the eye caused by sixth cranial nerve palsy. The conditions that are associated with Pseudotumor Cerebri include; obesity, menstrual irregularities, Addison disease, pregnancy, Hypoparathyroidism, Iron Deficiency Anemia, middle ear disease, Vitamin A excess or deficiency, Steroid therapy, Oral Contraceptive use, diseases that obstruct the cerebral spinal fluid pathways and obstruction of the major venous sinuses.(1,2)

You will find that as you become more involved with the health care field that medicine is not an exact science. When it is determined that a certain type of person has a risk factor for a disease or that a disease is associated with other findings, this does not mean that every patient needs to have a certain characteristic or condition in order to be diagnosed. All this means is that through researching past cases, common factors were found. Many times the reason for the association is not known. So the fact that you are not obese does not change your diagnosis of Pseudotumor cerebri.

You did mention that you were diagnosed with a dura sinus thrombosis. This can lead to an obstuction of the major venous sinuses which happens to be an assoociated finding in patients with Pseudotumor cerebri. Chances are this finding contributed to your Pseudotumor cerebri diagnosis more than your weight or level of fitness.

The next thing that I would like to mention is that I am not sure I understand the outcome of the visit with your Neurologist last week. You mentioned that you had a spinal tap to see if your pressure was still high and you were told that your pressure was 165 and normal, suggesting that the Diamox was working and/or that you no longer had a problem with Pseudotumor. I am not a Neurologist, but from the sources that I have, the lumbar puncture of patients with Pseudotumor cerebri demonstrates elevated opening pressure, often more than 20 cm H20. (2) Increased intra-cranial pressure (ICP) is defined as a sustained elevation in pressure above 20mm of Hg/cm of H20. (3 ) So I am not sure that I understand the results of your lumbar puncture reading. Since a reading over 20mm of Hg/cm of H20 is considered elevated, the report that your reading of 165 is normal is confusing. Perhaps the number was miscommunicated to you. I suggest investigating this further by discussing the results and the interpretation of those results with your Doctor.

It is common for a patient and their doctor to attribute new symptoms to a past medical condition. For example, it may be assumed that joint pain is most likely Arthritis in a patient with a history of Rheumatoid Arthritis or headaches are due to a Migraine in a patient with a history of migraines. When symptoms have a different presentation, persist, are resistant to therapy or come without an explanation it is important to step back and look at the whole picture. Sometimes you need to start from the very beginning and evaluate all possible causes of a Headache.

The evaluation should start with a routine screen and physical examination that is typically performed the first time a patient complains of recurrent or chronic headaches.
An initial screening for headaches includes; a physical examination including Vital signs and blood pressure screening, an neurologic evaluation, cardiac evaluation, routine bloodwork screening evaluating liver and kidney function and thyroid levels, imaging studies ruling out an AVM malformation, lesion or mass, an ear, nose and throat examination to rule out sinus or middle ear disease, an ophthalmologic examination and an evaluation of the cervical spine. (4) In addition, all medications and herbal remedies used should be reviewed in order to determine if any interactions or common side effects could be responsible for symptoms.

Hypertension or High Blood Pressure is a potential cause of headaches that may be overlooked. (4) Symptoms of High Blood Pressure include headaches, more frequent nosebleeds than normal and dizzy spells. Although most people with High Blood Pressure have no symptoms at all. (5) Many patients with known High Blood Pressure have told me that they feel a hot sensation in their face or head or humming by their ear when their blood pressure is out of control.

More importantly, in your case, the prescription medication, “Amerge” belongs to the 5-HT1 agonist class and can potentially cause High Blood Pressure as a side effect. (6) In healthy volunteers, dose related increases in systemic blood pressure have been observed after administration of up to 20 mg of oral naratriptan (Amerge). Significant elevation in blood pressure , including hypertensive crisis has been reported on rare occasions in patients receiving 5-HT1 agonists with and without a history of hypertension. (6)

Since you are taking this medication and presently suffering from a reoccurrence of you headaches it would be a good idea to have your blood pressure monitored to make sure that you are not having an elevation in your blood pressure. I also think that it is important to have the pulsing and ‘swooshing” sound in your ear evaluated. Your Neurologist or an Otolaryngologist (ENT specialist) can perform this evaluation. When a patient complains of humming, swooshing or buzzing in only one ear, many times an MRI is ordered in order to determine the cause of the symptoms.

If it is determined that your evaluation is normal, it is likely that you will find that the headaches that you are having are due to a Migraine or a migraine variant such as a Cluster headache. A Cluster headache is a sharp very severe headache that usually localizes in or around one eye. This type of headache often begins 60 to 90 minutes after falling asleep and is commonly associated with tearing and nasal congestion on one side.(6) The cause of Cluster headaches is unknown but alcohol is a known precipitating factor. In some cases a Headache specialist is needed in order to decipher the type of migraine that a patient is having and determine the best course of treatment to relieve the pain.(7)

I hope this information was helpful and that you find resolution to your symptoms soon.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Cluster Headaches

Chronic Headaches

Migraine Triggers

References:
(1) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:640-641.
(2)Rubin D, Suecoff S, Knupp K. Headaches in Children. Pediatric Annals. 2006.35(5):345-353.(3)Neurosurgery on the Web. Thamburaj A. Intracranial pressure. Available at: http://www.thamburaj.com/intracranial_pressure.htm. Accessed Jan 2007.
(4) Linder S. Understanding the Comprehensive Pediatric Headache Examination. 2005.34(6):442-446.
(5)The Mayo Clinic. High Blood Pressure(Hypertension). Available at: http://www.mayoclinic.com/health/highbloodpressure//DS00100/. Accessed Jan 2007.
(6) Physician’s Desk Reference. 2004. Montvale, NJ. Thomson PDR at Montvale:1425.
(7)Alper B, Passarelli B. Cluster Headache. The Clinical Advisor. 2006. August:85-86.


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

Pediatric Advice About Common Health Problems

Infant Colic

Dear Lisa,

My 6 week old son is very fussy. He has changed formulas 3 times and now is onNutramigen. He is also on Axid for reflux. However he seems to be in pain. He will cry and scream for hours and won’t settle down until he has a bowel movement. Sometimes he can’t go and I have to use a thermometer with jelly to get him to go. He doesn’t like to lay flat on his back, isn't sleeping much, holds his breath when he gets going and seems to always be hungry. It breaks my heart when he’s like this. It's usually between the hours of 6pm and 3am, but also during the day sometimes. Any advice????

“SLB80”

Dear “SLB80”

It looks like you and your baby have had a rough time for the last 6 weeks. It also looks like you and your Physician have tried many avenues to help your son find some comfort. Nutramigen is one of the recommended formulas for children allergic to milk protein. (1) The switch to this formula should have addressed a possible milk sensitivity. Your son’s Gastroesophageal Reflux Disease (GERD) is also being addressed with the use of the medication Axid that he is taking.

Axid is an H2 receptor antagonist which works by blocking stomach acid secreted by histamine. H2 receptor antagonists are the first line treatment for children with GERD. H2 receptor antagonists typically need to be administered twice per day because the medication’s effectiveness runs out approximately 9 to 11 hours after the morning dose. Infants who are prescribed this type of medications only once per day tend to have a return of their symptoms in the evening hours when the medication is no longer working.

H2 antagonists also tend to gradually lose their efficacy with long-term administration.(2) Because of this children treated with H2 antagonists for a length of time can experience a return of their GER symptoms. Therefore it is common for children on H2 antagonists to be stepped up to the next treatment option, such as a Proton Pump Inhibitor (PPI) when GER symptoms occur.(3)

Proton pump inhibitors (PPIs) are superior to H2 receptor antagonists as acid suppressors.(4) Proton pump inhibitors prevent acid secretion stimulated by histamine as well as acetylcholine and gastrin.(5) In addition, the use of PPIs results in faster and higher rates of erosive esophagitis healing compared with H2 receptor antagonists.(4) Prevacid is one of the Proton pump Inhibitor that is approved in the pediatric population.(5) Even though it is recommended for children from 1-11 years old, it is prescribed by many Doctors and Nurse Practitioners to children less than 1 year old.(6)

Typical GER symptoms experienced by infants include vomiting, regurgitating, back arching, excessive hiccoughing and irritability. Some children with Silent Reflux will experience irritability with no obvious signs of vomiting.(3) You did not mention if your son’s GER symptoms improved with the institution of Axid or if he is presently experiencing GER symptoms. If this is the case, the approach to the treatment of his GERD may need to be re-evaluated.

In some cases medications need to be adjusted, non-medical treatments need to be initiated or further diagnostic testing needs to be performed. One of the non-medical treatmtnets for GER includes thickening the infant formula. Many doctors have moved away from the practice of thickening baby formula with rice cereal as a treatment for GER. It is true that it will not cure the disease, but it has been shown to decrease the amount of times per day that a baby spits up and has brought relief to many children.(3,7) You might want to discuss this option with your Doctor if your son is having vomiting with his GERD.

Another non-medical treatment is positioning. Babies with GER tend to experience less symptoms when they are elevated at a 30 degree angle.(3) Since your son has GER, it is not surprising that he has discomfort when he lies flat. You may want to purchase a bouncy seat that is made to maintain an infant in an elevated position. Placing a child in an infant car seat is usually not effective. Infant car seats cause the baby’s hips to flex which places pressure on the stomach and increases reflux. (5)

Babies with gas also have a lot of abdominal discomfort, abdominal pain and crying. Some infants entrap a lot of air with their vigorous sucking which causes air to be trapped in their stomach. In addition certain bottles allow more air to enter the baby’s stomach during a feeding than others. If your son is having a lot of burping you may want to consider adjusting your feeding technique. From my experience many parents have found success with the use of a Dr. Brown’s bottle which is designed to prevent air from entering the baby’s stomach.

Once all of these areas have been addressed and your baby’s Doctor determines that there is no other medical cause for your son’s crying, Colic should be considered. Colic usually begins in the first three weeks of life and typically lasts up until a child is three months old. In rare cases it may persist up until 6 month of age.

The symptoms include crying episodes accompanied by pulling the knees to the chest as if the baby is in pain. The crying episodes typically last 30 minutes to 2 hours and occur one to two times per day, usually concentrated in the evening hours. In between the crying spells the babies with colic are quite content and happy.

Taking care of a baby with colic can be extremely exhausting and can have a strong emotional impact on the whole family. It is very difficult to watch your baby cry, especially when measures taken to provide comfort do not seem to help. This stress can profoundly affect the primary caregiver who needs some time away from the baby.

When a baby has colic it is a good idea to have a friend or relative take care of the baby on a regular basis in order to give the major caretaker a break. In addition to parental breaks, there are some measures that may help soothe the baby’s symptoms. Parents may need to experiment with these interventions because each baby is different and different techniques work for different babies.

Some infants respond favorably to gentle pressure over the abdominal area. Walking with the infant held over your arm can provide the gentle pressure that is needed.(8) Other babies find relief if their position is changed frequently. Measures to distract the baby may work for some families. Music with a varied rhythm or a beating heartbeat in the background may stop the baby from crying.(8) Other babies find comfort from loud humming sounds such as the noise made by a clothes dryer, motor of a car or vacuum cleaner.

Swaddling an infant may also reduce the amount of crying and fussiness. The swaddled position replicates the position of comfort that neonates experienced in the womb. Swaddling promotes restful sleep, reduces scratching of the infant’s face and diminishes frequency, intensity and duration of crying episodes.(9) You can ask the Nurse in your Doctor’s office to show you how to swaddle your baby and practice on a doll or stuffed animal if necessary.

I hope this information helps because I understand how heart wrenching it can be to see your baby cry. Just be assured that many times it is normal for a baby to cry because it is their way of communicating. Also be assured that colic, and GER improve with age and this period will soon come to an end.

Signs that a crying baby needs medical attention include a baby with a fever, continuous crying, abdominal distention, bilious vomiting (foamy yellowish green vomit), projectile vomiting, lethargy, muscle weakness, a baby with improper head circumference growth, ineffective voiding and/or blood in the stool. These situations require medical attention and a further workup in order to determine the cause of the vomiting.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Swaddling

Infant Vomiting

Gastroesophageal Reflux

Infant Back Arching

Gassy Baby

References:
(1)Rudolph CD, Mazur L, 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.
(2)Gillen D, McColl Ke. Problems related to acid rebound and tachyphylaxis. Best Pratct Res Clin Gastroenterol. 2001.15:487-95.
(3)Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006.35(4):259-266.
(4)Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapeutic Spotlight. 2005. August:4-13.
(5)Christensen M, Gold B. Clinical Management of Infants and Children with Gastroesophageal Reflux Disease: Disease Recognition and Therapeutic Options. Presented at: ASHP Midyear Clinical Meeting; Dec 9, 2002:Atlanta.
(6)Schwartz R, Guthrie K. GERD: the lessons my new grandchild taught me. Infectious Diseases in Children. 2006. April:14.
(7)Wenzi TG, Schneider S, Scheele F. Effects of the thickened feeding on Gastroesophageal reflux in infants. A placebo-controlled crossover study using intraluminal impedance. Pediatrics. 2003; 11:355-359.
(8)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1486-1487.
(9)Schwarz R, Guthrie K. Musings on infant swaddling. Infectious Diseases in Children. 2006. June:14.


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

Pediatric Advice For Parents with Infants

Vaginal Odor

Dear Lisa,

My daughter is almost 2 years old and today for the first time she had this really bad odor coming from her vagina. I tried looking it up online thinking its a yeast infection but there is no discharge and she gets a bath(she's not dirty or anything) What could this be? I can't seem to find an answer to make me feel better.

“Two year old with odor”,

Dear “Two year old with odor”,

Malodorous urine or foul smelling urine can be a sign of a Urinary Tract Infection in a young child. Therefore if the odor you are smelling is really an odor from your daughter’s urine, or her diaper filled with urine, a visit to the Doctor would be necessary in order to rule out a Urinary Tract Infection. Symptoms of a Urinary Tract infection in young children do not necessarily present the way that Urinary Tract Infections do in older children or adults. The typical urinary symptoms such as burning with urination or urinary frequency may not be present.

Instead infants and toddlers can develop non-specific symptoms such as a fever, vomiting, diarrhea, decrease appetite, weight loss, abdominal pain, pale grey skin color, lethargy, irritability or respiratory distress.(1) Older children are more likely to have the classic symptoms or other symptoms such as dribbling, incontinence, abdominal pain, decreased appetite, urinary urgency, blood in the urine or vomiting.

If the odor that your are smelling is from the vagina this may be normal. Many parents are surprised to find that girls as young as two can develop an odor in their private area the same way that adults do. Normal bathing should keep this odor under control. Although, a vaginal odor can be particularly noticeable in a child who still wears diapers.

Wearing a diaper traps moisture and provides a breeding ground for Candida albicans which is the microorganism responsible for yeast infections. Young girls can develop a yeast infection of the skin in the diaper area as well as in their vagina. Those children at risk for developing a Candia Yeast infection include children in diapers, children treated with antibiotics, children with Diabetes Mellitus and children treated with steroids. (2)

A child with a vaginal yeast infection does not display the same symptoms as an adult with this type of infection. The typical symptoms of a vaginal yeast infection in a child include vaginal discomfort, itching, redness, urinary frequency, or burning with urination. Sometimes children can be found rubbing thier private area on furniture. (3) From my experience, most young girls (including toddlers) with a vaginal yeast infection do not have a discharge coming from their vagina. Typically young girls do not develop an odor from a vaginal yeast infection.

The treatment for a vaginal yeast infection in a young child includes baking soda baths, exposing the area to air and the application of anti-fungal crèmes. Over-the counter antifungal crèmes such as Monistat or Lotrimin are used to treat yeast infections. In some cases a prescription antifungal crème may need to be prescribed.

Candida albicans is not the only cause of Vaginitis in a young girl. Vaginitis or the inflammation of the vaginal area can be caused by other infectious agents, irritation, or emotional stress.(4) Normal anatomical variations such as a high or microperforate hymen put some young girls more at risk for developing Vaginitis than others.(4)

Young girls with a high or microperforate hymen are more likely to trap urine or mucus in the area. The pooling of secretions in this area provides a good environment for microorganisms to grow. This cause should be considered in young girls who experience recurrent Vaginitis.

Irritation is a very common cause of Vaginitis in young girls. Items such as scented soap or lotions, bubble baths, tight fitting clothing, stockings and dyes in colored toilet paper or diapers can cause irritation and inflammation of the vaginal area that lead to symptoms. (4) Improper wiping of the female genital area after toileting is a common cause of vaginal irritation and subsequent Vaginitis.

Special care needs to be given to the cleansing of a young girl after toileting, always wiping from front to back, not back to front. Wiping from front to back prevents stool from being pushed into the vagina and contaminating the area. Sometimes a small piece of toilet paper or piece of stool can become trapped in the vaginal area which can cause irritation and in some cases an infection.(4)

As a part of normal development, toddlers and preschoolers learn about and explore their genital area through touching.(4) Frequent touching and playing with the genitals is another potential cause of Vaginitis in young girls. A tiny vaginal laceration may result if the child touches themsleves with sharp, untrimmed nails. The signs of a vaginal laceration include vaginal discomfort, burning with urination or bleeding.

In some cases a child’s natural exploring may lead to the insertion of a foreign body into the vagina. Items such a bead or a part from a small toy can become accidentally lodged in the area. (3) Symptoms of a foreign body in the vagina include vaginal discomfort, vaginal bleeding, a toddler who points to the area or an older child who says something is stuck.

Many times children will not tell a parent or even remember that they put something in one of their orifices. If a foreign body remains in the vagina for a length of time an infection can develop which can lead to odor and in some cases a discharge.

Symptoms of Vaginitis can mimic many disorders; therefore it is important to have a child who has vaginal symptoms evaluated by a Doctor or Nurse Practitioner. Urinary frequency and burning with urination can be caused by a Urinary Tract Infection. Redness and excessive itching of the vaginal area can be due to a vaginal strep infection. Pinworms, a common childhood infestation may also present with Vaginitis.(5)

If your daughter’s vaginal odor is relieved with bathing and only worsened after prolonged periods in her diaper this may be normal. If the odor is quite noticeable, not relieved by bathing or associated with fever, discharge or discomfort an evaluation by your Doctor or Nurse Practitioner is warranted. If you have noticed that your daughter has recently been touching and exploring her genital area and are not sure whether or not she placed a foreign body in her vagina, an evaluation would also be necessary.

I hope this answers your questions.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Burning with Urination

Candida Diaper Rash

Oral Candida Infection

Toddler Swallowed Paper Clips

Pinworms

Vaginal Strep

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. 1990:532.
(2)Goldstein SM. Advances in the treatment of superficial candida infections. Semin Dermatol. 1993;12:315-330.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:832-833.
(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1711-1714,209-210.
(5) Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:489.


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

Pediatric Advice About Childhood Illnesses

Seizures

Dear Lisa,

My little toddler has just recently had a seizure due to an elevated fever. He is 27 months old. Now I am beginning to wonder if he has epilepsy due to several reasons. Number one is...for several months he will just stare with a blank look in his eyes (as if he is really thinking about something) when we try to talk to him he acts as if we are not speaking to him at all. Then in a minute or so he will just begin to act like himself again. He also has just now started saying MaMa and DaDa..he is only able to say one or two more words...not very clearly though...however, he is extremely intelligent...as he knows exactly what you are saying to him and he has ways of letting you know what he wants...but he will not talk. Now that he has had this seizure due to a high fever from an ear infection...I am concerned that he may have been having seizures all along.. Please tell me if the symptoms I have described seem to be seizure related.....I love him so very much....

“Son with Staring Spells”

Dear “Son with Staring Spells’,

Epilepsy (also known as a seizure disorder) is one of the three most common neurologic disorders seen in the pediatric population.(1) Epilepsy is a chronic disorder of recurrent unprovoked seizures. A seizure is defined as a paradoxical nervous system event that is caused by an abnormal electrical discharge and associated with a change in usual functioning.(1} Seizures tend to occur more often in both the elderly and the very young and many Epileptic syndromes do present in childhood.

The typical manifestations of a seizure include twitching of the extremities, fluttering of the eyes, muscle rigidity or loss of muscle tone followed by a period of weakness. There are different types of seizures, some of them having a more subtle presentation. A simple partial seizure may present with something as mild as hand twitching and an Absence seizure can occur and appear as if a child is daydreaming.

There are triggers or conditions that can cause a seizure to occur. These triggers include; fever, injury, infection, sleep deprivation or use of elicit drugs.(1) The trigger itself can be quite serious and needs to be addressed as well as the seizure itself. It has been determined that one in eleven people will experience a seizure sometime in their lifetime.(2) Therefore, not everyone who has a seizure is considered to have Epilepsy. A diagnosis of Epilepsy is only made when a child has two or more unprovoked seizures or one unprovoked seizure with an abnormal EEG.(1)

Unprovoked means the seizure is not caused by a trigger. Therefore children who experience a seizure caused by a trigger are not considered to have Epilepsy. A seizure associated with a fever or a Febrile Seizure is considered a provoked seizure and is different from Epilepsy.

A Febrile Seizure is defined as a seizure that is associated with a fever in a child who is over 6 months old and free from a central nervous system infection or electrolyte imbalance. Febrile seizures more commonly occur in children between the ages of 6 months and 6 years old, with the average age of occurrence being 18 months old.

Children at risk for developing Febrile Seizures include those with a first or second degree relative with a history of Febrile Seizures, children who had a neonatal nursery stay for more than 30 days, children with a developmental delay and those attending daycare.(3) Although, it is possible for any child to develop a Febrile Seizure.

Witnessing a Febrile Seizure is a very scary experience, especially if it is your child having the seizure. Thirty three percent of children who have a Febrile Seizure will experience a second one and 10% will have three or more. (4) Children who experience their first Febrile Seizure before 18 months old are more likely to have recurrences.(1) Many doctors recommend control of future fevers with Tylenol every 4 hours or Ibuprofen every 6 hours, but there is limited evidence that these measures prevent a Febrile Seizure from occurring.(1)

When a child experiences a Febrile Seizure, this does not mean he will develop a seizure disorder later in life. You should be relieved to know that researchers on the Perinatal Collaborative Study noted that young children with febrile seizures do not go on to have chronic seizures.(5)

Even though your son’s Febrile Seizure does not constitute a seizure disorder such as Epilepsy, his staring spells are a concern. One type of generalized seizure, an Absence Seizure can present as a staring spell in children. The usual age of occurrence of Absence seizures is between 4 and 25 years old. During an Absence seizure a child experiences a brief loss of environmental awareness. Typically these staring spells only last a few seconds. Many times they are accompanied by eye fluttering or other manifestations such as turning of the head/eyes or humming.(6) Unlike other types of seizure activity, postictal symptoms such as weakness or confusion do not occur after an Absence Seizure.

In order to determine if these staring spells represent true seizure activity, an evaluation by a Pediatric Neurologist should be performed. A detailed description of the events is needed in order for the Doctor to diagnose a seizure disorder or determine if the episodes are due to another cause.(1) In addition to the evaluation, bloodwork and diagnostic testing including an EEG are typically part of the work-up.

In order to provide a thorough description of your son’s spells , it would be a good idea to keep a diary of the events. The diary should include the time of day, duration of the spell, any associated symptoms, your son’s activity before and after the episode, whether there is a change in color or breathing pattern and whether or not there are vocalizations during the event.(1) Other information such as your son’s sleep and family history will also need to be related to the doctor in order to make the presentation complete. It would be helpful if the doctor had a video recording of the event so that he can witness the episode firsthand.

Staring spells could also be a sign of a developmental delay. Having a developmental delay does not mean that a child is not intelligent. In some cases there may be a deficit in a specific area such as expressive language or hearing that may prevent a child from attaining his developmental milestones. One of the risk factors for a Febrile Seizure is a developmental delay and from the description of your son’s speech, it sounds like he may have a delay in his speech development.

Typically by the time a toddler is 25 months old he should be able to express up to 270 words with an average of 75 words spoken per hour during free play. At this age a child should use phrases in their speech by putting two words together such as, “Give me” or “milk please”. (7) Since your son is 27 months old and saying only 4 single words, this puts him in the category of a child who has a delay in speech development. It would be important to discuss this with your son’s Pediatrician.

Your Pediatrician can refer you to a Speech Therapist of Early Intervention Program in your area for an evaluation. Addressing this issue should be done at this time because early treatment is the key to promoting childhood development. Early Intervention Programs do have a cut off age which means your son may not be eligible for these services if you wait until he is older.

If your son is diagnosed with a speech delay it is also important to have other areas of childhood development evaluated. A comprehensive evaluation is necessary because in some cases a language delay in childhood can be a presenting symptom of another problem.(8) A child’s coordination, sensory skills, neurological status, perceptual-motor function, neurologic status and hearing are additional areas that should be assessed. An initial screening at the Pediatrician’s office is usually the first step and in some cases a referral to a Neurodevelopmental specialist may be necessary.

Your son is very luck to have a mother that is so concerned about him and loves him so much. By approaching these issues one day at a time you will be able to get all of the information that you need. I wish you and your son well.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Speech Delay

Infant with Back Arching

References:
(1)Wolf S McGoldrick P. Recognition and Management of Pediatric Seizures. Pediatric Annals.2006.35(5):332-344.
(2)Resnick TJ. Epilepsy 101: practical points for pediatricians. Presented at: Miami Children’s Hospital’s 41st Annual Pediatric Postgraduate Course: “Perspectives in Pediatric”:February 6-9,2006; Miami Beach, Fla.
(3)Camfield P, Camfield C, Gordon K. Antecedents and risk factors for febrile seizures. Febrile Seizures. In: Baram TZ, Shinnar S (eds) Febrile Seizure. Philadelphia, PA: Elsevier; 2002:27-35.
(4)Shinnar S. Pellock JM. Update on the epidemiology and prognosis of pediatric epilepsy. J Child Neurol. 2002;17(Suppl 1):S1-S14.
(5) Zacharyczuk C. New Data lead to better treatment for children with seizures. Infectious Diseases in Children. 2006. February:47.
(6) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:647.
(7)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:933-955.
(8)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:2074.


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

Advice For Parents About Childhood Health Conditions

Discipline

Dear Lisa,

My three year old is hitting, mostly siblings and other children what do I do? 1,2,3 is no longer working and I feel hitting a child (spanking) only promotes this behavior.

“10mama12”

Dear “10mama12”,

In order to approach a child’s undesirable behavior, it helps to first understand why a child is engaging in the activity. As a child grows he needs to go through stages which help develop his personality and abilities. At each stage of development a child needs to master certain goals or tasks in order to move on to the next stage and continue to grow.

Developmentally, a three year old child is learning about Autonomy. Children at this age attempt to develop autonomy by learning to control their own bodily functions. This includes learning how to eat, how to go to the bathroom and how to go to sleep on their own. A three year old also needs to learn how to behave socially and interact with other children as well as adults. Young children need to use their newly acquired motor, speech and cognitive skills to explore the world around them. While attempting these tasks, children test their limits and learn what behavior is acceptable. Unfortunately this learning and exploring can get them into a lot of trouble.

A parent needs to help their children master the tasks of each developmental stage safely, guiding and teaching them along the way. Parents provide role models for socially acceptable behavior, teach their children about their cultural and religious beliefs and provide discipline and guidance. Children need discipline and guidance so that they can be socialized into the community.

Bringing up a child is the most important and the most difficult job you will ever have in your life. It takes an exorbitant amount of patience, fortitude, mental strength, forbearance, understanding, energy and sacrifice. This does not mean that a parent is meant to be a doormat, take abuse from their children or happily accept bad behavior. It means that in the midst of all of the confusion, tantrums, exhaustion, frustration and judgments from onlookers who think they can do better; you need to keep your composure, remain a good role model and stay in control. After all, a three year old does not have the cognitive ability or personality development to understand the complete consequences of their behavior. A three year old cannot comprehend the damage that can occur from running freely in a parking lot on a Saturday afternoon, but a parent surely does.

It is important for each parent to know that all children engage in negative behaviors. At some point, every child will hit, bite, talk back, touch the stove, pull the dog’s tail, curse and run in the street. Just because your child engages in these undesirable behaviors does not mean that you are a bad parent. As soon a parent comes to the realization that it is normal for their child to go through these same stages, it will be much easier to embrace a plan for disciplining their child.

The one thing that is more important than a child’s negative behavior is how a parent reacts to this behavior. Children thrive on all types of attention and therefore yelling and screaming at a child as a form of discipline usually does not work. If a child is looking for attention from their parent, they will continue to engage in negative behaviors in order to get the attention that they feel that they need, whether it be positive or negative.

I can make a few suggestions that may help parents deal with the different stages that their children are going through. By no means will each intervention work for every child nor will the suggestions miraculously work on the very first try. Each parent knows their child best and will be able to determine which interventions will work for their particular situation.

When I refer to discipline, I am not talking about physically hitting a child. Corporal punishment has never been proven to result in discipline.(1) Hitting a child is a parent’s way of venting their anger and can be physically and psychologically damaging to a child. This form of discipline is not recommended.

Because of this misuse of discipline, many people believe that the word discipline has a negative connotation. I like to refer to discipline on a more positive note. Basically, discipline is learning. If a parent views discipline as a learning process, they will be more willing to embrace the idea knowing that it actually helps a child develop. Learning is a process that occurs over time, and so is discipline. Therefore patience and consistency are needed in order to help a child progress through the normal stages of development.(1)

When disciplining a child, it is important to be consistent in your expectations and to enforce the consequences that you set. Repeatedly threatening to punish your son for hitting without actually following through with the punishment does not work. When this approach is taken, a child does not interpret the reprimand as being “important”, nor will he understand the need to change his behavior.

Consistency also means each child in the family needs to follow the same rules. Allowing one child to do something and not the other can lead to frustration, sibling rivalry and bad behavior.(1) Adult caregivers also need to be consistent in their approach by agreeing upon and enforcing the same house rules. Acceptance of a certain behavior by one parent and not the other can give the child the wrong message and contribute to unwanted behavior.(1)

The first step in disciplining a child is “giving praise”. This may sound absurd, but children can learn to get the attention they need from positive feedback. Non-verbal gestures and showing signs of affection such as giving a hug, a pat on the head or a kiss are very important to a child. Providing positive reinforcement can condition your child to want to please you with his behavior.

Taking time out of your busy day to praise your child for something that he does right will be time well spent. This will take an extra effort and some days it may be very difficult to find anything that your child does right. You can choose something very simple to praise your son for, such as how well he puts on his socks. You will be surprised how your child’s face will light up and how well he will behave when he is praised for no reason.

For example if you are having a problem with your son kicking a ball in the house, you can say to him, “You are big and strong and really good at kicking. Kids like you need to kick the ball outside where there is more room. Only babies who kick the ball a few inches should kick the ball inside". You can follow this by taking him outside to kick the ball in the yard for a short while. Children thrive on this type of attention and will want to show you what else they can do. You may find that running around outdoors for a few minutes with your son may be the break that you both need.

You are more likely to receive the response that you want by using a positive approach. This will work much better than repeatedly yelling at your child each time he kicks the ball in the house and becoming frustrated when he does not listen.

Immediate positive attention will probably work best. At the same time, it is important not to make promises that will likely be broken. If you say, “Daddy will play ball with you when he comes home from work” and there is a chance that Dad will get home late, it is better not to offer this as a solution.

Unfortunately, because of life’s circumstances, it may not always be physically possible to give your child the type of attention that he needs. If this is the case, don’t be afraid to recruit the help of friends or relatives. You may not have the time to go outside and play ball, but an uncle or Grandpa may welcome the chance.

The second step in disciplining a child is paying attention to the surrounding circumstances that trigger your child’s unwanted behavior. Is your son hitting because he is seeking attention? Overtired? Was he hit first ? Is he is frustrated or bored? Does he hit because he doesn’t know how to verbalize his needs? Many times adjusting the inciting factor is more productive than repeatedly reprimanding your child.

If a child tends to hit when he is tired, it’s better to break up the playtime and give your child a nap before the situation gets out of control. If your child hits because he has free time or he is bored, scheduling activities may be the answer for you.

Some children hit another child because they are looking for attention. If you find that this is the case with your child, it would be important to give the attention to the child who was hit and not your son. By giving the attention the person who is hit, your son will learn that he will not get the outcome that he was expecting and will eventually stop the behavior.(2)

When observing your child’s behavior, if you see that the other child constantly grabs his toys, pushes him or hits him; and after holding back your son finally hits this child, this is a different story. Expecting your son not to hit back in this scenario is setting your expectations much too high. It is only natural for a child to react this way when he is treated badly. Learning to deal with this type of treatment requires a level of maturity and self control that needs to be developed over time. In such a scenario you may want to talk with the other child or the other child’s parent about preventing this type of behavior in the future.

On the other hand, if your son is the one doing the hitting for no apparent reason or because he doesn’t get what he wants, this needs to be addressed. If this is the case, your child needs guidance regarding the socially acceptable way of getting what he wants. The first step in disciplining socially unacceptable behavior is to show your son that you are displeased.

You can show your child that you are displeased with your facial expressions, tone of voice and by refraining from affection. Children learn to pick up on non-verbal cues and gestures at a very young age and can learn how to behave from these cues from their parents.(1)

Smiling at a child, using a sweet voice and saying, “Now honey, Mommy doesn’t like that behavior” is not the way to portray that you disapprove. Your child needs to know that you are not happy with the behavior, that you will not tolerate the behavior and that there will be consequences. When mixed messages are communicated, unclear expectation are established.

Children need to learn that there are consequences to bad behavior. If your son was at school and hit an older child, that older child most likely would hit him back and hurt him or use other measures to ostracize him from the group. Therefore it is important for children to learn at a young age that you can not get away with bad behavior without something bad happening. This lesson will only help your child socialize better when he is older.

The next question that parents usually ask is, “What types of consequences are appropriate?” Typically removing a young child from the situation, away from the attention, away from the activity and putting him in “time out” is a good option. Explain to your child that his behavior is not acceptable and now he can no longer play. Removing your child from the activity for just a few minutes is sufficient. Prolonged isolation is not effective because this can lead to bad feelings, frustration and worse behavior.(1) The purpose of a "time out" is to redirect bad behavior, not to fuel it.

Sometimes removing a child from the situation means, leaving a party early, taking your child outside of the house, taking him away from the party for a few minutes, leaving a play date early, leaving a store, sending a friend home early or changing your plans. This will very likely be inconvenient for you and cause your child to become very upset. Don’t be afraid about insulting friends or family members, because they should understand that discipline is a very important part of a child’s development. You will find that you will only need to do this once and your son will learn quickly that you mean business and that his actions will not be tolerated.

Removing or taking away privileges is a good option for older children.(1) As a parent you know what activity, if taken away will have the greatest impact; whether it be not watching television for an hour, not listening to music or not using the computer or favorite videogame. Privileges should be withheld shortly after the incident so that the child relates the unwanted behavior directly to a negative consequence. Putting off a punishment gives the child the opportunity to coerce you to take back the punishment. You can prevent this confrontation and the possibility of forgetting the offense if the punishment is not delayed.

If most of your son’s hitting is between siblings, reprimands should be reserved for instances when one child is clearly overpowering a younger child who is not able to defend himself or if the situation causes a frenzy that is out of control.(2) Sometimes children just need to roughhouse a little bit and enjoy tumbling around with no intent to hurt each other.

If this is the case, you may want to recruit the help from their father or grandparent who can spend time roughhousing outdoors or playing sports during the time of day that the children tend to need activity. If this is not possible it is important to set limits on their behavior so that they understand that roughhousing is not appropriate in certain situations. For example, they can not partake in this type of activity at the store or at Grandma’s house. When they are home children need to know that it is not acceptable to engage in behavior that is likely to result in injury such as jumping off furniture or throwing objects at each that other.

One of the most important things that a parent needs to understand about discipline is, it is impossible to control a child’s behavior, but it is possible to teach a child to control their own behavior.(2) It is also important to remember that you are older and smarter then your children. You have the power to react a certain way and to manipulate the environment.

For example, if your children tend to get into fights when you are preparing dinner, make this the time of day when they do their chores. Separate them and assign each child a chore in different parts of the house. One child picks up the toys, the other child takes the garbage out, while the other makes lunches for school. This way you take away the opportunity for them to become irritated or frustrated with each other which otherwise may have led to hitting.

If your children behave poorly and hit each other when they are tired or hungry then make sure they eat a good meal and take a nap before you go to a party. In some cases you may need to go to the party late or leave early before the commotion begins. If your youngest son hits because he can not join in with the activities of the older kids, you can plan family activities that gives each individual an opportunity to be involved. Just remember that you have the ability to create a change in the environment that can minimize the unwanted behavior.

Lastly, every parent heard of the phrase, “You have to pick your battles”. It is true that you have to decide which bad behavior needs to be reprimanded and which behavior can be overlooked. But I say, “Pick the battles that you know you will win”. In other words ,there are certain situations that you can predict that your children will misbehave.

For example, you know if you try to go out shopping with your children that they will fight; either because they are bored or because they don’t want to go shopping. If you take them out all day shopping, you know that you will lose the battle. Instead of putting yourself in a situation where you know that you will lose, it’s better not to choose that battle at all.

Instead, hire a babysitter and go shopping by yourself or send one of your children over another child’s house for a play date. Another option is to make a quick trip to only one store to purchase only one item or make a game out of the trip. Have a contest to see who can guess what mom is shopping for, who can find 25 red items in the store or have a scavenger hunt to see who can find items on a preprinted list. By keeping your children busy, you can avoid a battle and get your shopping done without your children spiraling out of control.

Simply reprimanding or punishing a child will not teach him the way to behave in the future. Teaching a new behavior is the final step and probably the most important part of disciplining your child. Once a child demonstrates bad behavior it is important to give him ideas how to deal with the situation better the next time. For example, tell your son that you expect him to use his words, not his hands. You can role play with him and figure out other ways to deal with a frustrating situation. You can teach him to ask for a toy, come to you for help or find another toy to play with instead of using “hitting” as a means to get what he wants.

I wish you success!

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:436-440.
(2)First LR. Creative and effective parenting tips- a generalist’s prospective. Presented at: Masters of Pediatrics 2006. Leadership Conference. January 20-25, 2006:Bal Harbour Fla.


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

Pediatric Advice About Childhood Development

Muffled Voice

Dear Lisa,

My 5 year old son's (6 next month) voice sounds like he has a large amount of spit in his mouth, I don't see anything in there, it sounds like Kermit the frog, my husband said it sounds like he has marbles in his throat. He says he feels ok, he's eating/drinking, he doesn't feel hot, no c/o sore throat, no coughing, no runny nose, he does snore loudly at night. What could this be?

“Mommy of 2”

Dear “Mommy of 2”,

Children usually develop a marbled, muffled voice when they have mucus in the upper airway or when they don’t swallow their saliva properly. Mucus can build up in the upper airway due to a multitude of reasons. A child can develop extra mucus during a cold, due to allergies or due to improper drainage because of a blockage in the upper airway.

If this is a new finding in your son, his symptoms may be due to an Upper Respiratory Infection such as a cold or virus. Since he does not have any pain, loss of appetite or fever with his symptoms, I would be inclined to think that his symptoms are due to another cause. Persistent or long standing symptoms could be due to, Allergies, Oral-motor dysfunction or a blockage in his airway caused by enlarged tonsils and/or adenoids.

Tonsillar or Adenoid Hypertrophy or enlarged tonsils or adenoids are two of the of the more common reasons for blockage in a child’s upper airway and ineffective drainage of secretions. During childhood, tonsils and adenoids become enlarged in response to infections in the upper respiratory tract.(1) In most children this enlargement is temporary, well tolerated and has no consequences.

In some cases, the enlargement of the tonsils and adenoids can become persistent or obstruct the airway. As a result children can develop symptoms of upper airway obstruction or Obstructive Sleep Apnea (OSA). Signs of upper airway obstruction include mouth breathing, difficulty swallowing, and failure to thrive. (2) Signs of Obstructive Sleep Apnea include loud snoring, pauses in breathing during sleep, restless sleep, interrupted sleep, excessive daytime sleepiness, Attention deficit disorder, impaired concentration, impaired attention, morning headaches, bedwetting, dry mouth, depression, irritability, and abnormal sleep positions. (2,3,4)

Obstructive Sleep Apnea causes a child to receive decreased amounts of oxygen while they sleep. (3) It is a major health concern because most cases go undetected and because the long term effects of untreated OSA can be quite serious.(3) These long term consequences include glucose intolerance, elevated cholesterol levels, hypertension and cardiovascular disease along with its complications. (5,6). Therefore it is prudent to take symptoms of Obstructive Sleep Apnea seriously and seek the expertise of an Otolarngologist if symptoms occur.

Another potential cause for a muffled voice and a child who sounds like he has marbles in his throat is Allergies or Hay Fever. Allergies or Hay fever usually present with sneezing, watery itchy eyes, runny nose and nasal congestion. Other signs of allergies include nasal blockage, post-nasal drip, nasal itching, and nose rubbing (also known as the Allergic Salute), an allergic crease on the nose, itchy throat, throat clearing, mouth breathing, snoring, and a nasal voice.(7) Typical indoor allergies that occur during the winter months include; dust mite allergies, mold allergies and allergies to mouse urine, cockroaches and domestic pets. (8)

Children are at risk for developing allergies if their parents suffer from Allergies or Hay Fever. It is expected that 47% of children who have two parents with allergies will also develop Allergies.(9) If your son is exhibiting symptoms of Allergies and there is a family history of Allergies it would be a good idea to bring this to your Doctor’s attention. In some cases, an Allergist may need to be consulted for an evaluation and allergy testing in order to confirm the diagnosis.

If your son’s symptoms are accompanied by drooling, difficulty chewing, garbled speech, a delay in his speech development or your inability to understand his words, Oral-motor dysfunction may need to be considered. Oral-motor dysfunction occurs when a child experiences decreased muscle tone or difficulty with coordination of the muscles in his mouth. Children with Oral-motor dysfunction tend to have difficulty handling their secretions, problems chewing and swallowing certain types of foods and a delay in speech development.

An evaluation by a Speech therapist can determine if a child is suffering from Oral-motor dysfunction, a problem with his swallowing mechanism or a Speech delay. If a problem is detected the Speech Therapist can provide therapy, teach your child exercises and recommend techniques that can be used at home to help rectify the situation.

A muffled voice accompanied by drooling, a sitting forward position, stridor (high pitched inspiratory sound), difficulty swallowing or fever may represent a different condition such as Foreign body aspiration, Epiglottitis or Tracheitis. (2) These conditions are considered to be Medical Emergencies that need to be evaluated by a Physician without delay.

I hope your son’s symptoms resolve and he is back to himself soon.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Tonsillectomy

Snoring

Hay Fever Symptoms

Treatment for Hay Fever

Speech Delay

Infant Drooling

Toddler Swallowed Paperclips

References:
(1) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1211-1213.
(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: 805,500-501.
(3)Butler D. An underdiagnosed cause of daytime fatigue. The Clinical Advisor. 2006. Sept:48-52.
(4)Picchietti D, England S, Walters A, Willis K, Verrico T. Periodic Limb Movement Disorder and Restless Legs Syndrome in Children with Attention-deficit Hyperactivity Disorder. Journal of Child Neurology. 1998. 13(12)588-594.
(5)Yaggi HK, Concato J, Kernan WN. Obstructive Sleep Apnea as a risk factor for stroke and death. N Engl J Med. 2005. 353:2034-2041.
(6)Mehra R, Benjamin EJ, Shahar E. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep heart Health Study. Am J Respir Crit Care Med. 2006.173:910-916.
(7)Lai L, Casale TB, Stokes J. Pediatric allergic rhinitis: Treatment. Immunol Allergy Clin N Am. 2005. 25:283-299.
(8)Phipatanakul W. Environmental Indoor Allergens. Pediatric Annals. 2003. 32(1):40-48.
(9)Berger W. Overview of allergic rhinitis. Ann Allergy Asthma Immonol. 203. 90:7-11.

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

Your Pediatric Health Questions Answered

Infant Sleeping

Dear Lisa,

My baby is 2 1/2 months old and I was wondering at what age should she be able to just sleep or nap on her own without being rocked?

“Mother of 1”

Dear ”Mother of 1”,

Before a parent considers putting an infant to sleep it is prudent to make sure that she is fed, burped and changed. Hunger, a wet diaper or a gas bubble can irritate a child so much that it doesn’t matter what measures you take, the child will never settle down and fall asleep on their own. This is quite a difficult task because infants require frequent feeding, burping and changing. Breastfed infants need to eat every 2 to 3 hours and are expected to wake at night at these intervals for feeding. Bottle fed infants typically eat every 3 to 4 hours and also wake up at these intervals for a feeding. By the time an infant is 3 months old, most infants will sleep for 4 to 6 hours at night in between feedings.(1)

In addition to these basic measures, a level of maturity is required for an infant to be able to sleep at night. The development of consolidated sleep where the infant sleeps for a longer period of time with fewer awakenings depends on central nervous system maturation.(2) On average it is not expected for a child to be able to sleep through the night until they are about 6 months old. (2). When the phrase “sleep through the night” is used it refers to sleeping after 8 p.m. without waking except for feedings.

Nighttime awakenings once again are expected to emerge between 6 to 12 months of age. At this age infants wake because of teething pain or due to individual child temperaments.(2) Sleeping in the same room as a parent at this age also has been related to night time wakening.(2) By the time a child is between 18 to 36 months she is expected to sleep from 7 ½ to 10 hours per night and receive the rest of the sleep needed during daytime napping. It is not realistic to expect a child younger than this to sleep for long intervals at night.

It is important for parents to understand the expected sleep patterns of infants so that they can be reassured that their baby is normal when it does not sleep through the night. Understanding an infant’s sleep pattern can also prevent the parents from becoming frustrated due to different expectations.

Once an infant’s normal sleep pattern is understood, measures can be taken to ensure that an infant goes to sleep in between feedings as opposed to staying awake all night. Some of these measures are based on the development of an infant’s circadian rhythm. The circadian rhythm is what dictates the body’s sleep wake cycle. This circadian rhythm is not developed in an infant until they are 3 to 6 months old.

The circadian rhythm or sleep cycle determines when a baby sleeps and when it is awake. It is mainly influenced by the timing and intensity of light. (3) The measures that parents can take to help change a child’s circadian rhythm is the use of light. Light has the greatest effect on a person’s circadian rhythm. Therefore parents should put all of the lights on and pull up all of the shades in the home starting early in the morning. When the infant sleeps during the daytime, she should not be put in a dark room with the shades pulled down. Instead she should nap in a common area such as the living room with the lights on.

At night, the opposite should occur. Starting at 9 or 10 p.m. at night all of the lights in the house or child’s bedroom should be turned off and all of the shades should be drawn. You can use a night light for diapering and feeding. Parents should engage in as little activity as possible. Exposing the infant to these two opposite environments on a daily basis the child will learn that night time is for sleeping and daytime is for activity and playing. By following this procedure, at three months old an infant should develop its circadian rhythm, begin to sleep more at night and have an established daytime nap schedule. (3)

The next important step in teaching an infant to go to sleep at night is to develop a sleep routine that is reasonable for both the parents and the child. Elaborate sleep routines that require a lot of time can physically drain a parent and lead to exhaustion. As time goes on, parents will not physically be able to continue this level of attention in order to get their child to go to sleep.

Physical exhaustion can lead to parental stress which ultimately can have a negative effect on the infant’s sleep pattern. Research has shown that infant sleep problems are associated with parental stress and depression. In addition, it has been shown that infants whose mothers reported lower level of stress slept longer at night.(2)

Sleep routines that promote self soothing behaviors and minimal parental intervention are more realistic and healthy for both parent and child. Elaborate routines involving prolonged periods of holding and rocking a child develop into a learned behavior that an infant expects each and every time he or she needs to go to sleep. Therefore, it is best to put a child in the bassinet or crib when they are still partially awake so that they can learn to settle themselves down and fall asleep on their own. If an infant learns to settle themselves early in infancy, they will not require prolonged periods of attention in order to fall asleep when they are older.(4)

In regards to your question about the age your daughter should be expected to sleep on her own without being rocked; this is a good question. A child can be put down without rocking, starting from birth. Once a child as been rocked to sleep, there is not an age that she will automaticaly not need to be rocked anymore. Unfortunately, the bedtime routines that babies learn early in infancy in order to settle down and fall asleep cannot easily be changed. Since your baby has been rocked to sleep for the first 2 ½ months of her life, this is the sleep behavior that she has learned to become accustomed to. Now that a pattern has been established, it will be difficult to break.

The best way for your child to learn to go to sleep on her own is to put her to sleep partially awake. This way she will learn self soothing behavior that will settle her and help her fall asleep without the need to be rocked. Since she is used to being rocked, this approach most likely will not be well received.

There are some measures that you can take to help the transition to the new routine. First, start by limiting the rocking time and instead put her down, pat her and talk to her with a soothing voice.(2) Replicating the in utero environment is an approach that also can be utilized.

The fetal position and the warmth experienced in the womb can be duplicated with the use of swaddling. Swaddling during early infancy is said to promote restful sleep in the “back to sleep position”, is easily accepted by most babies, reduces the frequency and intensity of brainstem arousals during deep nocturnal sleep and diminishes frequency, intensity and duration of crying episodes.(5)

Swaddling can be done with a common commercially available 42 inch by 42 inch cotton flannelette infant receiving blanket.(5) The technique is usually taught to parents in the newborn nursery. You can get instructions on how to swaddle your baby correctly from the staff in your child’s Doctor’s office or from a Pediatric Nurse. There are also some swaddling blankets that are available that have Velcro and flaps that perform the same task. These blankets include; Swaddle Me by Kiddopotamus and Company, the Miracle Blanket, Loving Baby Swaddle Blanket, the Cuddle Bug Cloverleaf Swaddling Blankets and the Slumber Bug Swaddling Blanket. The choice of a swaddling blanket or technique is a personal opinion that varies from parent to parent.

The problem with swaddling is, once a child reaches 3 to 4 months old, their size and movement usually precludes them from staying in a swaddled position. Typically the arms and legs of an infant this age pop out of the blanket and the infant does not maintain a swaddled position. In cases where a child is too large or breaks out of the blanket, a helpful technique is to leave one or both arms free outside of the blanket.(5) I swaddled my own daughter this way once she became too large to stay in a traditional swaddle.

When swaddling an infant it is important to make sure that the child does not overheat. The ambient temperature in the infant’s room should not be too high because this can present a danger to the child. Overheating can occur if an infant is tightly swaddled in several layers of clothes and blankets and the temperature of the room is warm.(5)


Another self soothing method that can be utilized in helping an infant go to sleep is the use of music. Tapes or CD’s of a heart beat or rushing, swishing water can also replicate the comfortable, familiar in utero environment. Many of these CD’s play a soothing lullaby with the sound of a beating heart in the background. Other tapes have humming or swishing sounds that replicate the sounds of the mother’s circulatory system. These familiar sounds can be very soothing to an infant.

I have seen these tapes work first hand on infants that I took care of in the hospital after they had surgery. The infants who listened to these tapes settled down and fell asleep easily, some of them did not even require pain medication. The music alone was all that they needed to feel comfortable and fall asleep.

Getting an infant to fall asleep requires a lot of mental strength, patience and persistence. The task can become very tiresome. It is a good idea to recruit the help of family members or friends in order to accomplish the task. It also helps to take naps during the day when your baby naps so that you can regain the strength that you need to take care of your baby. If your infant continues to resist sleeping without being rocked I suggest discussing the topic with your Doctor or Nurse Practitioner who can give you further guidance.


If you are interested in reading additional Pediatric Advice stories about sleep issues:

Infant Sleeping

Sleeping Through the Night

Infant Pillow and Blanket Use

Crying at Night

Problem Waking in the Morning

References:
(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:341-342.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:171-176.
(3)Rosen G. General Overview of Neuroanatomy and Neurophysiology of Sleep. Presented at: Pediatric Sleep Disorders Conference;May 31, 2002:Edison.
(4)Rosen G.Conditioned Insomnia inChildren. Presented at: Pediatric Sleep Disorders Conference; May 31, 2002:Edison.
(5) Schwartz R, Guthrie K. Musings on infant swaddling. Infectious Diseases in Children. 2006. June:14.

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

Pediatric Advice About Infant Care

Hypoglycemia

Dear Lisa,

My 11 year old daughter has been having bouts of vomiting once a month for the past 4 months. Her episodes always start with a feeling of extreme hunger and body shakes and immediately she feels a loss of appetite when she is about to eat. She will then have diarrhea and will vomit about 1/2 hour later. She will usually vomit a few times before feeling better. Her diarrhea will continue for the majority of the day. She has never had a fever with these bouts but once complained of a bad headache and fatigue. I have a doctor’s appointment for the end of the month but I am growing very concerned. She has started puberty but is not menstruating yet. I did not know if this was hormone related or not. Please let me know what your thoughts may be.

Thanks so much!

“Mom to 11 year old with frequent vomiting”

Dear ”Mom to 11 year old with frequent vomiting”,

Your daughter’s symptoms aren’t consistent with the typical causes of vomiting and diarrhea in an adolescent child. Being that her symptoms have been occurring on a regular basis for the past four months an investigation into the cause is warranted. An evaluation and consultation with your Physician is a very good idea. Your Doctor will be able to answer your questions after performing a complete history and physical examination on your daughter.

In the meantime it is only natural to be concerned and wonder about the possible causes of your daughter’s problems. Without performing a complete medical examination and having knowledge of her past medical history and family history is not possible to tell you the cause of her problems. I can only tell you potential causes based on the symptoms that you described.

The interesting thing about your daughter’s symptoms is that they begin with a feeling of extreme hunger and body shakes. This would lead one to suspect that her gastrointestinal symptoms are related to an electrolyte imbalance such as low levels of blood glucose also known as Hypoglycemia. Some children are sensitive to sugar levels in their blood that are at the lower levels of normal and others may have a condition that causes their blood glucose levels to be low.

Hypoglycemia is a rare finding in late childhood, after the newborn period. Metabolic disorders, hormone deficiencies and problems with glucose metabolism that lead to hypoglycemia are usually detected in the newborn period. The development of hypoglycemia in an older child usually signifies a milder form of metabolic disease or hormone deficiency. Other causes of Hypoglycemia include acute alcohol intoxication, drug poisoning, liver disease, malnutrition and Malabsorption.

Signs of Hypoglycemia include perspiration, palpitations, pale color, trembling, anxiety, hunger, weakness, nausea, vomiting, headache, mental confusion, inability to concentrate, staring, personality changes and convulsions. (1) The inability to maintain a normal glucose level during fasting is a common finding.

The symptoms of hypoglycemia are non-specific and may represent other disorders. Therefore the only way to determine that Hypoglycemia is the reason for a child’s presenting symptoms is to have testing done during an episode.

In regards to your daughter’s situation it would be important to know if she is presently taking any medication that could be causing her symptoms. Excess amounts of Aspirin, alcohol, Propranolol, Pentamidine, Quinine or oral hypoglycemic agents can cause Hypoglycemia. (1) It would also be important to know about your daughter’s dietary habits. Is she overly concerned about her weight or a picky eater or dieting? Does she have a history of diarrhea, fatty stools or problems digesting certain types of food that would be suggestive of malabsorption? Do these episodes occur after a period of fasting or skipping a meal? This is the type of information that you need to bring with you to the evaluation at your Physician’s office.

In addition, it would be helpful to your doctor if you keep a diary of the episodes. You should record each event, the time of day, duration, activity before the episode, what she ate that day, associated symptoms, medications taken and social surroundings. A record of your daughter’s height and weight over the last couple of years will also aid your Doctor in making a diagnosis.

The last issue to consider is a psychosocial cause for your daughter’s symptoms. Psychogenic vomiting can occur in some children in a response to stress, fear, depression or anticipation of unpleasant events. (2) It would be important to discuss with your doctor if there are any social changes in your daughter’s life that may be precipitating her symptoms. Is there a monthly event in your household or at school that may be upsetting your daughter? Some children may become upset after visiting a sick grandparent in a nursing home or sleeping over their father’s house during a marital separation. Many times these negative feeling are manifested in somatic complaints such as headaches or bellyaches. It might be a good idea to sit down and talk with your daughter about her social life, school or possible stressors in her life before your Doctor's visit. This way you can collect and present information to the doctor that will be needed in order to make a diagnosis.

I wish you and your daughter a speedy resolution to her problems and a healthy future.

References:
(1)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:616-618.
(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: 355-356.

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

Pediatric Advice For Parents

Fatigue & Excessive Thirst

Dear Lisa,

I have a 5 year old son who often complains that he is tired. He gets 10-11 hours of sleep a night on a regular basis, takes vitamins, and eats a fair amount of fruits and vegetables. He seems, however, to drink an extraordinary amount for his age, about 64 oz. or so a day of liquid, with as little sugar as possible. He also craves sugar and salt, consistently asking for candy over toys and other rewards, and sneaking the salt shaker to eat it straight from his hand. He has regular doctor visits, and all his tests come back normal, but I wonder if there isn't something we're missing? Any idea if there is something else we should be concerned about?

“Mom of 3”

Dear “Mom of 3”,

Repeated complaints of Fatigue or complaints of being tired in a five year old can occur due to a multitude of reasons. The most common causes are an electrolyte imbalance, thyroid disorder, anemia, insufficient amount of sleep or a metabolic disease.(1) Since your son is receiving the required amount of sleep, which is 11 hours per night for a five year old child, insufficient sleep should not be an issue in his case.(1)

Lack of nutrition should also not be a factor since your son takes vitamins and eats fruits and vegetables on a regular basis. Anemia may be a concern since you did not mention that your son eats iron fortified foods such as beans, meat or iron-fortified cereals. The most common cause of Anemia in childhood is Iron Deficiency Anemia which is caused by the insufficient dietary intake of iron. The symptoms include pale appearance, irritability, short attention span, poor scholastic performance, pica and fatigue, but some children do not experience any symptoms at all.(1,2) Iron deficiency anemia is diagnosed from a complete blood cell count.

An electrolyte imbalance is another potential cause of Fatigue. Electrolytes such as salt, sugar and potassium need to be in balance in order for the bodily functions to work properly. Our bodies tend to crave things that they need. Therefore an electrolyte imbalance would be suspected in a child who craves salt and/or sugar. One of the most common causes of fluid and electrolyte imbalance in the pediatric population is vomiting and diarrhea due to a stomach virus. Other causes include fever, injuries such as burns, excess sweating and diet.

The body has normal defense mechanisms which attempt to maintain a balance of electrolytes in the body. Infants and young children are more vulnerable towards rapid changes in fluid and electrolyte balance because their regulatory mechanisms are immature.(3) The constant attempts to regulate such imbalances could place a strain on the body and results in symptoms of Fatigue.

Water intoxication can occur when a child drinks too much water. The intake of excessive amounts of water can cause an electrolyte imbalance and a deficit in the amount of sodium in the blood. The symptoms of water intoxication include restlessness, nausea, vomiting, diarrhea, seizures, excessive urination and excessive drinking.(3)

Children at risk for developing water intoxication include infants who are fed formula that is not mixed properly and too much water is added to the mixture, older children who drink fluids that are intentionally diluted with water and children who receive tap water enemas.(4) Water intoxication and the resulting Hyponatremia that develops can cause a person to crave salt which contains sodium. The symptoms of Hyponatremia or insufficient amount of sodium in the blood include lethargy, anorexia, agitation, disorientation, muscles cramps, decreased deep tendon reflexes and seizures.(4)

Besides your son’s complaint of fatigue, the excessive amounts of fluids that he takes is an issue that should be investigated. You reported that he receives about 64 ounces of fluid per day with as little sugar as possible. It would be important to know if the liquid that he is drinking is diluted with water. If the large amount of fluid that your son has been drinking is water or watered down juice, a fluid and electrolyte imbalance may need to be considered. If this is the case it would be a good idea to discuss this with your Doctor and make changes in his diet so that he does not receive more water than he needs.

There are medical conditions that cause a child to have excess thirst or drink a lot. These conditions include Diabetes mellitus, Diabetes Insipidus, abnormal Antidiuretic Hormone (ADH) production and Syndrome of Inappropriate Antidiuretic Hormone. The Antidiuretic hormone (ADH) controls the body’s excretion of water. This hormone is produced by the hypothalamus which is a part of the brain. This hormone causes the kidneys to concentrate urine and balance water and electrolytes. When there is an imbalance in the ADH a child may have too much or too little fluids in their body and a resulting electrolyte imbalance.

A disorder in the production of ADH can occur due to a variety of disorders including Pneumonia, Asthma, Cystic Fibrosis, side effects of medication and Renal tubular acidosis. This does not seem to be the case with your child because you did not mention that he was suffering from any of these conditions. Typically children with these disorders are quite ill.

Diabetes Insipidus is a condition that occurs when the there is a deficiency in the ADH secretion. This deficiency in ADH leads to excess urination, the inability to concentrate urine and conserve body water. As a result a child urinates excessively, urinates at night, and is excessively thirsty. The urine output of a child with Diabetes Insipidus can be between 4 and 10 liters per day.(3)

The symptoms of Diabetes Insipidus are so excessive that they often interfere with the child’s play and sleep. If the child does not get the water that they crave they become irritable. Children with Diabetes Insipidus also experience poor weight gain, growth failure and high levels of sodium in the child’s blood. Diabetes Insipidus is often associated with an underlying disorder.

Diabetes Mellitus is another disorder that causes a child to become dehydrated and have symptoms of excess urination and excess thirst. Diabetes Mellitus is the type of Diabetes that the general public refers to when they are talking about “Diabetes”. Diabetes Mellitus is the inability of the body to properly metabolize sugar, carbohydrates, protein and fat. It is caused by an insulin deficiency which leads to high blood glucose levels.

The symptoms of Diabetes Mellitus include increased fluid intake, increased food intake, increased urination, nausea, vomiting, abdominal pain, weight loss, dehydration, fruity odor on the breath, blurred vision, disorientation and vaginal yeast infections.(4,5) The screening test for Diabetes checks the level of glucose in the blood after a patient has been fasting for eight hours.(6)

There are two types of Diabetes Mellitus, Type 1 and Type 2. Type 1 Diabetes is the type most frequently found in childhood and is caused by a deficiency of insulin secretion. Type 2 Diabetes is associated with insulin resistance and an insufficiency of insulin. There has been an increased incidence of Type 2 Diabetes in children which previously has been considered an adult disease.

This increased frequency of Type 2 Diabetes in children has been linked to the increase in childhood obesity. (6) The symptoms of Type 1 and Type 2 Diabetes are the same, but investigators announced at the American Diabetes Associations recent scientific meeting in Washington, D.C. that new data shows that 2/3 of type 2 Diabetic patients report having no more than one symptom. Most commonly the symptoms reported were frequent urination and fatigue.(5)

Since you reported that your child has had repeat physical examinations and testing, chances are Diabetes and ADH imbalance have already been ruled out. Your Doctor is the best person to speak to regarding the findings of your son’s physical examination and test results. At this point it would be a good idea to keep a 72 hour food diary, recording everything that your child eats and drinks and bring this record to your Physician’s office. Your child’s Doctor will be able to tell you if your child is receiving the correct amount of calories and water for his age and size.

If it is determined that your child is not receiving enough calories for his size, this may be an explanation why he is drinking so much. If he is consuming the correct amount calories and water then continued symptoms of fatigue should be addressed at a follow up appointment with your Doctor.

Acute or sudden onset of Fatigue or weakness in a child can be a sign of a serious or even life threatening condition and needs to be evaluated by a physician without delay. Sudden onset of Fatigue or weakness can be caused by an infection, viral myositis, Transverse myelitis, Guillain-Barre’ Syndrome, Epidural Abscess, Poliomyelitis, Botulism, Tick paralysis or trauma. (1) These conditions can result in serious consequences that can be worsened by a delay in treatment.

For Information about topics discussed read other Pediatric Advice stories:

Gastroenteritis

Vomiting and Dehydration

Anemia

Iron Requirements for Children


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: 347-349, 69-70,440-441.
(2)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:617.
(3)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:554,1949-1950.
(4)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:556,917,610.
(5)Newsline. Diabetes symptoms often absent, study finds. The Clinical Advisor. 2006. August:14.
(6 )Ho J, Pacaud D, Leung A. Type 2 Diabetes Mellitus in children: A New Challenge for Diagnosis and Prevention. Consultant for Pediatricians. 2006. Feb:77-89.

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

Pediatric Advice For Sick Children