Ask Lisa - Free Pediatric Advice

MRSA

2007-11-14T10:10:00.000-05:00

Dear Lisa,

My son joined the wrestling team and I am very worried about him catching MURSA. What is MURSA and is there anything that I can do to prevent him from catching it?

“Wrestler’s Worried Mom“

Dear “Wrestler’s Worried Mom”,

MRSA, spelled M., R., S., A., stands for Methicillin-resistant Staphylococcus aureus. It is a bacterium that causes "staph" infections which are resistant to treatment with usual antibiotics. MRSA happens to be the most common Antibiotic resistant pathogen in many parts of the world including; The Americas, Europe, North Africa, The Middle East and East Asia. (1)

MRSA can cause a very serious and sometimes fatal infection. The skin, lungs, bones and blood can become infected. (2) Most cases of MRSA in the community involve infections of the skin. MRSA may appear as pustules or boils which may be red, swollen, painful, or have pus or other drainage. In some cases MRSA appear like a “Spider Bite”. (2)

MRSA skin infections tend to occur at sites on the skin where visible trauma has occurred. For example, a spot where a person was cut or developed an abrasion is a likely site. MRSA skin infections are commonly found on the areas of the body covered by hair such as the back of neck, groin, buttock, armpit or beard area of men.

For many years MRSA had been confined to the the Hospital and Nursing Home settings. But people who are healthy and people outside of the hospital can catch MRSA too. In particular the places or settings where MRSA tends to be transmitted include what the Healthcare community refers to as the 5 C’s:

1. Crowded places- such as schools, dormitories, correctional facilities, and daycare centers.
2. Contact- places where there is frequent skin-to-skin contact such as in football, wrestling, fencing and drill teams.
3. Compromised skin- skin with cuts or abrasions
4. Contaminated items and surfaces
5. and lack of Cleanliness. (3,4,5)

MRSA may be transmitted or spread when a person is directly exposed to someone with MRSA. Therefore a good way to help prevent the spread of infection is:

1. Do Not touch the skin or objects contaminated with body fluids from a person with signs of possible MRSA infection
2. Children with a boil, or a pus filled pimple should avoid direct contact with other children and consult their doctor for evaluation.
3. Athletes should shower immediately after engaging in their sport.
4. Avoid sharing personal items such as clothes, towels or razors that come into contact with bare skin.
5. Use a barrier such as clothing or a towel between your skin and shared equipment such as weight-training benches.
6. Maintain a clean environment by establishing cleaning procedures for frequently touched surfaces and surfaces that come into direct contact with people's skin.
7. Always practice good hand-washing techniques by washing your hands with warm soapy water. (3,4,5)

The best thing that you can do for your son is check his skin regularly during his sport season. Monitor his skin for rashes that look like bug bites or boils. If he develops a suspicious looking rash or lesion, bring him to your health care provider for an evaluation. It is also a good idea to make sure that all cuts and abrasions are covered with a secure dressing. If it is not posssible to keep a secure dressing intact during your child's sport then it is best to refrain from that sport until the wound is healed.

It is important to teach your son to not share towels, clothes, razors or any other personal items with his teammates. MRSA can be spread from personal items of a person who may not appear ill. Some people can be carriers of MRSA and spread the infection to others. In addition MRSA can remain alive on environmental surfaces, such as benches, mats or gym equipment for varying amounts of time, sometimes weeks or longer. (6) Therefore using a barrier (such as a towel) between you son’s bare skin and these items can help prevent the spread of infection.

Lastly, make sure you son showers immediately after returning home from practice or games. Although the CDC does not recommend a particular soap, Herbalists and Practitioners of Homeopathic medicine support the use of soap with Tea Tree oil. Tea tree oil comes from the Melaleuca tree which is native to Australia. It has been used as a traditional medicine by the people of Australia for over a hundred years. Tea tree oil has potent anti-bacterial and anti-fungal properties and can be effective against MRSA (7, 8, 9, 10).

I wish you luck with your son and hope he stays infection free!

For More Information About Topics Discussed:

Methicillin-resistant Staphylococcus aureus

Recurrent Boils

Skin Infections

Tea Tree Oil

References:
(1)Grundmann H, Aires-de-Sousa M, Boyce J, Teimersma E. Emergence and resurgence of methicillin-resistant Staphylococcus aureus as a public-health threat. Lancet: DOI: 10. 1016/S0140-6736(06)68853-3.
(2)Stephenson M. MRSA on the rise, even in newborns. Infectious Diseases in Children. 2006. Sept:43-44.
(3)Centers for Disease Control and Prevention. Community-Associated Methicillin Resistant Staphylococcus aureus (CA-MRSA). Available at: http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html. Accessed Nov 2007.
(4)Stphenson M. Community-acquired MRSA a ‘new normal’. Infectious Diseases in Children. 2006. Sept. 68-69.
(5)Elston D. More MRSA infections are headed your way. The Clinical Advisor. 2006. July:67-69.
(6)Wood D. On the Front Lines Against MRSA. Nursing Spectrum. 2007. Nov:12-13.
(7)Hammer KA, Carson CF, Riley TV. Susceptibility of transient and commensal skin flora to the essential oil of Melaleuca alternifolia (tea tree oil). Am J Infection Control. 1996. June 24(3):186-9.
(8) Pepping J. Medicinal Uses of Herbs. Audio-Digest Pediatrics. 2000. 46(8).
(9) Hada T, Furuse S, Matsumoto Y, Hamashima H, Masuda K, Shiojima K, Arai T, Sasatsu M. Comparison of the effects in vitro of tea tree oil and plaunotol on methicillin-susceptible and methicillin-resistant strains of Staphylococcus aureus. Microbios. 2001. 106(Supp) 2:131-41.
(10)Carson CF, Cookson BD, Farrelly HD, Riley TV. Susceptibility of methicillin-resistant Staphylococcus aureus to the essential oil of Melaleuca alternifolia. J Antimicrob Chemother. 1995. Mar;35(3):421-4.

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

Pediatric Advice on the Web

Car Accident

2007-08-20T23:54:00.000-04:00

Dear Lisa,

My 9 year old brother was in car accident and he is located in a different state and the doctors said that he has swelling of the brain, fluid in his lungs, and his eye is big as a golf ball and black, he is also currently in a coma. I was wondering what you think might go wrong and if there is a chance he might not make it, because if so I want to fly down to get to him as quick as possible.

Thank You!!!!!!!

NewlyWedJW07

Dear "NewlyWedJW07",

I am very sorry to hear about your brother's accident. It sounds like his condition is very serious. I suggest that you call the Intensive Care Unit and ask to speak to the Intensivist (a doctor who specializes in Intensive Care Medicine) in charge of his case. The Intensivist will be able to give you information about your brother’s condition, his progress and his prognosis. One important question to ask is, if your brother is in a coma because of his condition, or if the coma was medically induced in order to help him heal.

The Intensivist will be able to tell you when your brother is in the condition to be transferred to another facility. He will also be able to tell you what type of facility that would suit your brother’s needs. If you are an adult and are in a position to make decisions about your brother's health then your presence in the Intensive Care Unit, at his side, would benefit him during this difficult time. Decisions regarding your brother's treatment and care need to be discussed with the responsible adult. These types of discussions are typically best done in person because of the complexity of the situation.

I wish you and your family Godspeed and hope your brother’s situation improves.

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

Pediatric Advice on the Web

Sexual Activity

2007-04-16T01:39:00.000-04:00

Dear Lisa,

Can an exam by an Ob/Gyn determine how long ago a 15 year old female has had sex?

“Curious Father”

Dear “Curious Father”,

A gynecological examination of a teenager cannot necessarily reveal whether or not sexual activity has taken place. Nor can a vaginal examination tell you how long ago a female had sex. Many people are under the impression that an examination of the female's hymen can reveal if and when she had sex. This is not true. The appearance of a normal hymen is quite variable.(1,2) These many different presentations are all considered normal. Not only does the hymen’s appearance vary from person to person, but examination techniques and positioning can affect what the examiner sees.(3)

Once a female experiences puberty normal hormonal changes cause the hymen to become very elastic and distensible. Because of this elasticity, it is unlikely that injury will occur when vaginal penetration occurs.(4) Therefore if an adolescent with a history of vaginal penetration is examined, it is unlikely that there will be signs present that penetration occurred. Actually, genital examinations performed on sexually abused children are often normal.(5,6,7)

On the other hand, the presence of a Sexually Transmitted Disease (STD) in an adolescent is evidence that the child engaged in sexual activity. Although, this does not reveal what type of sexual activity occurred. When a child or an adolescent has a sexually transmitted disease the assumption is that the child had to have come in contact with infected genital secretions.(4) This contact with genital secretions could have been either direct genital to genital contact or indirect contact through touching with hands containing infected secretions.(4)

Some Sexually Transmitted Diseases such as Syphilis or Genital Herpes can present with visual skin manifestations that can be observed upon physical examination. Symptoms of Genital Herpes for example may develop within four to six days of initial exposure ,with healing of the lesions often taking several weeks. (8) Primary Syphilis causes a deep, indurated, painless lesion 10 days or more after infection.(9) Many times the Primary Syphilis lesion goes unnoticed. Secondary Syphilis symptoms can be seen 2 to 6 weeks after initial infection. These signs may include a diffuse rash on the arms, legs, trunk, palms and soles or wart like growths in the genital area.(9)

Other STD’s may not present with any physical findings or symptoms at all. These include Human Papillomavirus, Chlamydia, Gonorrhea and HIV. (10,11,12 ) Therefore specific testing for Sexually Transmitted Diseases needs to be performed in order to determine if a Sexually Transmitted Disease exists.

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

Preventing Sexually Transmitted Diseases

Signs of Sexually Transmitted Diseases

Child Abuse

Adolescent Sexual Behavior

References:
(1)Gardner JJ. Descriptive study of genital variation in healthy, non-abused premenarchal girls. J Pediatr. 1992. 120(2 Pt 1):251-257.
(2)Mccann J, Kerns DL. The Anatomy of Child And Adolescent Sexual Abuse. A CD-ROM Atlas/Reference. St. Louis, MO:Intercorp:1999.
(3)Finkel M, DeJong A. Medical findings in child sexual abuse. In: Reece, R, Ludwig, S. eds. Child Abuse: medical Diagnosis and Management. 2nd ed. Philadelphia, PA. Lippincott Williams & Wilkins. 2001:207-286.
(4)Giardino A, Finkel M. Evaluating Child Sexual Abuse. Pediatric Annals. 2005. 34(5):382-394.
(5)Adams JA, Harper K, Knudson S, Revila J. Examination findings in legally confirmed child sexual abuse: it’s normal to be normal. Pediatrics. 1994. 94(3):310-317.
(6)Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Negl. 2002. June 26(6-7):645-659.
(7)Adams JA. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Child Maltreat. 2001. Feb:6(1):31-36.
(8)Greers TA, Isado CM. Update on antiviral therapy for genital herpes infection. Cleve Clin J Med. 2000. 67:567-573.
(9)Fortenberry JD. Sexually Transmitted Infections. Pediatric Annals. 2005. 34(10):803-810.(10)Grimshaw-Mulcahy L. Chlamydia: Diagnosing the Hidden STD. The Clinical Advisor. 2006. March:32-42.
(11)Reitman D. Update on Sexually Transmitted Diseases: Gonorrhea and Chlamydial Infections. Consultant for Pediatricians. 2006. March:155-160.
(12)Reitman D. Update of Sexually Transmitted Diseases: Human Papillomavirus Infection. Consultant for Pediatricians. 2006. June:353-360.

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

Pediatric Advice for Parents with Teenagers

Nocturnal Enuresis

2007-04-13T00:07:00.000-04:00

Dear Lisa,

I have a 5 1/2 year old daughter who still wets the bed every night. She never really had a long span of time that she woke up dry, a day here and there. Before she started kindergarten this past year I really wanted her night trained. I have tried to stay kind and gentle, reminders that she needs to stay dry, waking her before I went to bed and then again during the night, then upon waking telling her to use the toilet. I did the waking her up once or twice during the night for a month before I got frustrated. She would actually go the bathroom with me, but would argue that she didn't need to go. After a minute or two sitting on the toilet I would say ok and send her back to bed. Then 30 minutes give or take later she would be waking me with a wet sheet. She even got to the point that she would just change the pad herself and not wake me. But, she couldn't do it. So, I gave her the goodnight pull ups back and we are still there. She is a sound sleeper.

The Pediatrician group we see says not to worry that it's common and no further testing is required until she's six. She is a healthy growing girl, active and vivacious. She is bright and easy going. This is my only concern about her. I am not 100% certain but my feeling is that she just doesn't mind being wet, may be even enjoys the sensation. She every now and then will have an accident soon after going to bed when I think she is still awake, and in the morning likes to lay in bed awake for a while. I have talked to her many times and she does not like to talk about it, so I don't press it. I have tried one of those hypnosis CD's for kids that still wet their beds, she listened to it once and was uncomfortable with it. So, I gave up on that. I tried bribes, didn't work. What has made this even more frustrating is that my 2 year old son has self potty trained and stays dry at night for months now. I'm not comparing and I'm not sure she even has noticed. But, for some reason I am losing my patience and don't want to wait until she is six.

“Looking forward to dry nights"

Dear “Looking forward to dry nights”,

Nocturnal Enuresis or “Bedwetting” is the involuntary passage of urine at night in a child over three years old. A child who never obtains night time dryness is considered to have Primary Nocturnal Enuresis. Primary Nocturnal Enuresis is a common condition, affecting 5 to 7 million children over the age of five years old.(1)

A question frequently asked by parents of children with Nocturnal Enuresis is, “When will my child stop wetting the bed?” In order to answer this question it would be helpful to investigate the child’s family history. Nocturnal Enuresis is an inherited trait that runs in families. In many cases it is found that the mother or father suffered from the same condition when they were a child. A good indicator regarding when the bedwetting will stop is the age that the parent stopped wetting their bed.(1) Children are often consoled when they find out that their mother or father suffered from “Bedwetting” until they were 9 or 10 years old. It also helps a child to realize that is not their fault that they cannot stay dry at night.

There are multiple reasons why a child may suffer from Nocturnal Enuresis. The most common cause is decreased arousal from sleep.(1) When this occurs, the child does not have the ability to sense a full bladder during sleep and spontaneously awake in response to this message. Bedwetting may also be caused by a small bladder capacity. A small bladder capacity does not allow the child to store the urine that the body makes overnight.

In order to determine a child’s bladder capacity the urine output is measured over the span of three days. This is done by collecting 10 daytime voids over a three day period. Each individual amount is measured and recorded and then the average is calculated. The average of the collections is that particular child’s bladder capacity. This number is then compared to the average bladder capacity of a child that same age. The sum of a child’s age in years plus two equals the number of ounces of average bladder capacity.(2) For example, a 5 year old child is expected to have a bladder capacity equal to : 5 + 2 = 7 ounces. It is not unusual for the bladder capacity of bedwetting children to be much less than average for their age.(1)

Some children experience bedwetting because they do not have sufficient amounts of anti-diuretic hormone or ADH.(3) The production of this hormone normally increases at nighttime in a person who does not suffer from enuresis. This normal physiologic change causes a smaller amount of more concentrated urine to be produced at night. In children with decreased secretion of ADH, diluted urine continues to be produced at night at the same rate that it is produced during the day. As a result children need to wake several times during the night to eliminate the urine that they produce.

Children can also suffer from other medical conditions that may contribute to Nocturnal Enuresis. Food sensitivities, Constipation, Obstructive Sleep Apnea, Attention Deficit Disorder, Psychological factors and stress can all cause a child to wet their bed at night.(4) Side effects to certain medications such as antihistamines or antidepressants are another potential cause of bedwetting in the pediatric population.

Generally speaking, interventions to alleviate bedwetting are not initiated until a child is six years old.(1) It is quite normal for many children to experience daytime control first with night time wetting continuing on a nightly basis. Nighttime dryness is then achieved gradually, where a child experiences less frequent wet nights over a period of time. (4) In about 15 % of the cases ,night time dryness is spontaneously achieved with no intervention.(1) Therefore a child following this pattern may not need any interventions in order to stop the behavior.

For children who require interventions, natural measures are recommended before the initiation of pharmacological therapy. Typically medication is not utilized as first line therapy because of the potential for high relapse rates and potential side effects to the medication.(4)

Children with daytime wetting, daytime leaking, stool incontinence, constipation, history of Urinary Tract Infections, a sacral dimple or tuft of hair, or abnormal gait should be evaluated and treated by a health care professional without delay. These are concerning signs that may represent complications or more serious health conditions. Otherwise pressuring a child to accomplish dryness at night before they are ready may cause undue stress and feelings of inadequacy or embarrassment. Measures such as punishing or shaming may also be harmful and can contribute to feelings of low self esteem.(5)

From the information that you gave, your daughter’s symptoms are consistent with Primary Nocturnal Enuresis. It also seems that the measures that you have taken so far have not made a difference in her behavior. It sounds like these failed attempts are beginning to frustrate you. Be assured that Primary Nocturnal Enuresis is a common condition found in children your daughter's age. Your daughter may just not be mature enough at this point to overcome her problem.

Since your daughter was already evaluated by your Pediatrician, is not suffering from any health conditions and is not experiencing any concerning signs, a good approach at this point would be to not bring attention to her condition. This does not mean that you should ignore her bedwetting all together, but instead re-address the issue when she is 6 years old just as your Pediatrician suggested. Otherwise the negative feelings and defeat that you are experiencing may be transferred to your daughter which may ultimately worsen the situation.

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

Secondary Enuresis

Food Sensitivities and Enuresis

Treatment for Bedwetting

Urinary Tract Infection

Attention Deficit Disorder

Obstructive Sleep Apnea

Risk Factors for Obstructive Sleep Apnea

Constipation

References:
(1)Mercer R. Dry at Night. Advance for Nurse Practitioners. 2003.February:26-29.
(2)Maizels M, Rosenbaum D, Keating B. Getting to Dry: How to Help Your Child Overcome Bedwetting. Boston, Mass: The Harvard Common Press;1999.
(3)Rittig S, Knudsen R, Horgaard J, Pedersen E, Djurhuus J. Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. Am Physiologic Soc. 1989.363:6127-6189.
(4)Zacharyczuk C. Psychosocial implications of nocturnal enuresis demand treatment.Infectious Diseases in Children. 2006. April:72-73.
(5) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1042-1043.

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

Pediatric Advice on the Web

Death of a Friend

2007-04-11T11:59:00.000-04:00

Dear Lisa,

My 5 year old daughter has had a friend die. She did not know her very well, only has played with her a few times. They attended the same school but were in different classes. But, the school became quite involved having fundraising activities. Her teacher had the class make several crafts for her during her illness (inoperable brain tumor) and her Daisy Troop also has made things for her. They have had discussions in class that were general and have hospice and counselors on hand for them if needed.

Here is my question. If my daughter does not understand what happened (death), and is not showing any signs of sadness or grief, should I take her to the funeral? Many of the families in my situation are contemplating taking their children. I'm not sure and do not want to cause any unnecessary stress for her or the family that has suffered this terrible loss(seeing a child that may be smiling or laughing or seeking out a playmate at the funeral). Hospice says let your child take the lead, should I ask her if she wants to go? This has been tough, her first exposure to sickness and death. The family of this child has welcomed the community to the interment. I have read the book, What’s Heaven to my daughter and she does not really understand or seem phased. What are your thoughts?

Thank you,

“Sad Situation”

Dear “Sad Situation”,

I am sorry to hear about the loss in your life. Understanding and coping with the concept of death is very difficult for a family, especially when a young child is involved. Children at different ages deal with death differently. The way a child handles death depends upon their developmental stage, psychological development, previous experience with death, emotional maturity, coping abilities, environment, culture and parental attitudes.(1) The way that your daughter is responding to her friend’s death is quite normal.

In order to help a young child cope with death it is important to understand their thinking processes. Because of your daughter’s young age and developmental stage, she does not fully comprehend the meaning of death. This is especially true because she has had no previous experience with death in her life. Young children may use the word “die” or “death” in conversation but this does not mean that they truly understand what the word means.

Naturally a young child will handle death much differently than a teenager or an adult would. This is because specific patterns of behavior and understanding are expected at different ages. Developmentally speaking, a pre-school child, or a child between 3 and 6 years old, views the world from the perspective of their own experience. In other words, they see themselves as the "center" of the world. Young children interpret experiences depending upon how they relate to them directly. Young children can not relate to the feelings of others or to situations that occur to families outside of their “world”. Therefore it is normal for a young child not to display sympathy for others or not to seem phased by something bad that happens to someone else. A death occurring to a person outside of their immediate circle may not seem to affect them.

Children at a young age also cannot comprehend the finality of death. It is hard for them to believe that death is a “permanent” separation. Very often children view death as a temporary situation. Most young children believe that death is reversible.(2) This may be due to their exposure to death from the media through the shows that they watch on television.(1) While watching a cartoon a child sees a character die only to see them come right back to life again, usually unharmed. A child can watch a television show one day where a character dies and the next day the same character is on the television appearing very alive and healthy. This only confuses their perception of death and reinforces their belief that death is reversible.

Since your daughter’s friend was a casual acquaintance that only played with her a few times, her death probably will not directly affect your daughter's everyday life or seem to bother her. Most likely she will not need the funeral ceremony to help her cope with this young girl’s death. Since her friend was not a close family member, your daughter’s attendance at the funeral would not likely be a necessary step in her coping processes and understanding of death.

Ultimately it is a parent’s decision if a young child should attend a funeral. When making this decision it is important to know that children under seven years old and girls are particularly sensitive to funeral activities. (2) Therefore having your daughter attend the funeral may not be beneficial in this particular situation. If a parent decides that their child should go to a funeral, it is a good idea to discuss it with the child first. A young child needs preparation and an explanation of what to expect; what it will look like and how others will be acting.

If you ask a young child if she wants to go to a funeral, chances are she will not have the ability to make that decision because she doesn’t have any experience with death and never has been to a funeral. When you explain to a child that a funeral is not a place for playing with friends or make noise, but a place to be quiet, most children will not want to attend.

If a child does not attend a funeral it is still important that you answer any questions that she may have about the funeral and death. Young children experience magical thinking and it is often necessary to clarify any misconceptions that they may have. Young children tend to believe that their thoughts can control what happens to others.(1) Therefore, if a young child had a disagreement with a friend and wished bad thoughts for that friend and then their friend died, the child may believe that they caused the death. This is why it is important to talk to a child about their understanding of a death that occurs in their life.

Children also lack the reasoning power that adults have. They cannot make appropriate connections between events or the sequence of events.(1) Young children do not have the cognitive ability to think through the beginning, the middle and the end of a story. Instead, young children tend to connect events that do not belong together. As a result they commonly fill in the blanks with their imagination. Many times the images that they conjure up are scarier then the truth itself. For example, if your daughter was playing with dolls the last time she played with her friend, she may come to the conclusion that the dolls caused her friend to die. This is why it is better to tell a young child the truth about the circumstnces surrounding a death experienced in their life. Specific details are not necessary, but the proper order of events is.

It is wonderful that you read your daughter the book that you did. She may not have seemed to understand the concepts that you were trying to teach her but spending time with her reading this book let her know that you are there to love and support her. I suggest that you sit down and talk to your daughter about her feelings about her friend’s death. Let her know that it is okay to ask questions. Answer any questions that she may have very simply and at a level that she can understand.

It is likely that you will need more emotional support than she does at this time. Seeking comfort and counseling from support systems for yourself will help you cope with this tragic loss and in the end benefit your family as a whole.

I wish your family peace during this sad time.

References:
(1)Huntley T. Helping Children Grieve. When Someone They Love Dies. Minneapolis, MN: Augsburg Fortress. 1991:9-42.
(2) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA: W.B.Saunders Company. 1994:689-709.

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

Pediatric Advice For Parents of Young Children

Mouth Sores

2007-04-09T10:21:00.000-04:00

Dear Lisa,

Is there anything that can be done at home if your 2 year old has mouth sores?

“Child with Mouth Sores”

Dear “Child with Mouth Sores”,

That is a very good question! We all know how painful and irritating mouth sores can be. Sores in the mouth can interfere with eating and talking. For children, mouth sores can be a major problem. The pain can keep them from eating and drinking which can lead to dehydration and its complications. (1)

In order to prevent dehydration it is a good idea to offer foods that will not irritate the lesions. Foods with sharp edges such as crackers, pretzels or chips can cause pain and scratch the mouth sores. This will most likely worsen the situation and cause the child to refuse further atempts to eat or drink. Ice pops are a good choice because the coldness helps take away the pain and provides a fun way to get fluids into a child that may not be eating or drinking well. Offering cold liquids with a straw under parental supervision can also be helpful. Using a straw directs the fluid away from the sores and towards the side of the mouth without pain. Foods such as sherbet, Jell-O, pudding, ice cream, applesauce and soft fruits in syrup, such as cling peaches are easy to eat and can help soothe painful mouth sores.

In order to treat the pain you can apply Baby Oragel to the lesions with a Q-tip. Many Doctors and Nurse Practitioners also recommend a homemade mixture of Benadryl and Maalox. Equal parts of Benadryl and Maalox mixed together and applied with a Q-tip directly to the sores can help soothe the pain. Both of these remedies numb the area and temporarily take away the pain.

These interventions are helpful for sores located at on the gums, on the inner lips, on the inner cheeks and on the tip of the tongue. It is important not to apply Baby Oragel or Benadryl/Maalox mixtures to the back of the mouth of a young child and not to let the child drink the solution. The numbing affects may interfere with a young child’s ability to swallow properly.

Mouth sores that persist, accompanied by a fever, or those interfering with eating should be evaluated by a Physician or Nurse Practitioner. Some common causes of mouth sores in the Pediatric population include Cold sores from a virus, Coxsackievirus and Oral thrush. Other signs of Coxsackievirus include fever, diarrhea, sore throat and lesions on the palms of the hands and soles of feet.(2)

I hope your child is feeling better soon.

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

Coxsackievirus

Hand Foot Mouth Disease

Oral Thrush

Signs of Dehydration

Ways to Determine if Your Child is Urinating

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1675.
(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. 1990:478.

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

Pediatric Advice On the Web

Itchy Rash

2007-04-06T08:34:00.000-04:00

Dear Lisa,

My daughter's skin has been having these weird bumps. They spread faster than anything I've seen. They itch her incredibly and scratch all the time. They are red and once they go away, they leave scars, big black scars. I don't know how to help her get rid of them. I have been to the doctor with her, and they gave her an ointment that worked just a little bit, unfortunately after a few weeks or months, it would spread all over her body again.

She also has a wedding to go to in a few months and she can't even show her legs in the dress she wants. I'm hopeless and have no idea how to help her. Lisa, what should I do?

“bday4life111”

Dear “bday41ife111”,

Unfortunately without physically examining your daughter I cannot tell you the cause of her rash. I can tell you about itchy rashes that commonly occur in childhood. These rashes include Atopic Dermatitis or Eczema, Scabies, Bed bugs and Chicken Pox.

Atopic dermatitis (AD) or Eczema is a hereditary skin condition that is commonly found in the pediatric population. It is a chronic, relapsing inflammatory skin rash that tends to occur in allergic individuals. The main symptom of eczema includes itching, which in some cases can be so intense that it wakes a child at night. The incidence of AD or Eczema is on the rise in Western and developing countries worldwide. The prevalence of Atopic Dermatitis is 15 to 20 % in school children in the United States and Western Europe which reflects a two to threefold increase in the past 30 years.(1)

Outbreaks of Eczema can be triggered by psychological stress, weather changes, humidity, texture of fabrics, contact irritants, excessive bathing and food. In younger children, food allergy is a common trigger with eggs, milk, soy and wheat being the most likely candidates.(2,3,4)

Scabies is a rash that is caused by a hypersensitivity to a parasitic mite. The symptoms of Scabies include intense itching which occurs especially at night. (5) The rash is very similar to a wide spread case of contact dermatitis and many times is mistaken for Eczema. In older children the rash is typically found on the skin between the fingers, around the belly button area, the wrists, the buttocks, the belt line, thighs and the penis. Infants younger than two years old typically do not present with the classic “Scabies” rash. The rash on younger children appears more like vesicles and is likely to occur on the head, neck, palms of the hands and soles of the feet.

Occasionally, 2-5 mm red-brown nodules can be found that persist for weeks or even months after a person is treated. These nodules are formed in response to the dead mites that remain on the skin after treatment. Scabies is spread through close personal contact with people who have the condition and is usually found in more than one person in the family. Once a family member is diagnosed with Scabies measures should be taken to prevent the spread of the condition to other members in the household.

There has been a recent resurgence of “Bed Bugs” or Cimex Lectularius Cimicidae. “Bed bugs” are flat wingless bugs that tend to be found in people’s mattresses. Their size ranges from the size of a poppy seed to ¼ inch in length. They live off of the blood of warm blooded animals and tend to bite humans in their bed at night when they are sleeping. Their color ranges from nearly white (just after molting) or a light tan to a deep brown or burnt orange. (6)

A child bit by “Bed Bugs” can develop a hypersensitivity reaction to the bug’s saliva. This allergic response is quite itchy and looks like a flea or mosquito bite. The rash usually occurs 1 ½ days after the bite occurs. The location of the bites from “Bed Bugs” include the parts of the body that are exposed during sleep, as opposed to flea bites which tend to occur on the ankles. (7)

Chicken Pox is another skin condition that causes a child to develop itchy skin lesions. Chicken Pox is an acute illness caused by the Varicella Zoster virus. The symptoms include a one to three day prodrome in which the exposed person experiences a fever, respiratory symptoms and a headache. Following this three day period a rash develops. At first the rash appears as red flat lesions which then erupt into dew dropped shaped, fluid filled sacs on top of a red base.(1)

The rash typically spreads throughout the entire body including the torso, extremities, face, scalp and in some cases the mucosal surfaces(inside the mouth).(8) Chicken Pox lesions can cause intense pruritis (itchiness) and lead a patient to have uncontrollable scratching. Once scratched, the lesions form a scab and once healed may leave scarring. New crops of lesions erupt each day, leaving a patient with a rash consisting of lesions at all different stages.

Once the rash develops, Chicken Pox lasts for approximately five days but may last for more than a week especially in immunocompromised patients. Since you described your daughter’s rash to occur for a few weeks and then reoccur weeks or months later, it does not fit the description of a Chicken Pox rash.

The best way to determine the cause of your daughter’s skin condition and the proper treatment course is to have her evaluated by a Pediatric Dermatologist. In most cases a diagnosis can be made through your child’s history and direct examination. In some cases a biopsy may need to be performed to determine the cause of a rash. A Dermatologist will also be able to recommend special make-up to cover up the scars on your daughter’s legs if they have not faded in time for the wedding.

I hope your daughter finds relief from her symptoms and enjoys the wedding.

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

Scabies

Norwegian Scabies

Eczema Treatment

Bed Bugs

Chicken Pox

References:
(1)Dohil M, Eichenfield L. A Treatment Approach for Atopic Dermatitis. Pediatric Annals. 2005. 34(3):201-210.
(2)Rosenthal M. Pediatricians treating more patients with atopic dermatitis. Infectious Diseases in Children. 2006. April:56.
(3)Photo Quiz. Blame the Family Pet for These Rashes? Consultant for Pediatricians. 2006. May:308.
(4)Nassif A, Chan SC, Storrs FJ, Hanifin JM. Abnormal skin irritancy in atopic dermatitis and in atopy without dermatitis. Arch Dermatol. 1994. 130(11):1402-1407.
(5) American Academy of Pediatrics. Scabies. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:387-390:468-470.
(6) Harvard School of Public health. Available at: http://www.hsph.harvard.edu/bedbugs/#examined. Accessed April 2007.
(7) University of Kentucky Entomology. Available at: http://www.uky.edu/Ag/Entomology/entfacts/struct/ef636.htm. Accessed April 2007.
(8)Pang M. Spot the Rash. Infectious Diseases in Children. 2006. March:90.

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

Pediatric Advice For Parents

Coughing Infant

2007-03-24T20:32:00.000-04:00

Dear Lisa,

My 6-month old baby is teething, but for the last, she had a running nose. This morning when she woke up, she had a very bad cough. We don't have a medical aid, but she has to see a doctor. Can you please give me some advice?

God bless.

“Worried Mom”

Dear “Worried Mom”,

Babies that are teething tend to have a runny nose and drool a lot. Other signs of teething include waking at night, bulging gums, bleeding gums, fussiness, irritability, putting objects or fists in the mouth, biting and gnawing.(1) These symptoms seem to intensify a few days before a tooth actually erupts. Babies may also experience diarrhea, a diaper rash, low grade fever and cough right before they “break a tooth”.

It is normal for a baby that is teething to cough a few times per day. Coughing is a natural protective mechanism that clears the secretions from the baby’s airway. If the frequency of the cough is more than a few times per day or if the quality of the cough is deep or harsh, it may be due to another condition.

Constantly putting hands and teething rings in the mouth increases an infant’s exposure to germs that cause Upper Respiratory Infections. It is common for a baby to develop a virus or an Upper Respiratory Tract infection while teething. Therefore, the development of a cough in a teething infant can be a sign of a respiratory infection. Signs of an Upper Respiratory Tract infection include; nasal discharge, sneezing, fussiness, decreased appetite and cough.(2)

Many times it is difficult to differentiate a baby who is teething from one with an Upper Respiratory Tract infection. Therefore it is a good idea to have a baby with a cough or signs of a respiratory infection evaluated by a health care professional. In addition, infants are at risk for developing complications from an upper respiratory infection. These complications may include Otitis Media (Middle Ear Infection), Bronchiolitis or Pneumonia.

Otitis Media is the infection of the middle ear cavity. It is commonly referred to as a Middle Ear Infection. A Middle Ear infection is a common childhood ailment which accounts for 20% of all visits to the doctor during the first five years of life.(3) The symptoms include earache, sensation of “blockage” of ears, rubbing or pulling ears, hearing loss, fever, irritability, upper respiratory symptoms, vomiting or diarrhea.(3)

Bronchiolitis is one of the most common and serious viral infection that affects the lower respiratory tract in young children.(4) Almost 85% of cases are caused by the RSV virus. 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.(5) Signs and symptoms of Bronchiolitis last for 10 to 14 days with the most intense symptoms occurring by the fifth day.(5)

Bronchiolitis is usually a mild and self limiting disorder, but in some cases it can become quite serious. It happens to be the most common cause of hospitalization among infants. 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.

Signs of Pneumonia in an infant include fever, fast breathing and irritability. (6) In some cases an Atypical Pneumonia may occur which presents with different symptoms. Signs of Atypical Pneumonia include; cough, fast breathing or wheezing. A fever is typically not present in a child with Atypical Pneumonia. (6)

The diagnosis of Pneumonia is made from a physical examination, bloodwork and X-rays. Many times X-ray results will "lag behind" the clinical presentation of Pneumonia. In other words, an initial X-ray will show normal results, but a follow-up X-ray performed at a later date demonstrates signs of Pneumonia. (6) Sputum analysis is routinely not performed on children because of the difficulty of obtaining a suitable specimen. (6)

It is a good sign that your daughter is not experiencing difficulty with feeding, irritability, fast breathing or fever. It is important to watch for these signs because they can represent a condition more serious than teething. Concerning signs include a baby who will not drink, fever over 100 degrees Fahrenheit, increased respiratory rate, increased work of breathing, nasal flaring, retractions (chest wall sucks in between the ribs with breathing), wheezing, pale or blue color and a baby that cannot be consoled. If your baby is experiencing any of these symptoms an evaluation by a Physician should be performed without delay.

I hope your baby is feeling better soon.

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

Teething

Baby with Cold Symptoms

Otitis Media

Treatment for Cough

Chronic Cough

Bronchiolitis

Pneumonia

References:
(1)Grassia T. Talking teething: Start god oral hygiene early. Infectious Diseases in Children. 2006. August:44.
(2) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 707-708.
(3)Alper B, Fox G. Acute Otitis Media. The Clinical Advisor. 2005. April:78-86.
(4)Linzer JF, Guthrie CG. Managing a winter season risk: bronchiolitis in Children. Pediat Emerg Med Rep. 2003.8:13—24.
(5)Bradin SA. Croup and Bronchiolitis: Classic Childhood Maladies Still Pack a Punch. Consultant for Pediatricians. 2006. Jan:23-30.
(6)Nield L, Mahajan P, Kamat D. Pneumonia: Update on Causes-and Treatment Options. Consultant for Pediatricians. 2005. Sept:365-370.

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

Pediatric Advice For Parents

Noisy Breathing

2007-03-22T19:09:00.000-04:00

Dear Lisa,

My 6-week-old's chest is noisy when he breathes. His nose is not running, he doesn't have a fever, he doesn't have a rash, his appetite is not affected, but he is irritable. What could be wrong with him?

“Buttaflies”

Dear “Buttaflies”,

The chest wall of an infant is very thin and pliable as compared to the chest wall of an adult. Because of this it is very easy to see the muscles in the chest move and hear rumbling from inside of the chest. Babies are also obligate nose breathers which means they breathe only through their nose, not their mouth. They continue to be nose breathers for the entire first year of life. Since all of an infant’s breathing is through his nose, the slightest congestion or mucus tends to make a lot of noise.

Young infants can be very noisy breathers when their nasal passages are congested. The sounds of upper airway congestion can transmit to the lower airway and sound like they are coming from the chest instead. A newborn can develop nasal congestion due to irritants in the environment or due to the build up of secretions from an Upper Respiratory Tract Infection. Signs of an Upper Respiratory Tract infection include nasal discharge, sneezing, fussiness, decreased appetite and an occasional mild cough.(1)

One of the most common causes of obstruction of the airway and resulting noisy breathing in a child is Adenoidal Tonsillar Hypertrophy or enlarged tonsils and adenoids. Tonsil and adenoid tissue can enlarge from recurrent infection, allergy and from non-specific stimuli. (2) Signs of enlarged tonsils and adenoids include snoring, snorting, obstructive sleep apnea and recurrent ear infections.(2) Enlarged tonsils and Adenoids are diagnosed by neck x-ray or by nasopharyngoscopy performed by an Otolaryngologist. (2)

As a child grows the diameter of his airway naturally enlarges. The increased size of the airway can better accommodate the tonsillar and adenoid tissue. In many cases the symptoms of enlarged tonsils and adenoids disappear as a child grows older.

Laryngomalacia is another common pediatric condition that causes noisy breathing during infancy. The symptoms include Stridor or a “high” pitched inspiratory wheeze that begins at birth or shortly after birth. Laryngomalacia is caused by a softening of the cartilage in the upper airway. When a child has Laryngomalacia his upper airway temporarily collapses during inspiration. The airway then opens again during expiration or when the baby exhales.

The breathing of a child with Laryngomalacia is the loudest when he is feeding or quietly relaxing. Viral infections tend to exacerbate the symptoms of Laryngomalacia. The loud breathing usually diminishes during sleep or when the child is crying.(2) As a child grows the cartilage all over the body, including the cartilage in the airway hardens. Because of this, as a child ages the symptoms of Laryngomalacia decreases. In most cases Laryngomalacia resolves on its own by the time the child is one year old.(2)

The presence of a Hemangioma in the airway is another potential cause of Stridor in the newborn period. A Hemangioma in the subglottic space is one of the most common types of airway lesions found in the pediatric population.(2) Children with stridor who also have a Hemangioma on their skin have an increased chance of having a Hemangioma in the airway.(2)

The facts that your baby does not have a fever, has a good appetite and is not in respiratory distress are all good signs. The noisy breathing that you hear may be due to normal newborn congestion or due to an Upper Respiratory Infection or the "Common Cold". An evaluation by your Pediatrician can guide you regarding the proper diagnosis and treatment. If your child’s symptoms continue to concern you a consultation with a Pediatric Pulmonologist can ease your worries by diagnosing the condition that is causing his noisy breathing.

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

Baby with Stuffy Nose

Newborn Congestion

Treating Baby’s Cold Symptoms

Newborn Breathing Problem

Obstructive Sleep Apnea

References:
(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 707-708.
(2)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:424-425.

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

Pediatric Advice For Moms with Newborns

Strep Infection

2007-03-20T14:11:00.000-04:00

Hello Lisa,

I just happened to come across your site and am so glad I did. My question is that I have a 3 year old daughter who since early this morning has vomited four times in four hours and her morning stool had streaks of blood and when I wiped her there was pinkish red blood on the paper. I'm not sure if this would help but two days ago she broke out in what almost looked like acne on her chin and neck. I counted 13 little bumps. I'm not sure if they could be related but just in case I wanted to mention it. I tend to over react so your opinion would be greatly appreciated.

Thank you in advance.

“Pimples on the chin”

Dear "Pimples on the chin",

Pimples around the mouth in a young child and vomiting can both be signs of a group A beta hemolytic Streptococcus infection or Strep throat. Other signs of Strep throat include fever, painful throat, decreased appetite, drooling, stomach ache, bad breath, headache, runny nose, swollen lymph nodes in the neck, nausea, and abdominal pain. (1,2) Although Strep Pharyngitis is usually associated with fever, some children with Strep have little or no fever at all.(1)

Symptoms that are specific for a Strep infection include pettechiae or red spots on the soft palate and a fine sandpapery like rash on the torso. (1,2) A new type of skin rash associated with Strep pharyngitis has been documented in the literature. It has been described as a painful, itchy, burning rash on the palms of the hands, soles of the feet, buttocks and knees. Once the infection resolves the skin in the area of the rash tends to peel. This new presentation of Strep is thought to be caused by a toxin-mediated immune response. (3)

Young children are known to put their hands in their mouth and touch their buttocks or vagina. This activity puts a child with Strep throat at risk for also developing Rectal Strep (Perianal Streptococcal Dermatitis) and Vaginal Strep. (4) Signs of Rectal Strep include rectal pain with defecation, rectal itching, redness, and rectal bleeding.(4) When a child infected with Rectal Strep scratches her rectal area the skin becomes irritated and bleeding may occur. Signs of Vaginal Strep include itching and redness of the vaginal area. Discomfort with urination is also commonly found.

Blood in the stool can be a sign of a gastro-intestinal infection, especially if diarrhea accompanies the symptoms. An example of a gastro-intestinal infection that causes blood to appear in the stool is Salmonella. When a child experiences blood in her stool it is necessary to determine its cause. It is a good idea to bring the suspicious stool sample to the Doctor’s office with your daughter for the evaluation. There is a test called a Guaiac or Hemoccult that can be performed on a stool specimen to determine if the red color is truly blood.

Blood in the stool may also occur when a child is constipated. The hardness and large size of the stool can cause a tiny cut or laceration when the stool is passed. This tiny laceration can bleed when a child has a bowel movement. A child with a history of constipation who develops vomiting at the same time should be evaluated by a Physician in order to rule out an intestinal obstruction. Other signs of an intestinal obstruction include abdominal pain and abdominal distention.

It is difficult to assess symptoms in the pediatric population because young children do not have the ability to effectively verbalize and describe what they are feeling. To make matters more complicated, a child’s symptoms can be very general or subtle in nature. For example, a change in temperament or sleep pattern is sometimes the only noticeable sign that a child is ill. A young child with a sore throat is not likely to tell her mother that her throat hurts. Instead she may have a decrease in appetite or refuse to eat or drink all together. Health Professionals who have experience with children are aware of the difficulties in assessing a child’s condition. Therefore, you should not be concerned that you are overreacting when it comes to your child's health.

Without physically examining your child I am not able to definitively tell you what is causing your daughter's symptoms. Only the Physician who performs a physical examination on your child and knows her family and medical history can determine the cause of her symptoms and make a diagnosis. I do feel that your daughter’s symptoms warrant an examination by her Physician . Since her symptoms include vomiting, blood in the stool and pimples around her mouth, a Strep infection should be a consideration.

I hope you find the answers that you are looking for real soon.

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

Strep Pharyngitis

Scarlet Fever

Scarlatina

Breastfeeding with Strep

Infant Exposed to Strep

Pimples around the mouth

Tonsillectomy

Blood in Stool

Constipation

Fecal Impaction

Salmonella

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: 496-498.
(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; 1997:483-485.
(3)Photoclinic. Atypical Rash Associated With Streptococcal Pharyngitis. Consultant for Pediatricians. 2005. Sept:390-391.
(4)Perianal Streptococcal Pharyngitis. Consultant for Pediatricians. 2005. Oct:441.

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

Pediatric Advice About Infectious Diseases

Severe Asthma

2007-03-16T17:55:00.000-04:00

Dear Lisa,

My 8 year old son suffers from severe asthma. We have problems every week to two weeks. It seems that it is getting worse. We are currently taking Singulair, Advair diskus, and Maxair. We also do updraft treatments. Do you have any suggestions? I am worried that it might be something else. We have a family history of COPD, Asthma, alpha 1 antitrypsin def. and lung cancer.

Any thing would greatly be appreciated. Thanks.

“Mom4kids”

Dear “Mom4kids”,

Your son is lucky to have a mom that is so concerned about him and interested in finding ways to improve his condition. Unfortunately, Asthma is a chronic medical condition consisting of periods of exacerbations. It requires frequent medical evaluations, follow up care and in many cases daily medication and treatments.

When a child’s Asthma symptoms occur more than twice per week, the condition is considered to be out of control. The first step in gaining control of your son’s Asthma is to determine and eliminate the triggers that may be exacerbating his condition. Potential Asthma triggers include Allergies, infections, irritants, weather, medications, exercise, hormone fluctuations and emotional stress. (1) The most likely triggers for an eight year old child include Allergies, irritants and emotional stress.

It is important to rule out Allergies as a contributng factor in your son’s condition. If your son is constantly being exposed to products that he is allergic to, his Asthma will continue to remain out of control. Irritants in his environment should also be considered. Irritants known to trigger Asthma include cigarette smoke, wood burning stoves, diesel fuel, air pollution, household cleaning products, air fresheners, powder, perfume and scented candles.

Has there been a change in the environment which may be responsible for the exacerbation of your son’s symptoms? Does he have a new friend that he has been playing with who owns a pet? Does his condition worsen when he sleeps on the sofa or over a relative’s house? Are there cat or dog hairs on his coat or hat? Does he have a new coat or blanket made with down feathers? Is there construction going on in your home or at school? Have you changed the position of the bed in his bedroom? Is the bed now located under a heating vent with the air blowing dust and re-circulated irritants into his face all night while he is sleeping? Is he under stress at school due to a change in work load? These are some of the questions that you need to ask yourself in order to determine if there is something in his environment that is triggering his Asthma.

It may be helpful to keep a diary and write down the environmental conditions, exposures, his activities, the weather, his state of health and any over-the-counter medications that he may be taking. You should record information from the day before his symptoms begin. In some cases there may be a late phase response where symtpoms do not develop until up to 12 hours after an exposure. That is why it is important to record what he was doing the night before his symptoms begin. A consultation with a Nurse Practitioner at an Asthma Specialist’s office can guide you in determining your son’s triggers. There may be certain measures that you can take to control his environment, eliminate triggers and ultimately control his symptoms.

It is important that you have your son evaluated by an Asthma Specialist. Pulmonary Function Testing is a necessary part of the work up which will evaluate his lung function and determine the effectiveness of his medication regime. A complete evaluation should also include the evaluation for underlying conditions that that may be contributing to your son's Asthma. An infection with Sinusitis, Allergies, Gastroesophageal Reflux, Vocal Cord Dysfunction and side effects from medications can all contribute to the worsening of a child’s Asthma.(2)

An evaluation by an Allergist and allergy testing are recommended in order to determine if Allergies are playing a part in your son’s condition. Allergies and Asthma frequently come hand and hand. Allergen exposure happens to be a major trigger of symptoms in 80% to 90% of children with Asthma.(3) If a child is determined to have Allergies; measures taken to control the child’s allergies will also help control the child’s Asthma.

An association between the presence of Gastroesophageal Reflux Disease (GERD) and Asthma in the pediatric population has been noted. GERD is thought to contribute to ongoing Asthma symptoms and may be substantially involved in the underlying pathogenesis of Asthma.(4) Studies have shown that 50 to 63% of children with Asthma also have underlying GERD. Signs of Gastroesophageal Reflux in an older child include heartburn and difficulty swallowing. (5) Other symptoms may include abdominal pain, vomiting, coughing at night, belching and a sour taste in the mouth.(6)

In some cases Gastroesophageal Reflux can be silent, which means there may not be any vomiting or obvious symptoms. The symptoms could present as a cough or worsening of a child’s underlying Asthma. A significant amount of Asthmatic children with unstable disease have silent GERD.(6) A consultation with an Asthma Specialist or Gastroenterologist will be able to tell you if your son’s Asthma is affected by Gastroesophageal Reflux Disease and treat him accordingly.

Vocal Cord Dysfunction (VCD) is another condition that is associated with Asthma. VCD often occurs in patients with Asthma.(7) When a child suffers from VCD they experience a paradoxical movement of their vocal cords which leads to stridor, wheezing, voice changes and cough.(7) A child experiencing an episode of Vocal Cord Dysfunction appears to have difficulty breathing but continues to maintain normal oxygen levels in their body. VCD can be triggered by exercise and stress. An evaluation by an Asthma specialist during an acute episode can diagnose the problem. The treatment for VCD includes speech therapy performed by a speech therapist who has experience with the condition.

Medications that can trigger Asthma include Non-steroidal anti-inflammatory drugs(NSAIDs) and Beta-blockers. Examples of NSAIDs include Motrin, Advil and Aleve. These over-the-counter products are commonly given to children, many times without consulting a Physician. It is important for parents of children with Asthma to know that this drug class can trigger Asthma and should not be given unless under the direction and observation of your Physician. Asthmatic patients can have worsening of their condition when taking these medications and not realize the association.

There has been recent research linking the administration of Acetaminophen with prevalence of Asthma. The proposed mechanism includes the acetaminophen-induced glutathione depletion theory. Glutathione is found in its largest amount in the respiratory tract. It serves as an anti-oxidant and removes molecules that cause airway inflammation.(8) Results from clinical studies suggest that Acetaminophen can exacerbate Asthma.(9)

In regards to your comments about your family history of COPD, alpha 1-Antitrypsin deficiency and lung cancer; of the three, alpha-1-antitrypsin disorder is a potential cause for chronic respiratory symptoms in childhood. COPD is a chronic lung condition that occurs in the adult population and lung cancer is typically found in adults after years of exposure to carcinogens. Children may develop lung cancer if they have cancer in another part of their body that metastasizes to the lungs.

Alpha-1-Antitrypsin Deficiency is a condition that causes liver or lung disease. Jaundice within the first 3 months of life is usually the presenting sign.(10) The diagnosis is made through quantifying levels of Alpha-1-antitrypsin levels in the blood. Since there is a family history of Alpha-1-Antitrypsin Deficiency you may want to discuss having testing done to rule out this condition with your Doctor.

Other conditions that may cause chronic respiratory symptoms in childhood include Foreign Body Aspiration, Cystic Fibrosis, Pertussis, Tuberculosis and IgA deficiency.(6) Cystic Fibrosis is a chronic disorder that is typically found in Caucasians. It is usually associated with difficulties gaining weight, sinus disease and GI symptoms. When a child suffers from an IgA deficiency they experience an increased susceptibility to respiratory infections. IgA is responsible for fighting respiratory infections such as Sinusitis and Pneumonia. Children with a history of recurrent Sinusitis or Pneumonia should be tested for an IgA deficiency.

I hope this information helps and your son finds control of his Asthma symptoms soon.

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

Asthma Triggers

Asthma Treatment

Early Warning Signs of Asthma

Chronic Cough

Allergy Symptoms

Hayfever Treatments

Food Allergies

Pet Allergy

Pneumonia

Sinusitis

Gastroesophageal Reflux

GER in Infancy

References:
(1)Mahr T, Crisalida T, Holingsworth J, Ortiz G, Senske Heier B, Briscoe Waldrop J. Attaining the Inside Track on Asthma Control. The Clinical Advisor. 2006. Dec:S2-14.
(2)The Allergy Report. Allergic Disorders: Promoting Best Practice. Available at: http://www.theallergyreport.com/reportindex.html. Accessed March 2007.
(3)Phipatanakul W. Environmental Factors and Childhood Asthma. Pediatric Annals. 2006. 35(9):647-656.
(4)Gold BD. Review article: epidemiology and management of gastro-esophageal reflux in children. Ailment Pharmacol Ther. 2004. 19(supple 1):22-27.
(5)Hogan M, Wilson N. Asthma in the School-Aged Child. Pediatric Annals. 2003. 32(1):20-25.(6)Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006. 35(4):259-266.
(7)Kaplan A. All that wheezes is not pediatric asthma. The Clinical Advisor. 2007. Jan:31-39.
(8)Eneli I. Acetaminophen and Asthma: Any Connection? Consultant for Pediatricians. 2006. May:281-282.
(9)Eneli, Sadri K, Camargo C Jr, Barr RG. Acetaminophen and the risk of asthma: the epidemiologic and pathophysiologic evidence. Chest. 2005.127:604-612.
(10)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia,PA:W.B.Saunders Company. 1990:408-409.

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

Pediatric Advice For Parents with Sick Children

First Tooth

2007-03-15T19:07:00.000-04:00

Hi Lisa,

I am writing to you to ask you if it is normal for a one month old baby to have teeth coming in? It hasn't broken in yet but I just wanted to know if that is normal.

Well Thank you.

“momsbadgirl”

Dear “momsbadgirl”,

The onset of teething varies from child to child. The duration of teething and amount of pain experienced is also different for each child. The average age for the first tooth eruption is between 6 and 8 months old. (1) This does not mean that it is not normal for a child to “break a tooth” as early as one month old or as late as a year old. The onset of teething often follows heredity patterns. Therefore, if the mother or father was an early teether, then the child may follow the same pattern.(1)

In general, an “early teether” experiences her first tooth eruption at 4 months old. A “late teether” may not develop her first tooth until after she turns one year old.(1) The lower central incisors (bottom middle teeth) are usually the first teeth to come in, followed by the four upper incisors. Next the first four molars usually erupt. The second molars typically do not erupt until after the age of two. Between the ages of 2 and 3 years old a child is expected to have 20 teeth.

Signs of teething typically begin a month or more before the tooth actually erupts. The signs of teething include; drooling, waking at night, bulging gums, bleeding gums, fussiness, irritability, putting objects or fists in the mouth, biting and gnawing.(1) Just before a tooth is about to erupt other symptoms may develop such as a diaper rash, diarrhea, low grade fever and cough. (1)
Some people are under the impression that a high fever is a sign of teething. There is no research or data that supports this notion.(1)

A high fever in a baby that is teething is more likely due to an infection such as a virus. Children who are teething frequently develop viruses.(1) The frequent mouthing of various items such as their hands or teething rings may be responsible for transmitting the germs to the child that cause the infection.

So you do not have to be concerned if your child “breaks a tooth” at one month old. The only challenge of an early teether is keeping the teeth clean. It can be quite difficult to open a young infant's mouth and maneuver your fingers in order to properly clean the teeth. Once the first tooth erupts, it is recommended that it should be cleaned on a daily basis.

The way to clean a young infant’s teeth is to wet a clean wash cloth or piece of gauze and gently rub the teeth each night before bedtime. (1) Using a soft bristle toothbrush and water is another alternative. The American Academy of Pediatric Dentistry does not recommend using toothpaste with fluoride until a child is 2 or 3 years old.

On many occasions parents have informed me that they believed their infant was teething because they saw something white on their child’s gums. In many of these cases a coating of milk or a plaque of oral thrush were mistaken for a tooth. So I would not be surprised if the white you are seeing is something else besides teething. If you are not sure, an examination by your Doctor or Nurse Practitioner will be able to tell you if your child is teething or not.

It is a challenge for many parents to figure out if their child is teething. One major clue is, in many cases teething is accompanied by other symptoms such as drooling or waking at night. Therefore looking for other signs of teething may be helpful. It is true that some children can "break a tooth" and show little or no symptoms at all.(1) From my experience, “early teethers” tend to have additional symptoms such as drooling, gnawing or irritability.

I hope this information helps. I wish you good luck with your new baby.

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

Infant Drooling

Caring for Infant's Teeth

Oral Thrush

References:
(1)Grassia T. Talking teething: Start god oral hygiene early. Infectious Diseases in Children. 2006. August:44.

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

Pediatric Advice About Infant Care

Not Urinating

2007-03-13T22:22:00.000-04:00

Dear Lisa,

My baby daughter has not urinated in about a week what can be the cause of this?

“Baby not Urinating”

Dear “Baby not Urinating”,

If your baby has not urinated in a week she would be extremely ill. Infants and children are expected to urinate approximately 6 times in a twenty-four hour period. Urine is produced hourly at the rate of 1 ml of urine per kilogram of weight per hour.(1) Therefore if your infant weighs 22 pounds or 10 kg she should urinate 10 ml which is equivalent to two teaspoons per hour. This is such a small amount of urine that it can easily go unnoticed.

It is expected that an infant will urinate every 1 ½ hours. Children that are potty trained have the ability to hold in their urine for a few hours and will urinate at intervals throughout the day. Many times parents believe that their child is not urinating because the amount of urine that a child passes is so small that it is difficult to detect in the diaper. This is particularly true for children who wear disposable diapers. Disposable diapers are so absorbent that it is sometimes impossible to tell if a child urinated. To make matters worse, children often urinate at the same time that they have a bowel movement. When this occurs it is too difficult to decipher what part of the dirty diaper is stool and what part is urine.

If you are not sure if your child is urinating, you should rip apart the inside part of the diaper and expose the gel like beads that are beneath the surface. These beads will feel wet and smell like urine if your child urinated. If the inside of the diaper is dry, you should recheck the diaper in 1 ½ hours.

If it is too difficult to determine whether or not the beads are wet, you should bring your baby and the diaper to your Doctor’s office for an evaluation. They will be able to tell if your baby has urinated by weighing her diaper on an infant scale. You should also bring a dry diaper from the same package so that the weight of the two diapers can be compared. If the diaper that your child is wearing weighs more than a brand new diaper, then you will know that your child has urinated.

The conditions that cause a child not to urinate include dehydration, urinary obstruction, renal failure and medication side effects.(1) Other signs of dehydration include dry mucus membranes, a sunken fontanelle (soft spot), decreased tear production during crying, sunken eyeballs, weight loss, increased heart rate, non-elastic skin turgor, weak cry, high pitched cry, muscle weakness, irritability or lethargy.(1) The principle manifestation of Acute Renal Failure is oliguria or anuria. Oliguria is the medical term for scant urine output and anuria is the term for no urine output. Additional signs of Acute Renal Failure include edema(swelling), drowsiness, and fast breathing (1)

The severe reduction or absence of urination in an infant or child is a sign of a serious problem. Any child experiencing decreased or absent urination needs to be evaluated by a health care professional without delay in order to determine and treat the cause.

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

Detecting Urine Output

Particles in Urine

Burning with Urination

Dehydration

References:
(1) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 928-932, 1538.

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

Pediatric Advice on the Web

Pneumococcal Vaccine

2007-03-12T11:56:00.000-04:00

Dear Lisa,

My daughter is 21 months old. She still didn't get her last (4th) Pneumococcal Conjugate vaccine. Her doctor keeps telling me that it's O.K., that there is no rush with this one. Is that so?

Here is when my daughter had her previous PCV shots:

#1- when she was 2 months old
#2- when she was 4.5 months old
#3- when she was 12 months old

Should I worry that so much time already passed and the vaccine is still not done?

Should I tell the doctor to give the 4th shot at our next appointment?

“Pneumococcal Conjugate Vaccine”

Dear “Pneumococcal Conjugate Vaccine”,

When a child receives a vaccination her body mounts an immune response. The immune response results in the formation of antibodies or special white blood cells that fight a particular organism. If a child is exposed to that particular organism at a later date, she will be better equipped to fight the infection because the antibodies that are needed are already made and available.

When a child receives a vaccine at a young age, the immune response is not as effective as the immune response of an older child or an adult. Less antibodies are formed and the child is not as well equipped to fight the infection when exposed to it. Therefore, multiple vaccines are given to young infants in order to achieve antibody levels that are sufficient to combat the organism if it is encountered.

The companies that manufacture vaccines perform studies to determine the body’s immune response to vaccines given at specific ages. From this information, a vaccine schedule is recommended so that children will receive the greatest benefit from a vaccine. Following the vaccine schedule gives the child the opportunity to fight infections based on scientific research results.

If a vaccine schedule is not followed, a “catch up” schedule is recommended. The total number of actual injections given according to a “catch up” schedule may be different from the amount of injections given to a child who follows the recommended schedule. For many vaccines, fewer injections are needed if the vaccinations are given at an older age. The down side of this approach is that the young infant is not protected against the disease when they are most susceptible.

The recommended schedule for Prevnar or the Pneumococcal Conjugate Vaccine is three doses at approximately 2 month intervals, followed by a fourth dose at 12 to 15 months old. (1) The recommended dosing interval is 4 to 8 weeks. The fourth dose should be administered at least 2 months after the 3rd dose. (1)

The recommended schedule is as follows:

First Dose: 2 months
Second Dose: 4 months
Third Dose: 6 months
Fourth Dose: 12 – 15 months

The "catch up" schedule for Prevnar can be confusing. When a child misses a vaccination, the total recommended amount of injections changes. For example, if a child did not receive their first Prevnar immunization until they were 2 years old, then only one dose is recommended. (1) If a Child receives the first Prevnar vaccination between 7 and 11 months old, then only a total of 3 doses are recommended.

The schedule that you provided shows that your child missed the 3rd dose or the 6 month vaccination. According to the “catch up” schedule, Dose #3, when administered 8 weeks after dosage #2 is considered the “final” dose if it is given to a child that is greater than or equal to 12 months old. (2) Dose number 4 is only necessary for children aged 12 months to 5 years old who received 3 doses before the age of 12 months. Since your daughter is 21 months old and her 3rd dose was given at 12 months old, that dose would be considered her final dose. In her case, the 4th dose is not necessary.

So you do not have to worry that time has passed and you do not need to insist that the fourth dose be given now. At your daughter’s next scheduled visit, her Doctor should tell you if he recommends the fourth dose or not.

References:
(1)Physician’s Desk Reference. 2004. Montvale, NJ. Thomson PDR at Montvale:3471-3479.
(2)RedBook Online. Recommended Immunization Schedule for Children and Adolescents who start late or who are More than 1 month behind, 2007. Available at: http://www.aapredbook.org/. Accessed March 2007.

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

Pediatric Advice About Keeping Children Healthy

Blue Lips

2007-03-08T14:28:00.000-05:00

Dear Lisa,

My son has just had tonsillitis and upset stomach (prescribed a/b) he has been suffering from occasional blue lips but gp's not taking seriously as they haven't seen it and said can't do anything until see what I mean. Lasts 5 or so mins at a time happens 3+ times a day and at night. Please help.

“Son has Blue Lips”,

Dear “Son has Blue Lips”,

Cyanosis is the medical term for the bluish discoloration of the skin. During normal circulation, the oxygen in a child’s blood passes to the tissues. When this passage of oxygen occurs, the blood turns a darker red or bluish color. If there is not enough oxygen in a child’s blood, the bluish color of the blood becomes more pronounced and as a result the skin also appears blue. Therefore Cyanosis is a symptom that should be taken seriously. It can represent an underlying problem with a child’s blood, heart or lungs.

Not every case of Cyanosis represents a serious problem. In some cases, Cyanois can occur as a normal response to various stimuli. For example, if a child is very anxious or exposed to a very cold environment, the amount of blood flow to the arms and legs decreases and slows. (1) This can result in a bluish discoloration of the nail beds. (1) I have seen children with no underlying medical problems experience high temperatures and skin color changes. When a young child’s fever is high their abdomen and back can feel very hot to touch while their arms and legs feel cool. In some of these children the hands and feet may also appear to be bluish in color.

Skin color is also affected by the scattering of light as it is reflected back through the superficial layers of the skin. This scattering of light can make the skin color appear blue and less red. (1) From my experience, this scattering of light tends to make a child’s skin to appear bluish in color when they are sitting in a blue colored room or wearing blue clothes.

Methemoglobinemia is another potential cause of bluish discolored skin in children. Congenital Methemoglobinemia is a condition that a child is born with that involves an abnormality in the processing of iron in the blood. Acquired Methemoglobinemia can occur when a child ingests certain oxidants. Nitrates and nitrites derived from fertilizer and disinfectants in well water and foods are major causes of Acquired Methemoglobinemia. (2). The treatment for Methemoglobinemia includes the administration of Intravenous Methylene blue which reverses the condition by converting Fe +3 to Fe +2. (2)

Very young patients or patients with glucose-6-phosphate deficiencies are more susceptible to Methemoglobinemia. Patients taking drugs associated with drug-induced-Methemoglobinemia such as sulfonamides, acetaminophen (Tylenol), Phenobarbital, phenytoin, acetanilid, aniline dyes, benzocaine, chloroquine, dapsone, naphthalene, nitrates, nitrites, nitrofurantoin, nitroglycerin, nitroprusside, pamaquine, para-aminosalicylic acid, phenacetin , primaquine, quinine and emla crème are also at risk for developing Methemoglobinemia.(3) If you are not sure if the medication that your child is receiving is included in this group you can contact your Pharmacist and read the medication labels to him. He should be able to tell you if the medication that your child is taking contains any of these products.

If your son’s symptoms are new and have only recently developed with this llness, you may want to consider one of the foods or medications that he is taking as a potential cause. You report that your general practitioner is not taking your son’s symptoms seriously since he hasn’t witnessed it; I suggest taking a video recording of the event and bring it into the office.

Since your son’s symptoms are occurring frequently it would be a good idea to keep a diary of the episodes. You should note the room temperature, the relation to activity or other symptoms, any food or medication that your child is taking and the time and duration of the events. This information can help your Doctor determine the cause of your son’s symptoms. If there is a specific time of day that the episodes occur, you may want to make a doctor’s appointment at that particular time of day. You can wait in the waiting area until your son turns blue so that your Doctor can witness the event.

There are tests that can be performed to determine the cause of a child’s blue skin. These tests include a special type of blood sample called an arterial blood gas or a non-invasive test called Pulse Oximetry. These tests performed on a child during a "blue" spell can help your Doctor diagnose the problem.

You seem concerned because your Doctor is not taking your son's symptoms seriously. If your attempts to display your son's symptoms to his Doctor are not successful, it may benefit you to get a second opionion with a Physician who is willing to believe you.

I hope you get to the bottom of your son’s cyanotic spells soon.

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

Tonsillitis

Breath Holding Spells

Pulse Oximetry

References:
(1)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:140.
(2)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:507.
(3)Physician’s Desk Reference. 2004. Montvale, NJ. Thomson PDR at Montvale:606-607.

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

Pediatric Advice Updated Daily