Ask Lisa - Free Pediatric Advice

Swine Flu

2009-05-03T15:33:00.007-04:00

Dear Lisa,

Why are so many people making such a big deal about the Swine Flu? It's all they talk about in the news. Not that many people died from it so far, so why are so many people worried? My son is coughing a little and he has allergies, do I need to keep him home from school just because he has a cough?

"What's the Big Deal?"

Dear "What's the Big Deal?"

The Swine Flu is a new virus that people do not have immunity to. The reason why so many people are making a big deal is, without immunity, some people have the potential for becoming very ill. The Swine Flu virus has been renamed the Influenza A H1N1 Flu because scientists discovered that the microorganism contains swine flu genes as well as bird genes and human flu genes. Usually flu viruses with animal genes do not spread from person to person. H1N1 Flu is spreading from person to person. There are confirmed cases in 30 states in the U.S. and 18 countries. The reason for the great concern is because the last great flu pandemic in 1918 was caused by a flu which contained bird flu genes. That flu virus containing bird flu genes also passed from person to person.

You are correct, there have not been a high number of deaths so far from H1N1 Flu. Up to this point there have been 20 deaths from the H1N1 Flu, which is small compared to the thousands of deaths that occur each year from the seasonal flu virus. Even a small number of deaths is devastating to the families and communities involved, so yes , it is a big deal. Yes, it is also true that most of the cases of the H1N1 Flu have been mild. The concern is that flu viruses can mutate and change into a more virulent strain. If that was to occur, then more serious illnesses may result.

In regards to your son, if he only has a cough from his allergies, there should be no reason why you cannot send him to school as long as his allergies are under control and he is not having an exacerbation of Asthma. The symptoms of the H1NI Flu virus include fever, body aches, fatigue, headache, respiratory symptoms, sore throat, vomiting and diarrhea. If your son has other symptoms besides a cough or if he is too young to describe his symptoms and is not acting normally, you should contact your health care provider for an evaluation.

For More Information about H1N1 Flu:

Track Outbreaks of H1N1 Flu

H1N1 Flu Facts

How to Care for a Person with H1N1 Flu

Information in Spanish

References:
(1)Centers for Disease Control and Prevention. H1N1 Flu (Swine Flu). Available at http://www.cdc.gov/h1n1flu. Accessed May 3, 2009.

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

Pediatric Advice Updated Daily

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

Learning Disability

2007-03-05T07:42:00.000-05:00

Dear Lisa,

My son is in 1st grade. It was recommended that we hold him back in Kindergarten. We didn't. He was out two weeks after having his tonsils out. We have about 2 1/2 months of school left. During a recent IEP meeting (yes, disabilities are involved), the Principal announced that he will probably be recommended for hold back this year (he is currently failing reading and spelling).

Homework is such a struggle and none of us seems to be in the same page. Can we let homework go until the Fall?

Thanks.

“Dear “Mom of 1st Grader”,

Homework is a struggle for many children, whether there is a learning disability involved or not. Problems with homework are only intensified when a child suffers from a health condition such as a learning disability or Attention Deficit Disorder (ADD). Homework takes concentration, discipline, attention and patience. Some children naturally develop these attributes with age and maturity while others need special help. It can be quite frustrating for both the parent and the child when the process does not come naturally.

Be assured that you are not alone, many parents and children struggle with learning. Approximately 20% of school-aged children have academic performance problems.(1) Since your child is in the IEP, a leaning evaluation must have been performed and the type of learning disability should have been identified. Your son's school should provide him with the tools that he needs to help him with his struggles. In some cases a child may need in classroom support with an aide or other modalities. In other cases, additional tutoring outside of school may be recommended.

If you have not been informed regarding which type of learning disability that your child has, or you do not see an improvement with the interventions implemented, it may benefit your son to have a second opinion. If this is the case, a consultation with a Developmental Pediatrician or Neurodevelopmental specialist can provide you with the guidance that you need. Your Pediatrician can direct you regarding how to find a Developmental Pediatrician, or you can locate one at your local Children’s Hospital.

I can understand your point of view regarding your son’s homework. If your son is going to repeat 1st grade anyway, why suffer through two and a half more months of homework? On the other hand, the more review he receives this year, the smoother next year will go. I suggest asking his teacher how long each assignment is expected to take and then have your son only spend that amount of time on his assignments. On average, most 1st grade teachers will agree that the total homework time should not exceed a total of 45 minutes.

If your son’s teacher tells you that math homework is expected to take 15 minutes to complete then you can make an agreement with her based on this information. It would be reasonable to agree to have your son spend only 15 minutes on Math and finish as much as he can without any penalty for not finishing.

Choosing the time and place that homework is done is half the battle. If homework occurs late in the evening, children may be too tired or hungry to perform successfully. They can become distracted by the household activities such as dinner time and clean up. This is not a good time to do homework, especially if your child has a learning disability. A child with a learning disability requires an organized and structured environment. (2) For example, have your son do his homework in his bedroom or in the dining room, away from the other household noise and distractions. Provide a spacious area with all of the proper equipment available and organized.(2)

When approaching homework, start with a subject that comes easiest for your child. This can prevent him from becoming too frustrated and disappointed in the beginning of the homework period. It will also be helpful to have your son go to the bathroom and eat a snack before starting his homework. This will prevent interruptions that can set him off track.

Another important tool in helping homework time run smoothly is the egg timer. An egg timer can be used to time each part of your son’s homework assignment. If math homework is expected to take 15 minutes, put the timer on for fifteen minutes. Inform him that he is not to get up before the bell goes off. Once the bell rings your son is finished with his math. You can offer incentives, such as 15 minutes playing his favorite video game, if he finishes within the allotted time. It is also a good idea to space out the homework by giving him a 10 minute break between assignments.

Whether or not your son finishes all of his homework and gets every answer correct is not important. As long as he attempts his homework and does the best that he can, he will learn the skills that he needs to discipline himself for next year.

Having a child with a learning disability can be very physically and emotionally draining on a parent. It can also cause a child to experience a lot of stress, feelings of hopelessness and low self esteem. Children with learning disabilities may believe that they cannot learn, that school tasks are too difficult and not worth the effort. (2) As a parent, you are in the position to encourage your child and provide a positive attitude about learning. It is also very important to foster self-esteem and point out areas that your child is successful. Therefore giving your son frequent praise will not only give him encouragement but can help improve his self esteem.

It is important to remember that children do not only learn at school or from doing homework. They also learn from talking, listening, reading with their parents, telling stories and playing games.(2) A good way to reinforce lessons is to have your son play games with cards using numbers and sequences. Playing board games that involve waiting for your turn, counting, reading, matching and finishing the task will also help your son with learning and prepare him for next year. Playing Charades using spelling words or incorporating words and letters into artwork are other fun ways to reinforce school work. Playing games can help your son learn in a relaxed environment and take away the pressure to produce.

I hope these pointers help homework time go a little smoother for the both of you.

For Information About Learning Disabilities contact the following Agencies and Organizations:

Directory of Facilities and Services for the Learning Disabilities, 16th ed. Novato, CA: Academic Therapy; 1998.
Phone 1-800-422-7249 (outside California) or (415)883-3314 (in California)

Learning Disabilities Association of America (LDA)
4156 Library Road, Pittsburgh, PA 15234
Phone: (412)341-1515 or 1(888)300-6710
Email: ldanat@usaor.net, Web site: http://ldanatl.org

National Center for Learning Disabilities
381 Park Avenue South, Suite 1401
New York, New York 10016
Phone: (212)545-7510 or 1(888)575-7373
Web site: http://www.ncld.org

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

Homework Tips

Attention Deficit Disorder

Problems Focusing

References:
(1)Kelly D, Aylward G. Identifying School Performance Problems in the Pediatric Office. Pediatric Annals. 2005. 34(4):289-298.
(2)Lambros k, Leslie L. Mangement of the Child with a Learning Disorder. Pediatric Annals. 2005. 34(4):275-287.

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

Pediatric Advice on The Web

Newborn Breathing Problem

2007-03-02T23:24:00.000-05:00

Dear Lisa,

My nephew baby, 7bls 4 oz, was born three days ago has had trouble breathing through his nose. They have used meds to take swelling if any from inside of the nose. The oxygen levels are at 95% to 97%...Is this ok? They have a monitor and alarm on him at this point.

They are at a small Hospital in rural Arkansas. Would you suggest going to a children’s hospital at this point?

“Sassygilr”

Dear “Sassygilr”,

If a newborn has problems breathing through the nose, he should be checked for Choanal Atresia, also knonw as Choanal Stenosis. Choanal Atresia occurs when the nasal passage is too narrow or obstructed. The narrowing or obstruction can occur in one or both nasal passages. Either a membranous or bony septum between the nose and the throat is responsible for the obstruction.

When Choanal Atresia is present on one side, the symptoms can be very mild and may not surface until the baby develops his first cold. Signs of unilateral (one-sided) Choanal Atresia include the absence of air moving in and out of the nostril and nasal discharge from the involved side. These signs tend to become more pronounced during a respiratory infection.(1)

If Choanal Atresia is present on both sides, the child can suffer from respiratory distress. The severity of respiratory distress depends upon the degree of obstruction. Signs of bilateral Choanal Atresia include difficulty breathing after the initial cry at birth. The baby may turn blue and develop retractions. The baby also develops sucking in motions of the lips. The distress can be relieved by opening the child’s mouth (1)

If there is a concern that an infant has Choanal Atresia, the Doctor uses a firm catheter and passes it through each nostril, one at a time. If there is difficulty with this maneuver Choanal Atresia is suspected. The diagnosis can be confirmed by direct Nasopharyngoscope or Bronchoscope performed by an Otolaryngologist. In some cases the diagnosis may also be confirmed through a special type of x-ray.

The presence of nasal congestion in the newborn period that interferes with breathing can also be due to other conditions such as Gastroesophageal Reflux or a respiratory infection such as RSV or Sinusitis. The Doctor in charge of the case is responsible for determining the cause of your nephew's symptoms and providing interventions that are necessary to alleviate the problem.

Hemoglobin O2 saturation or pulse oximetry(a number given in a percentage) represents the total oxygen-binding sites on the hemoglobin that are bound with oxygen.(1). Generally speaking, a pulse oximetry reading between 95 and 97% is normal. How this one number relates to your nephew’s overall condition can only be interpreted by the Physician who is caring for him.

A pulse oximetry reading in and of itself is only one measure, one piece of a very large puzzle. Other factors need to be taken into consideration when interpreting a child’s respiratory condition which includes other diagnostic tests, findings from the physical examination and the need for artificial breathing devices or supplemental oxygen. In other words, the O2 saturation reading on a child breathing room air as compared to an O2 saturation reading on a child who is receiving oxygen represents two very different things, even if the number is the same.

Whether or not your nephew needs to be transferred to a Children’s hospital or a higher level Special Care Nursery can best be determined by the Doctor in charge of his case. This generally is a decision made by the Neonatal Intensive Care Physician. If your nephew’s parents do not see any improvement in their child’s condition, are unhappy with the care or are seeking a second opinion they do have the right to be transferred to a different hospital. If this is the case, they should discuss this with their Doctor because this is a decision that should be made in conjunction with the Physician in charge of the case and with the child’s Pediatrician.

It is a very difficult to be in the position of an Aunt, because you are concerned about your nephew’s health, but at the same time, you do not legally have the right to review his medical records, discuss his condition with his Doctor or make decisions about his care. Only his parents have that right. It is very stressful for parents to have a sick newborn. There is a lot of information to absorb and a lot of decisions to be made. In some cases, the opinions of others makes the situation more confusing. Many times parents need time and privacy to make these decisions on their own.

If your nephew’s parents asked your opinion about his medical condition, then it is very admirable of you to seek out the information that they need. In this case, the information that you give them can be very helpful. If they did not ask your opinion about their child’s medical condition then the best thing that you can do is ask them what you can do to help their life run a little smoother.

Congratulations on the birth of your Nephew and I hope that his health issues resolve quickly so that he can go home soon.

If you are interested in other Pediatric Advice Stories covering this material:

Newborn Congestion

Baby with a Stuffy Nose

Baby with Cold Symptoms

Gastroesophageal Reflux in infancy

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1265, 1177.

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

Pediatric Advice For Parents with Newborns

How Much Formula?

2007-02-27T20:20:00.000-05:00

Dear Lisa,

How much formula and how often should a 3 month, 13 pound baby drink? Thanks.

“How much formula?”

Dear “How much formula?”,

The amount of formula that an infant should take depends upon the weight of the child. A baby needs 50 calories per pound of body weight in a twenty-four hour period. (1)

Therefore a thirteen pound baby needs:

13 X 50 = 650 calories per day

Normal baby formula contains 20 calories per ounce. To figure out how many ounces a baby needs in one day, take the total calories required and divide by 20.

650 divided by 20 = 32.5 ounces of formula per day.

In general, most formula fed infants eat every 3 to 4 hours or 6 to 8 times per day. So in order to figure out how many ounces of formula are needed per feeding:

32.5 ounces divided by 6 = 5.4 ounces

32.5 ounces divided by 8 = 4 ounces

So your answer is:

A thirteen pound baby should drink 4 to 5 ½ ounces of formula per feeding.

This calculation does not apply to premature babies. If a baby is premature, the caloric requirements are different. In addition, premature babies many times are prescribed formulas that contain more then 20 calories per ounce.

It is a general belief that once a baby reaches 32 ounces per day, an increase in formula is not required. Instead, additional calories are given in the form of solid food fed to a baby by a spoon. A baby at three months old is too young to eat solid food. Solid food is typically introduced between the ages of 4 to 6 months old or when the infant doubles their birth weight. (2)

Besides reaching the age of 4 to 6 months, a child should be developmentally ready to accept the food. (2) An infant should have good head control and be able to sit up before he or she is allowed to eat solid food. (2) It is also important not to introduce solids before 4 months old because this may increase the risk of food allergies. A delay in the introduction of solid foods to an infant serves to reduce the risk of food allergies. (3)

Since your baby is already 13 pounds at 3 months old, it would be a good idea to discuss the proper time to introduce solids with your child's health care provider.

Congratulations on your new baby!

If you are interested in reading other Pediatric Advice stories discussing infant feeding issues:

Infant Feeding

Premature Infant Caloric Requirements

Nipple Confusion

Decreased Milk Production During Breastfeeding

Infant Colic

Gassy Baby

Introducing Cow’s Milk

Failure to Gain Weight

References:
(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 303.
(2 )Grassia T. Pediatricians: Discuss healthy nutrition during well child checks. Infectious Diseases in Children. 2006. August: 54.
(3 )Bassett C. What to do when foods become allergens. The Clinical Advisor. 2005. Dec: 43-48.

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

Pediatric Advice About Infant Care

Fecal Impaction

2007-02-26T08:34:00.000-05:00

Dear Lisa,

My daughter has recently gotten fecal impaction. We went 3 days with no bowel movement with the last one being one little ball. We tried karo syrup, glycerin suppository, magnesium citrate, and milk of mag with no results. We ended up in the ER with x-rays finding stool in the colon. They gave her an enema at the ER and got good results. She continued to c/o stomach pain throughout the next week and I called and took her to the Dr. numerous times that week. They kept insisting me to continue with the Miralax which she has been on for 1 year. I kept telling them it was doing nothing for her.

One week later with no BM I took her back with severe cramping and did a ct scan finding stool in the ascending and descending colon. They told me to do the Dulcolax. So we did the Dulcolax suppositories and on sun got one result. Mon morning she was able to go on her own and the Dr. also told me to give her another suppository. So I did and got another result on Mon. On Tues she went one time on her own and Dr. said, don't give another laxative. Wed. did not have one at all and Thurs did not have one. Fri had one with the pill form of Dulcolax and Sat(2-17-07)gave Dulcolax again with some results but not as good as they have been.

I went for a second opinion and this Dr. said to cut out the Dulcolax due to side effects are really bothersome to my daughter and said to try Senokot, mineral oil and to continue with my Miralax. So my concern is my daughter is constantly c/o leg aches, bad headaches, and just so fatigued. Is this a sign that the waste left in her is making her colon toxic? The DR. said she still has more in her can tell from pressing on stomach. How long can it stay in there before it starts making things toxic? Will she at some point just start having multiple BM's to get cleaned out all the way? B/c right now she is only having one a day or like now she has skipped 2 days. Should I let her skip or do I need to go back and do the suppository to get immediate results so that she is not getting further backed up? And what I don't understand either is that she stays hungry constantly and although she is having BM she is far from cleaned out with the look of her stomach. IT is so hard and so bulging. How can she possibly still want to continue to eat so much? Do you suggest taken her to a pediatric gastroenterologist also?

Thanks for any advice.

“Fecal Impaction”

Dear “Fecal Impaction”,

A fecal impaction occurs when a constipated child is not able to have a bowel movement. When a child develops constipation she experiences hard painful stools which are difficult to pass. This painful experience causes a child to hold back the stool because they fear it will hurt to have a bowel movement. As a result, a child becomes more constipated and the stool becomes larger and more difficult to pass.

The recommended treatment for fecal impaction is an enema, which is the treatment that your daughter received in the Emergency Room. (1) Once the initial problem is alleviated, and a bowel movement is produced it is imported to figure out the original cause of the constipation and fecal impaction. It is important to determine the cause so that the condition can be treated and the incidence of fecal impaction does not occur again.

Constipation in childhood is usually caused by the child’s diet. Excessive milk ingestion, insufficient amount of fluids and inadequate intake of bulk-forming foods are common causes of constipation in children. (1) Other potential causes include poor bowel habits, laxative misuse or underlying medical conditions. (1)

Medical conditions that may cause constipation include; Hypothyroidism, Celiac Disease, Hirschsprung Disease, muscle disorders, endocrine disorders such as Hypothyroidism or Diabetes mellitus, and medication side effects. (2) Medications that are commonly associated with constipation include; analgesics, anticholinergics, calcium channel blockers and stomach preparations containing Aluminum.

In some cases a child can develop constipation due to an anatomical defect such as rectal stenosis. Rectal stenosis is a condition that occurs when a child’s rectal openining is too tight or too small. Because the opening is so small it is very difficult to pass stools and as a result the child becomes constipated. Rectal stenosis can be confirmed by digital examination by a health care professional. (1)

Pelvic Floor Dyssynergia is another potential cause of constipation in children. This occurs when a child fails to learn to properly coordinate the muscle contractions necessary to pass a stool. When a child experiences Pelvic Floor Dyssynergia, the anal sphincter does not contract properly or in some cases, involuntary spasms occur during a bowel movement. This abnormal contraction prevents the stool from being expelled from the body. Signs of Pelvic Floor Dyssynergia include hard stools, fecal impaction, feelings of anal blockage, severe straining, and the need for digital maneuvers. (3)

Regardless of the cause of the constipation, the first step in treating the condition includes taking measures to promote adequate bowel movements. There needs to be an initial “clean out" period where the fecal material is removed from the colon. (4) This clean out period includes dietary alterations, behavior modification and the administration of laxatives under the supervision of a health care professional. Behavior modifications include having a child sit on the toilet for 10 minutes three times per day.

During this cleaning out process, a child should have a bowel movement on a daily basis until the stool is soft and no longer difficult to pass. If the stools become hard, difficult to pass or cause a lot of straining your doctor should be notified so that an adjustment can be made to the regimen. Since your daughter has an extensive history of constipation that has led to fecal impaction it would be important to not let her go too many days without having a bowel movement. Preferably, she should have a soft bowel movement on a daily basis until her system is cleaned out.

The purpose of laxatives is to soften the stool which allows it to pass more freely. Laxatives are not considered the cure for constipation, but a necessary measure to ensure the proper elimination of stool until the cause of the constipation is determined. It is important to address the underlying cause of your daughter’s symptoms, otherwise the symptoms will most likely return after the laxative is discontinued.

Miralax is one of the laxatives that is commonly used in the pediatric population. From my experience with children treated with Miralax, it works very well at loosening the stool. Typically within a couple of days of administering Miralax the stools should develop a softer consistency. Studies have shown that there is a statistically significant increase in bowel movement frequency observed when patients take Miralax as compared to a placebo. One study demonstrated that on average, patients receiving placebo had 2.7 bowel movements per week, while patients receiving Miralax had 4.5 bowl movements per week. (5)

You mentioned that your daughter was on Miralax for a year and that it was doing nothing for her. I’m not sure if you mean that it never loosened her stools or if the “need” for the Miralax persisted. The purpose of a laxatives is to loosen the stool so they will pass, not cure the cause of the constipation. If the underlying reason for the constipation was never addressed, it would be expected that your daughter’s constipation would return after discontinuing the Miralax. In general, if a child needs a laxative for a over three months, a work up is indicated in order to determine the cause of the constipation.

If your daughter is experiencing abdominal discomfort and pain with her bowel movements, it may helpful to have her to sit in a bath tub filled with warm water. The water should cover her abdomen and she should be allowed to play in the tub while she is monitored by an adult. This can serve as a “natural” enema because during her play in the tub she will relax and water will enter her rectum. This is a non-threatening and non-invasive way of getting water into her rectum, which will soften the stool and help it pass more readily. This approach is much more desirable than giving frequent enemas. Frequent enemas may be psychologically unsuitable and can cause electrolyte imbalances. (4)

Since your daughter has a long standing problem an evaluation by a Pediatric Gastroenterologist is a very reasonable next step. A Pediatric Gastroenterologist can perform a history and Physical examination on your child and order diagnostic testing in order to determine the cause of your daughter’s constipation. A Gastroenterologist can also recommend a treatment plan that addresses her present problem passing stools.

Pertaining to your question about your daughter’s food intake; all children requires a certain amount of calories per day based on their weight. A child needs to ingest the recommended amount of calories in a twenty-four hour period in order to achieve proper growth and development. The same amount of calories is needed whether or not a child has a bowel movement on that particular day. The fact that your daughter is hungry and wants to eat is normal.

It is true that constipation causes some children to experience a decrease in appetite. The abdominal distention and increased intra-abdominal pressure that results from being constipated can exacerbate Gastroesophageal reflux symptoms such as heartburn and regurgitation. These GER symptoms can cause a child to lose their appetite and suffer from insufficient weight grain. Other GER symptoms include vomiting, heartburn, difficulty swallowing, chronic cough, recurrent pneumonia, sore throat, hoarseness, wheezing, bad breath, sinusitis, dental erosions, feeding problems, poor weight gain and weight loss. (6,7,8) In particular children over 2 years old with GERD most often have symptoms related to heartburn as well as abdominal pain, vomiting and cough. (8,9)

The intestines are divided into two sections; the small intestine and the large intestine. The small intestine connects to the stomach and on average measures 21 feet long. It is in the small intestine that most of the absorption of water and nutrients takes place. The large intestine is connected to the small intestine and on average measures 5 feet long. The large intestine is also responsible for the absorption of water and nutrients. Additional purposes of the large intestine include the manufacturing of certain vitamins and the formation of stool. (10) It is the role of the intestines to form and hold stool, therefore presence of stool in the intestines is normal.

The reason why health care professionals are concerned about constipation is not because of toxicity, but because it is a problem that can worsen if not addressed. The longer the stool remains in the intestines, the more water and nutrients are absorbed from the stool into the body. When a lot of water is absorbed from the stool in the large intestines, the stool becomes hard and difficult to pass. This can just worsen the situation. Therefore the goal is to have a constipated child experience a soft bowel movement on a regular basis.

I would not worry that your child will become “toxic” if she doesn’t have a bowel movement. It is more important that the consistency of her stool is soft so she does not experience pain during a bowel movement or hold the stool in. Non-specific symptoms such as leg aches, headaches and fatigue, are common to many conditions and are not necessarily related to constipation. Even thought these specific symptoms may not be caused by constipation, chronic constipation can have a very significant impact on a patient’s overall health. A short term questionnaire given to patients demonstrated that physical functioning, vitality, social functioning, mental health, perception of health and pain scores were worse for patients that suffered from constipation. (11)

I hope your daughter finds relief from her symptoms soon.

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

Constipation

Constipation Treatment

Stool Withholding

Celiac Disease

Gastroesophageal Reflux

Gastroesophageal Reflux in Infancy

Nutritional Requirements

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1490-1492.
(2)Borum ML. Constipation: evaluation and management. Prim Care. 2001.28:577-590.
(3) Lembo A. Camilleri M, Chronic Constipation. N England J Med. 2003:349:1360-1368.
(4)Chronic Constipation in Children. Consultant for Peditricians. 2003. Apr:152-155.
(5)Brandt LJ, Prather CM, Quigley EM, Schiller LR, Schoenfeld P, Talley NJ. Systemic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005. 100(Suppl 1)S5-S21.
(6) Waring JP, Feiler MJ, Junter JG. Childhood Gastroesophageal reflux symptoms in adult patients. J Pediatr Gastroenterl Nutr. 2002; 35:334-348.
(7) Christensen M, Gold B. Clinical Management of Infants and Children with Gastroesophageal Reflux Disease: Disease Recognition and Therapeutic Options. Presented at: The Exhibitor’s Theatre Session at the 2002 ASHP Midyear Clinical Meeting, the Georgia World Congress Center; Dec 9, 2002:Atlanta.
(8)Hassall E. Decisions in diagnosing and managing chronic Gastroesophageal reflux disease in children. J Pediatr. 2005;146:S3-S12.
(9)Suwandhi E, Ton M, Schwarz M. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006;35(4):259-266.
(10)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:610-622.
(11)Irvine EJ, Ferrazzi S, Pare P, Thompson WG, Rance L. Health-related quality of life in functional GI disorders: focus on constipation and resource utilization. Am Journal Gastroenterology. 2002. 97:1986-1993.

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

Pediatric Health Advice

Chicken Pox

2007-02-20T01:00:00.000-05:00

Dear Lisa,

Can u have chicken pox more than once? i had it as a child but have broken out in sore blistery spots, also my nan has chicken pox which i found out yesterday.

“Chicken Pox Twice?”

Dear “Chicken Pox Twice?”,

Varicella Zoster virus is a herpes virus that causes both Chicken Pox and Shingles. Chicken Pox occurs in 90% of U.S. children before they are 10 years old. (1) Shingles usually occurs in the adult population.

The symptoms of the Chicken Pox 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 the classic Chicken Pox 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 is distributed throughout the entire body including the torso, extremities, face, scalp and in some cases the mucosal surfaces(inside the mouth).(1) 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 a person contracts Chicken Pox they usually do not get it again. Although, it is possible that an individual can develop Chicken Pox more than once. Studies have shown that the second case of Chicken Pox may be as severe as the first.(2) In particular, children with HIV infection can develop chronic or recurrent Chicken Pox with new lesions appearing for months. (3)

Many people are under the impression that they contracted Chicken Pox twice but in reality one of the episodes represented a different skin condition that looked like the Chicken Pox. Skin conditions that may be mistaken for Chicken Pox include; Coxsackie, Enterocytopathic human orphan, Impetigo, Papular urticaria, Scabies, drug eruption, Contact Dermatitis or Folliculitis.(1)

After a child develops Chicken Pox, the Varicella virus remains dormant or in a resting state in the dorsal root ganglia. The virus can then be reactivated later in life when a person is under stress. This reactivation of the Varicella virus causes Shingles.

When a person develops Shingles they first notice pain, pruritis(itchiness) or numbness on an area of their skin. Soon after this an eruption of grouped vesicles form which remain limited to that area. Typically the rash develops in a band like pattern concentrated in that one area and does not cross the midline of the body. (4) Common places to find the Shingles include the waist, torso or chest.

In rarer cases Shingles can affect the trigeminal nerve which can involve the eye and lead to blindness.(4) Therefore the presence of the Shingles on the face or around the eye warrants immediate medical attention and the expertise of an Ophthalmologist. Immunocompromised patients may develop a generalized rash which spreads throughout their body. (3)

Shingles is expected to occur in 20% of health adults and in 50% of immunocompromised patients.(4) It is most common in people older than fifty and in certain children. Children at risk for developing Shingles include those who contracted Chicken Pox before the age of one, those exposed to the Varicella virus in utero, immunocompromised children, children with Systemic Lupus erythematosus and children suffering from Acute Lymphocytic Leukemia or other malignancies.(5) Individuals who are vaccinated for Varicella are less likely to develop Shingles as compared to individuals who were not vaccinated and contracted live Chicken Pox.(6)

If your rash started with symptoms such as numbness, pain or itchiness and is localized to one area of your body, your condition may actually be a reactivation of the Varicella Virus or Shingles. The only way to determine the cause of your rash is to have it evaluated by a health care professional. In the mean time it would be prudent to cover the rash, avoid skin to skin contact with other people and stay away from immunocompromised individuals and children who are not immunized.

It is important to remember that other conditions can look like Chicken Pox, therefore it is essential that you seek medical attention in order to get a proper diagnosis. This way you will know the best way to treat your rash and prevent the spread of infection to others.

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

Chicken Pox Vaccine

Chicken Pox Immunity

Impetigo

Scabies

Norwegian Scabies

Contact Dermatitis

References:
(1)Pang M. Spot the Rash. Infectious Diseases in Children. 2006. March:90.
(2)Hall S, Maupin T, Seward J. Second varicella infections: Are they more common than previously thought: Pedaitrics.2002.
(3) American Academy of Pediatrics. Varicella-Zoster 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; 1997:573-577.
(4)Krathen R, Hsu S. Vesicular lesions in an elderly woman with pneumonia. The Clinical Advisor. 2006. July:86,93.
(5)Treadwell P. Spot the Rash. Infectious Diseases in Children. 2006. September:104.
(6)Sharrar RG, LaRussa P, Galea SA. The post marketing safety profile of varicella . Vaccine. 2001.19:915-923.

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

Pediatric Advice About Infectious Diseases

Persistent Fever

2007-02-19T01:32:00.000-05:00

Dear Lisa,

I've read over a few of your previous answers, but am still concerned. I have a 6 yr. old son who has a temperature. When it started it reached up to 104.4. It's highest point now is about 103 to 102.5. It's been 6 days and I'm really starting to worry. I took him in on day 3 and they said he had no strep but was sick. Dr. advised should last 3-5 days. He's got a stuffy nose, cough and mild nausea. Won't eat, and drinks very little. He doesn't act sick most of the time, wants to play and such. I can't afford to take him back to the dr. and am unsure of what to do next.

Thanx

“Concerned Mother”

Dear “Concerned Mother”,

Taking care of a child with a fever is probably one of the hardest things that a mother has to do. Watching your child experience such discomfort, not knowing the cause and worrying about complications is very stressful. I know, because I have been in the same situation with my own child. Luckily, the majority of fevers in children are caused by a virus, which means; fluids, rest, time and loving care is all that is needed for a child to get better. In time the child’s body fights the infection and the fever goes away.

There are some situations and signs that should cause a parent to be concerned and seek medical attention. Any child under 3 months old with a fever of 100.4 rectally or higher needs to be evaluated by a Physician. Children at this age are more susceptible to serious infections such as Meningitis or Bacteremia. In addition, fever many times is the only indicator that an infant has a serious infection.(1)

A fever accompanied by a stiff neck, headache, sore throat, rash, painful urination, inability to eat, joint pain, problems breathing or abdominal pain should also be evaluated. (1) Children with a chronic medical conditions such as Diabetes, Sickle Cell Anemia, Immune Deficiency or Asthma need to be seen by a Physician because an illness can cause complications and worsening of the their underlying condition.(1) An evaluation by a health care professional is also indicated in a child with a fever that persists beyond a 5 day period. Even if a child was seen early in the course of his illness, as in the case of your son, a re-evaluation is necessary.

One of the reasons a re-evaluation is necessary is because a child with a virus may develop a secondary bacterial infection. When a child develops a virus his body mounts an immune response and works hard to fight the infection. It is during this time of stress that a child is more susceptible to developing a bacterial infection. That is why it is common for infections such as Sinusitis and Pneumonia to occur after a child is diagnosed with a cold or a virus.

A persistent fever is one of the signs of a bacterial infection.(1) A bacterial infection can settle anywhere in the body, including the respiratory tract, sinuses, urinary tract, skin, blood or the bones. Without the benefit of an evaluation by a health care professional, there is no way for a parent to know if their child has a bacterial infection. In some cases a fever may be the only sign that a bacterial infection is present.

Surely, there are some viruses such as the Influenza Virus or Epstein-Barr Virus (Mononucleosis) that can cause a fever to last beyond 5 days.(2,3) Only a thorough history and physical examination performed by a Physician or Nurse Practitioner can determine if a bacterial infection exists. Therefore the only way to find out if further intervention is neeeded is to bring a child back to the Doctor’s office for an evaluation.

During a follow up examination further testing may be performed in order to determine the cause of a persistent fever. The specific type of testing ordered depends upon the age of the child, his immunization status, social situation, contact with sick people and the findings on his Physical Examination. Bloodwork, urine testing and a chest x-ray are tests that may be performed.

Each Physician has his or her own opinion regarding when a follow up is necessary and which testing needs to be performed on a child with a persistent fever. Since your son has a fever for 6 days now, I suggest that you telephone your Physician and let him know that you cannot afford to return to the office but are concerned about his persistent fever. Your physician should be able to guide you regarding the next step. He is the one that examined your son and is familiar with his condition. He also is aware of the viruses and infections that are prevalent in your community at this time. He may be able to tell you that “Influenza” for example is going around your community and causing a prolonged fever in children.

It is important to stress your financial situation to your Physician because he may be able to offer you options that could help. Some Physicians may be willing to set up a payment plan or defer payments when a parent financially cannot afford healthcare. Your physician can also help you cut down on the cost of health care by offering free medication samples when they are necessary or recommending generic prescription medications instead of brand for a less expensive price.

You may also want to consider calling your insurance broker, Personnel Department that handles your health insurance or Health Department in your town in order to get information about lowering your health care costs. Your local Health Department should be able to give you information about free health clinics in your area.

The US Department of Health and Human Services can provide you with information about low cost health coverage for your family. This agency can give you information about state run programs that provide health insurance to children who do not have insurance. There are financial requirements for the programs offered, but you may still qualify even if you work.

It is also important that you address your child’s fever because the longer he is sick the more days he will miss from school. A longer illness also puts him at risk for complications such as dehydration and also gives him more opportunities to spread the infection to others. Worrying about his fever is also not good for your health, therefore I suggest addressing the situation for both of your sakes.

For Information about Low Cost Health Insurance for Children:

U.S. Department of Health and Human Services Website

NJ FamilyCare Insurance

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

High Fever

Fever, Rash & Joint Pain

Scarlet Fever

Fever and Vomiting

Tylenol Dosage

Pneumonia

Tracking Flu Activity

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: 429-434.
(2)Nield L, Kamat D. “Flu” Season: Here We Go Again.. Consultant for Pediatricians. 2005. Oct:411-416.
(3)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1688-1689.

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

Pediatric Advice For Parents with Sick Children

Pressure in Vagina

2007-02-15T18:11:00.000-05:00

Dear Lisa,

My 10 year old daughter for years has complained of a "bubble" or vaginal pressure that annoys her greatly, however without pain. She has had ultra sounds of the kidney, bladder and abdomen, an MRI, and vaginoscopy and cystoscopy, all of which were normal. She does have a history of chronic UTI's and constipation and is on a laxative and antibiotic now for those. Any ideas of what could be causing her this pressure, that would not appear on any of these exams? We are very frustrated and desperate for any more ideas to explore.

Thanks so much!

“Bubble in Vagina”

Dear “Bubble in Vagina”,

It must be so frustrating to go on for years listening to your daughter complain and not know the reason. It sounds like she has had an extensive work-up to determine the cause. It is also very concerning that she has chronic Urinary Tract Infections for no known reason.

For some children, chronic constipation can cause Urinary Tract infections. The large, hard stools that are present in the abdomen of a constipated child can impede the normal flow of urine through the urinary tract. This can cause the urine to pool or be pushed upwards back into the kidney. This pooling of urine and retrograde movement can put a child at risk for developing a Urinary Tract Infection. Constipation and large, hard stools can also lead to bloating and abdominal discomfort which may be the cause of the pressure that your daughter is feeling in her vaginal area.

The treatment in this case is to address the constipation. Dietary management and laxatives should loosen and clear out the bowels and prevent symptoms from occurring. You did mention that your daughter is on a laxative, but did not mention if it is working or not. If constipation is still an issue, this problem should be addressed first because many times once the constipation resolves the other symptoms go away too. If your daughter’s vaginal symptoms persist even after her constipation has resolved then a different cause should be investigated.

If constipation was the cause of your daughter’s Urinary Tract Infections, then the infections should also be alleviated with the resolution of her constipation. If your daughter still develops Urinary Tract Infections even after the constipation has resolved, then there may be a different reason for her recurrent infections.

Most practitioners agree that young children with a Urinary Tract Infection need a diagnostic work-up to determine the cause. This work-up typically includes a Renal Ultrasound and a Voiding Cystourethrogram(VCUG). (1,2) A Renal Ultrasound can determine if there is an obstruction in the urinary tract, renal stones, or lower tract abnormalities. This test also assesses the size and contour of the kidneys. (1) Since your daughter’s ultrasound was normal these conditions should have been ruled out.

You did not mention if your daughter had a Voiding Cystourethrogram (VCUG) performed, unless the cystoscopy you mentioned was a VCUG. The purpose of the VCUG is to evaluate the lower urinary tract and determine if there are any anatomical abnormalities such as Vesicoureteral Reflux. (3)

The advantage of having a Voiding Cystourethrogram performed is two-fold. Not only can it determine if a child has an anatomical anomaly of the urinary tract, it can assess the walls of the vagina. During a Voiding Cystourethrogram, dye is injected into the urinary tract. This injected dye tends to collect in the vaginal vault. If there is an abnormal opening between the vagina and rectum such as a Rectovaginal fistula this dye can seep through the opening and cause dye to appear in the rectum.

A Rectovaginal fistula is an abnormal communication between the rectum and the vagina. During a bowel movement, pieces of stool can pass through this abnormal opening allowing the vagina to be contaminated. Microorganisms from the stool can travel into the urethra, up into the urinary tract and cause an infection. Therefore children with Rectovaginal fistulas can have stool come out of their vagina and also can develop recurrent Urinary Tract Infections. If a Rectovaginal fistula is suspected a test called a retrograde Urethrocystogram is performed in order to determine if the abnormality exists. (1)

The appearance of a bubble or protrusion upon examination of a child’s vagina can be due to an Imperforate hymen. The hymen is a layer a tissue that surrounds the vaginal opening of a child. It usually ruptures during the perinatal period. If the hymen fails to rupture an Imperforate hymen develops.

An Imperforate hymen is a rare finding, occurring once in every 1,000 to 2,000 females. (4) When it does occur, it tends to go undetected until a female reaches early adolescence. (5) The typical symptoms include abdominal pain, constipation, low back pain, urinary retention, painful urination or frequent urination. (4)

In some cases an Imperforate hymen is not diagnosed until a young girl is old enough to have her period. When a girl with an Imperforate hymen menstruates, menstrual blood accumulates behind the closed hymen and gives it a blue, bulging appearance. (5) Other conditions that may present with similar symptoms include vaginal atresia, transverse vaginal septum, hymenal cyst, hymenal skin tag, or labial adhesions.

Since your daughter’s complaints include “feeling” a bubble and not “seeing” a bubble an Imperforate hymen is not likely the cause of her symptoms. In addition the vaginoscopy that she had performed should have ruled out an abnormality of the hymen and the external genital structures.

Since your daughter is still complaining about pressure in her vaginal area it might be a good idea to have her evaluated by a Pediatric Gynecologist, unless you have already done this when she had her vaginoscopy. A Pediatric Gynecologist has the expertise to diagnose and treat genital abnormalities in children. A Pediatric Gynecologist can also identify normal variations that may be responsible for your daughter’s complaints. It is important that a genital evaluation be performed by an expert in the area because genital abnormalities are quite difficult to diagnose.

Studies have shown that Family practitioners, Pediatricians and Surgeons generally do not excel in this area. Two studies using surveys of Family Practitioners, Pediatricians and Surgeons demonstrated physician difficulty in correctly labeling and identifying basic genital structures on a photograph of a prepubertal child’s genitalia. (6,7) The inability to correctly label basic anatomy on a photograph questions their ability to correctly interpret and diagnose clinical findings.

The vagina tends to be a very sensitive area which frequently causes young girls to complain. Some girls have normal anatomical variations that may cause more complaints than others. These normal variations can lead to different sensations and complaints. For example a high or microperforate hymen may trap drops of urine or mucus and lead to vaginal symptoms. (1)

Another common condition that I found in many of my female patients was Vaginal Adhesions. Vaginal Adhesions occur when tissue in the vaginal area known as the Labia minora sticks together. This causes the vaginal opening to become partially covered and in some cases a pocket to be formed which can trap urine, air or mucus. Vaginal Adhesions also can cause various vaginal complaints.

For girls with vaginal complaints it is a good idea to avoid activities that may contribute to vaginal irritation. Items and activities that can cause vaginal irritation include bubble baths, perfumed soaps, dyes found in colored underwear or colored toilet paper, tight fitting clothes, sitting in tight fitting jeans for prolonged periods and wearing stockings. (1)

I hope this information helps and I hope your daughter finds relief from her discomfort soon.

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

Constipation

Urinary Tract Infections

Vaginal Odor

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1526,1470, 1710-1715.
(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. 1990:534.
(3)Moore J. Oral and IV Treatment similar to urinary tract infections. Infectious Diseases in Children. 2006. Dec. 64.
(4)Wall EM, Stone B, Klein BL. Imperforate hymen: a not-so-hidden diagnosis. Am J Emerg Med. 2003.21:249-250.
(5)McAlhany A, Popovich D. Girl, 13, With Swollen Uterus and Pelvic Pain. Clinician Reviews. 2006. 16(10):53-58.
(6)Ladson S, Johnson CF, Doty RE. Do physicians recognize sexual abuse: Am J Dis Child. 1987. 141(4):411-415.
(7)Lentsch K, Johnson C. Do physicians have adequate knowledge of child sexual abuse: The results of two surveys of practicing physicians. 1986 and 1996. Child Maltreat. 2000;5(1)72-78.

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

Pediatric Advice -Your Questions Answered

Enlarged Lymph Nodes

2007-02-14T12:40:00.000-05:00

Dear Lisa,

My 2 year old son has had enlarged lymph nodes on his neck for over 6 months now. He has been to 3 different pediatricians who say they have no concerns as its not growing and he has had a normal blood test and a normal physical exam. For 3 months now, he has been following up each month for a re-check. They measure it and check his liver and spleen. The doctor just keeps telling us that it's most likely nothing and that it might not go away for quite sometime, he even noted it may take years for it to go back to a normal size. It still worries me every day. Why does this happen to some kids and mean nothing? At what point do we go to a specialist for further testing? We live close to a very respectful children's hospital, why would they not be sending us there? Is there a point that we should see a specialist even if there is no change?

Thank you,

“Anxious and Worried Mom”

Dear "Anxious and Worried Mom",

Each time a child develops un upper respiratory infection or virus the body‘s immune system is activated. The lymphatic system is the part of the immune system that works to fight infections. The immune system consists of a special network of vessels and lymph nodes that are located throughout the body. Some of these lymph nodes are located close to the surface and can be visualized by the human eye while others are located so deep in the body that they never can be seen or felt. The cervical lymph nodes or lymph nodes located in the neck area are ones that are located close to the surface and can be seen and felt.

Children’s cervical lymph nodes enlarge with each upper respiratory tract infection that they contract. Since children are normally expected to develop 5 to 10 upper respiratory infections or viruses per year it is common for the lymph nodes in their neck area to appear enlarged for a long period of time. This is especially prevalent during the winter months when most of the upper respiratory tract infections occur.

Some viruses cause very obvious symptoms such as a fever or a sore throat. Other viruses can cause mild or non-specific symptoms such as irritability or tiredness. When this is the case, a parent may not even know that their child is ill. Therefore a child’s cervical lymph nodes may be swollen due to an infection that a parent does not recall.

Enlarged cervical lymph nodes in children are referred to as “Shotty nodes”. (1) This is a very common finding in the pediatric population and is considered normal. Shotty nodes are typically less than 2 centimeters in diameter, mobile, and not painful. As long as a child with Shotty nodes is evaluated and followed by a health care professional there should not be any cause for alarm.

Lymph nodes that are larger than 2 cm, painful, red or non-mobile are not considered to be normal. These symptoms require medical attention. In addition, enlarged lymph nodes associated with fever, pain, limited motion, weight loss, chronic cough, decreased appetite, rash, difficulty swallowing , abnormal movement of the tongue or joint pain are also a cause for concern. Children with enlarged lymph nodes associated with these symptoms need an evaluation in order to rule out another condition.

Without knowing the location or size of the lumps in you son's neck, it is impossible to determine if his condition is normal or not. Only a health care professional who physically examines your child and knows his medical and family history can make this determination. Since your son was evaluated by three separate Physicians and they all reported that his condition is normal it is unlikely that his condition represents a more serious condition. You can also be assured because his bloodwork was normal and he is not experiencing any other symptoms.

In regards to your question about seeing a specialist; usually the Primary Care Physician refers a patient to a specialist if he feels that it is necessary. Since you saw three Pediatricians and they all felt that your son’s condition is normal, I would be inclined to think that a specialist is not required.

Conditions that would lead me to think that your son may need further attention include the presence of the concerning symptoms mentioned above, swelling below the jaw line or bumps found in an area not consistent with the location of a lymph node. It is important to remember that not every bump or area of swelling in the neck is due to a lymph node. Swelling below the jaw line may be a sign of the Mumps. A mass in the center of the neck, near the Adam’s apple may represent a problem with the thyroid gland. A small round hard nodule located in the upper neck area that moves when a child swallows may be indicative of a Thyroglossal duct cyst. Thyroglossal duct cysts happen to be the most common cause of midline neck mass in children. (3)

If your son’s bumps are not consistent with the characteristics of normal lymph nodes, if they are located in an area not typical of the location of lymph nodes, or if you are still worried you may consider seeing a Pediatric Ear, Nose and Throat specialist or Otolaryngologist. This type of doctor will be able tell you if your son's bumps are normal lymph nodes and confirm your Pediatrician’s previous findings.

I wish you and your son well.

If you are interested in reading other Pediatric Advice Stories about this subject:

Lump in the Neck

Enlarged Lymph Nodes

Lump in the Groin

Inguinal Lymph Nodes

Mumps

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:475.
(2)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:588.
(3)Dedivitis RA, Camargo DI, Peixoto GL. Thyroglossal duct; a review of 55 cases. J Am Coll Surg. 2002. 194:274-277.

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

Pediatric Advice For Parents

Only Drinks Milk

2007-02-12T08:31:00.000-05:00

Dear Lisa,

My 3 year old has chronic constipation along with stool withholding on top of that he refuses to eat food he lives off milk. What can I do? Respectfully,

“Mrs. M”

Dear “Mrs. M”,

Your son’s constipation is very likely related to his diet. Children need fiber in their diet in order to maintain a normal stool pattern and prevent constipation. Foods such as fruits, vegetables and grains add roughage to the diet. Excessive amounts of milk can also cause a child to become constipated. (1)

Milk alone does not provide the appropriate amount of nutrients necessary for a child’s growth and development. In particular, cow’s milk is a poor source of iron, containing only 0.5mg to 1.5 mg iron per liter.(2) In addition, drinking excessive amounts of cow’s milk can lead to blood loss through the intestines. Children over 6 months old who drink more than 1 quart of cow’s milk per day are at risk for developing Iron Deficiency Anemia.(2)

When a child is constipated he experiences straining and pain when ta bowel movement is passed. Children remember and fear this pain and as a result attempt to hold in their stool to avoid it. When a child holds in his stool, water in the stool is pulled out into the body, leaving a harder, more difficult to pass bowel movement. The longer the child holds in the stool, the harder the bowel movement becomes and a vicious cycle begins. Stool withholding can develop into a chronic problem and lead to complications.

Besides the nutritional value of eating food, young children also need to eat food in order to promote speech development. Biting, chewing and moving food around in the mouth helps develop the muscles and coordination that are necessary for speech. Drinking alone does not help develop the muscles in the mouth, jaw and throat that are responsible for the production of clear speech.

The many benefits of eating solid food should outweigh any concerns you may have about your son’s behavior when you attempt to give him solid foods. It is very normal for children to confront any change in their routine with frustration and acting out. Therefore, his refusal to eat and his acting out behavior should not persuade you to give in to him. Transitioning your son to a diet consisting of solid food is necessary at this time.

At first, the transistion may be difficult and emotionally challenging, but you should be reassured that most children adjust to change in approximately 2 weeks time. During this two week transition period it is important to stay firm in your decision and not give in to your son's pleading or crying. This may be very difficult to do because this behavior does have the potential to wear a mother down. Just remember that the body has a natural instinct, need and desire to eat. When your child is hungry he will eat something.

It should be helpful to know that it is healthier for your child to eat food rather than continue with his present diet consisting only of cow’s milk. When a child drinks milk continually throughout the day, he does not develop hunger or the desire to eat solid food. Therefore it is necessary to take away the milk. If he is drinking from a bottle, it is a good idea to just throw all of his bottles away so that you will not be tempted to give them back to him. You can give him sips of water in the mean time and frequently offer different types of solid food. Your son will initially protest, but when he gets hungry he will eat.

I have some practical suggestions that I hope will help this transition go a little smoother. One suggestion is to have your son stay at an Aunt’s or Grandparent’s house for a couple of days. Have his aunt or Grandma tell your son that there is no more milk and instead, offer other types of solid food. They should offer him foods with different temperatures, textures , shapes and and flavors. Mostly likely he will protest less when he is staying with relatives. Once it is determined which foods he eats at his relative’s house, then you will know what type of solids to offer him when he returns home.

Another suggestion is to have your son visit a friend or neighbor’s with older children and have your son watch them eat. Children learn from each other and many times they like to copy the actions of other kids. It is more likely that your son will eat food if he sees other children eating it.

You can also bring your son with you to the market and ask him to pick out something that he wants to eat. You may be surprised what he picks out. There may be a type of food that he saw an adult eat that he would like to try. Lastly, and probably most importantly, have your son sit down with the rest of the family for meals. Watching other family members eat sets a good example for your son. Parents that eat healthy food with a big smile on their face give their child the message that eating is good. Children learn eating behaviors from their parents, and what better way to teach them than to eat a big plate of fruits and vegetables.

I wish you luck.

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

Constipation

Treating Constipation

Stool Withholding

Bottle Weaning

Picky Eater

Anemia

Childhood Nutritional Requirements

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. 1990:179.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1406.

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

Pediatric Advice About Childhood Growth and Development