Technical Name: Asthma

NickNames: reactive airways, wheezing

What is it? narrowing and swelling of the tubes of your lungs that occurs when trigged by a variety of stimuli such as viruses, allergens, season changes, pets, insect stings

How is the diagnosis made? Asthma is frequent wheezing and is a clinical diagnosis that is usually given after a child has wheezed on more than one occasion and responded to bronchodilators such as albuterol.

Typical Ages: infancy to adulthood

Treatment: when I think about asthma therapy, my goals are to:

1. decrease the severity of the episodes

2. maximize airway function

3. keep the child doing what the child loves to do

Some kids just have episodic asthma when faced with their trigger such as a cold or weather change. These kids may just need treatment of that exacerbation with:

1. a bronchodilator to get the airway big again: albuterol inhaler

2. an antiinflamatory medication to eliminate the swelling: a steroid – either oral or inhaled

For kids with frequent exacerbations or symptoms that are starting to interfere with the actitities they love such as sports, preventative medications are available: inhaled steroids and an immune mediator called Singulair.

How will I know what is best for my child?

Your pediatrician will help you develop an asthma action plan for your child so you’ll know what medication to use and when, including at school.

Can asthma be dangerous? The honest truth is that asthma can be very serious and can be fatal if not treated correctly. Any child having trouble breathing who has asthma needs to be seen right away – even in the middle of the night. So, if your child is having trouble breathing:

1. give your child a dose of albuterol by inhaler or nebulizer

2. go to the nearest emergency room or call 911

Will my child out grow asthma? May kids do “out grow” asthma meaning it is worse when they are younger but often asthma does persist in one way or another throughout a person’s life. Your child’s history over time will tell this story but keep in mind that there are many adults with asthma living full lives and doing great things!

Online Asthma Resources

1. KidsHealth Asthma Centers

• Parents
• Kids
• Teens

2. Does my baby have asthma?

Technical Names: RSV Bronchiolitis

NickNames: RSV, wheezing virus

What it is: viral infection of the small airways of the lung; can cause a true viral pneumoniaas well.

Typical Ages for Illness: All ages; most severe in young and premature infants and children with heart and lung problems including congenital heart disease and asthma. Interesting fact: all kids become infected by RSV by the age of 2 and many of us get it multiple times throughout our lives.

Typical Symptoms:

adults: bad cold symptoms

older infants and children: similar to a bad cold

young infants: lethargy, trouble eating, fast breathing, cough, wheeze.

Etiology: Respiratory Syncytial Virus

Seasonal Issues: occurs predictably between November to March

How’s It Spread? Direct contact with secretions – person to person or on objects.

Incubation Period: 4-6 days but can range from 2 to 8 days

Diagnosis: Usually clinical – based on symptoms and high index of suspicion given out breaks in community. Rapid assay test available in many offices and emergency rooms – most useful if a child needs to be hospitalized to control infection.

Symptom Duration: 7-14 days, as with most viral illnesses with the most intense symptoms early in the illness.

Treatment:

• cold treatment: saline nose spray and bulb syringe, humidifier
• +/- breathing treatments such as inhalers or nebulizers
• fluids
• tylenol or motrin for fever and discomfort
• some children do need to be hospitalized due to severe respiratory symptoms such as trouble breathing and needing oxygen, or due to underlying heart and lung problems.

Call Your Pediatrician if your child has:

• high fever, or fever not gone in 2-3 days
• vomiting or diarrhea and can’t hydrate well
• lethargy
• sick appearance
• trouble breathing despite treatment
• blue or gray color to lips or fingernail beds

Prevention:

• stay home if sick
• good hand washing
• having the child cover his or her mouth when coughing, if possible
• cleaning toys and objects likely contaminated by respiratory droplets
• a medication called Synagis before RSV season is available for kids under 2 years of age that are high risk – premature babies younger than 35 weeks and congenital heart disease children. This is usually given starting in November as RSV season begins. Your pediatrician will alert you if your child falls into this group.

School and After school Activity Issues

• may return to daycare when fever free for 24hours and able to eat and drink normally, and breathing normally
• avoid large groups of kids if cough is not controlled to prevent further spread
• if on antibiotics, needs to be on them for 24 hours before returning to school
• activities should be curtailed until the child has the energy to participate without becoming winded or fatigued.

Internet Resources For Parents

General Info on RSV (KidsHealth)

General Info on Bronchiolitis (Kids Health)

How Lungs Work (KidsHealth)

Technical Names: Streptococcal Pharyngitis

NickNames: Scarlet Fever, Strep Throat

What is it: infection of the throat involving the pharynx, tonsils or both

Typical Ages for Illness: school age kids and teens are the biggest population; can occur in adults; rare in children under 2 years of age.

Typical Symptoms:

sore throat and pain with swallowing; swollen neck glands

+/- abdominal pain and headache, common in school-aged kids

+/- fever

+/- sandpaper-like rash: when present, the illness is termed Scarlet Fever

+/-swollen tonsils with pus covering them

Etiology: Group A beta-hemolytic streptococci (Streptococcus pyogenes)

Seasonal Issues: outbreaks can occur year round but are more common from Fall to early Spring when people are more in doors and in close contact.

How’s It Spread? Person to person usually through direct contact or respiratory secretions (cough, sneeze)

Incubation Period: 2-5 days

Diagnosis: rapid strep test or throat culture at a doctor’s office

Symptom Duration: symptoms can go away without treatment in a few days; with treatment, improvement typically occurs within 24-48 hours of starting antibiotics.

Treatment:

• antibiotics once diagnosis is confirmed
• fluids
• rest
• tylenol or motrin for fever and discomfort
• popcicles, throat lozengers
• other medications as determined by your child’s doctor

Call Your Pediatrician if your child has:

• high fever, or fever not gone in 2-3 days
• vomiting or diarrhea and can’t hydrate well
• lethargy
• sick appearance

Prevention:

• stay home if sick
• good hand washing
• having the child cover his or her mouth when coughing, if possible
• cleaning toys and objects likely contaminated by respiratory droplets

School and After school Activity Issues

• may return to school when fever free for 24hours and able to eat and drink normally
• needs to be on antibiotics for 24 hours before returning to school
• avoid large groups of kids if cough is not controlled to prevent further spread

Internet Resources:

For Parents From KidsHealth

Strep Throat Information

Scarlet Fever Info

For Kids and Teens From KidsHealth

The Scoop on Strep

Teen Info on Strep

What is it? The inability for Seniors (typically) to focus due to a feeling that “they are done”. However, this can occur in all kids at various stages.

Symptoms:

Not applying as much effort in school work

Loosing interest in activities

Grades slipping

Lackadaisical attitude

What you should do as a parent:

• Talk to your child
• Talk to the school

The goal is to uncover from your child what is driving your child’s thinking and motivation. Your job is to be helpful and to be a good listener. The school is your best ally in helping you talk to your child and explaining the big picture.

The Cure

GRADUATION! And, staying busy and involved well before then.

However, your Senior needs to understand that some colleges and universities are not as forgiving if grades slip too much. Scholarships and awards have been revoked so it is important to keep GPAs respectable. Many schools have helped by keeping kids busy with projects and fun class activities.

See Resources for more information and tips.

Resources For Parents

What to do about Senioritis (College Board Association)

PedsNow article March 2006

Common Household Pets:

Hamster, cat, dog, guinnea pig, ferret, gerbil, rabbit, mouse

Do these pets carry a rabies risk? No.

Can I get infected from being bitten by my pet? Yes. Mouths of pets have bacteria and can infect you. As with all bites and cuts, you want to do the following:

1. Clean well with warm soapy water.

2. Apply antibiotic ointment.

3. Cover with bandaid/dressing and change when needed.

4. Keep a close eye on the bite site for signs that active infection is forming which include:

Redness

Warmth

Tenderness

Pus

If your pet or a friend’s pet has bitten you, find out about the health of the pet:

• How has the pet been acting?
• Is the pet up to date on shots? This applies to dogs and cats.
• When in doubt, contact a vet to see if the pet needs to be evaluated for infection. Often a vet can tell you over the phone if a type of pet needs to be seen or will put a person at risk from a bit.

What animal bites do I need to worry about for rabies risk?

Wild animals and unimunized cats and dogs.  So, if you don’t know the ownder of a cat or dog, those are the  cats and dogs to worry about. Also, all dog bites need to be reported to the local police by law.

Bites from the following animals need to be evaluated right away for rabies shots: bat, skunk, raccoon, fox, coyote, or large wild animal. Keep in mind that for bats, a bat in the house counts as a bat bite since bats often leave no bite marks.

Links For More Information

Dog Bite Law Site

University of Michigan Pet Bite Information

Technical Names: Allergic Rhinitis

Nicknames: Hayfever, Allergies

What it is: allergic reaction to something in the environment such as pollen, dust, molds, animal hai. It is an overreaction of the immune system – a “normal” reaction on overload. People can grow in and out of allergies throughout their lives. Genetics determines some predisposition but environmental factors can also overload the immune system.

Seasonal Issues:

Many people have season allergies particularly around season change times. Some people are allergen specific and others have year ’round allergies.

Symptoms:

Symptoms are different person to person but include some of the following:

• runny nose
• sneezing
• itchy skin
• watery eyes that may appear red
• wheezing or cough

Treatment:

Symptoms specific and may include:

• avoidance if possible of offending allergen (eg. if allergic to cats, avoid cats)
• antihistamines: over the counter and prescritpion
• expectorant for nasal congestion
• saline nose spray
• eye drops
• other medications as indicated by symptoms

When to Call Your Doctor

• symptoms interfering with activities
• symtpoms interfering with sleep
• trouble breathing
• worsening itchy rash

Internet Resources for Parents

All About Allergies (KidsHealth)

Internet Resources for Teens and Kids

For Teens

Two Steps Forward, One Step Back

In pediatrics medicine, we continuously strive to make kids healthier. But sometimes to improve one problem we inadvertently create another, as demonstrated by the American Academy of Pediatrics’ “Back to Sleep Campaign”.

Launched in 1992, the Back to Sleep Campaign has been a true success story, reducing the incidence of SIDS (Sudden Infant Death Syndrome) by nearly 50%!  The untoward consequence of the program, however, was a marked increase in flattening along the back of the head. While this problem is not life-threatening, like SIDS, it has become a source of anxiety to parents of affected infants. And, there is a lot of misinformation and confusion about what flat heads are really about and how, if at all, they should be addressed.

Ryan’s Story: A Common Tale

Ryan is a 6 month old baby boy from the North East United States who was placed on his back to sleep since birth. As he got bigger, his parents noticed a flattening develop on the right side of the back of his head which was very pronounced by 3 months of age.  Concerned, they consulted Ryan’s pediatrician who diagnosed Ryan with “positional plagiocephaly” and advised repositioning techniques, such as putting him down on different ends of the crib so his head will get used to turning in both directions.

Ryan’s parents attempted the repositioning for a month but saw little, if any, improvement.  They were also nervous to try this for too long fearing they’d lose their window for a helmet to be most effective.  To explore options, they consulted the large orthotic group in their area which was willing to make Ryan a helmet but they faced two hurdles. First, their insurance would not pay for the helmet, as this was a “cosmetic” problem. Second, the specialists were not convincing that the helmet was truly needed.

As their quest for information continued, Ryan’s head began to appear more round, not just to their eyes but to Ryan’s pediatrician and nurse practitioner as well.  So, with Ryan now 5 months old and moving around well in his crib, they opted to let nature take its course.

Ryan’s story has a happy ending but was it luck or something more?

Flat Heads: A Historical Perspective

Posterior head flattening, termed plagiocephaly (Greek “oblique head”) if it is asymmetric (only on one side), or brachycephaly (Greek “short head”) if it is symmetric (entire back flat), is not a new problem and has been in existence since ancient times. Many modern cultures, such as China and India, have practiced back sleeping for centuries. In these countries, moderate flattening is ubiquitous, well recognized, and more readily accepted.

In our country, however, flat infant heads are a relatively new phenomenon that we are not yet acclimated to. As a result, overwhelming attention has been focused on the diagnosis, prevention, and treatment of this deformity giving rise to an industry of unproven commercial devices and services that claim to treat or prevent the condition. Many simply don’t work, such as pillows and wedges, while others seem to work if initiated early enough such as the popular infant head helmets and bands, and the very new infant head cup, which is the only truly preventative modality available.

What is reassuring is that development and brain growth are not impacted by the myriad of head shapes that are developing with the Back to Sleep campaign. And, with more babies developing positional deformities, our definition of “normal” may be slowly changing.

A Postnatal Problem with a Prenatal Start

With the majority of babies sleeping on their backs, it is easy to imagine a future world of flat headed people. But, that is not the case at all. “Not every infant who lies on the back gets flat, and in fact, only about 20% actually develop clinically significant flattening”, notes Dr. Gary Rogers, plastic surgeon specializing in head shape abnormalities at the Children’s Hospital Boston.

According to Dr. Rogers, the problem starts before birth. If the baby’s head movement is restricted in utero, he or she may develop contracture of the neck muscles (torticollis). Like any muscle group, the neck muscles can become tight if they are not allowed to move freely. Once born, the tight neck will keep the infant’s head in a similar position to what it experienced while in mom’s womb. Other well established risk factors for plagiocephaly include: multiple births (e.g. twins), breech position, first born babies, male babies, low fluid in the uterus, and prematurity. It is no surprise that these are also risk factors for torticollis or neck muscle imbalance.

Once an infant is born, the head grows against a flat surface (bed, car seat, etc.). This is similar to a pumpkin growing in a field. If the pumpkin is not rotated during growth, it will become progressively flattened on the down side. But if the pumpkin is turned intermittently, the pumpkin will remain round.  This is the same for infants with poor neck mobility. If unable to move the head to both sides, their heads will become flatter as the head rapidly grows during the first few months of life. After 4 months, most infants, even those with tight neck muscles, have sufficient strength and neurologic development to reposition their head and the flattening usually stops getting worse.

What happens after this point has been a source of confusion for parents and physicians. There is little evidence to suggest that the flattening ever “pops out”. Whatever degree of flattening developed early on will persist but will look less pronounced as the head gets bigger.  “The improvement is relative to the increase in head size. Additionally, hair growth can act to camouflage flattening”, explains Dr. Rogers.  “It is analogous to comparing a one centimeter indentation in an apple (the 6 months old) vs. the same dent in a watermelon (the older child). The dent looks much less impressive on the later fruit, even though the actual size and depth of the indentation is identical.”

Diagnosing positional deformities is purely clinical. Radiographic studies are reserved for the very few times the head shape falls out of the range of what is expected from a baby sleeping on the back. And, even then, 99.9% turn out to be deformational. The remaining 0.1% are from a premature fusion of the posterior cranial sutures, called craniosynostosis.  While those situations do require further testing and surgery to correct, a baby can safely be diagnosed well into their first year of life. So, while specialists like Dr. Rogers are helpful for the few and rare cases of flat heads that are not typical, this is clearly a situation that can be handled by most pediatricians.

Beauty is in the eye of the beholder.

The Chinese still use swaddle boards to carry babies while they work. This results in the characteristic head shape of this culture. That is what their culture strives for.

In our culture, head shape is much more individual. This is truly a case where beauty is in the eye of the beholder. As long as you are comfortable with how your baby looks, whatever treatment you decide will be the right one.

(Acknowledgments: Dr. Gwenn would like to thank Dr. Gary Rogers from Children’s Hospital Boston for his time, input and contributions to this article, as well as for images from his picture collection.)

TYPES OF ORTHOTICS

Non-helmet Orthotic Devices and Resting Surface Alterations

Examples: memory foam, contoured pillows, cut-out surfaces, and slings.

What they claim to do: decrease focal pressure by increasing the area of contact with the supine infant’s occipital (the back of the head).

Why they don’t work: They do not expand to accommodate rapid head growth during infancy and do not provide for variable skull size. Soft or moldable surfaces, such as memory foam, are ineffective because the infant’s head, which weighs about 1 pound, cannot deform the surface into a concave, anatomically normal shape.

Repositioning Wedges

What they claim to do: they are intended to vary the point of contact between the surface and the infant’s occipital.

Why they don’t work: Most wedges only reposition the infant’s body, and many not change the head position at all. They also require constant adjustments by the parents who may be reluctant to continually awaken their sleeping infant. They are also relatively ineffective after about 4 months of age because most infants are mobile by this age and can easily slide off the wedge.

Molding helmets and headbands (cranial orthoses)

Background: described by Clarren and colleagues in 1981 (yes, flattening was treated well before 1992). Clarren founded the concept of helmet therapy on a simple premise: “If the pressure of a rapidly growing brain against a flat surface would flatten the skull, then pressure against a concave surface should round it back again.”

Do they work? Clarren and colleagues demonstrated improved cranial symmetry in all children treated with a helmet, but only 40% improvement when treatment was declined. There have been numerous subsequent reports that verify the effectiveness of helmet orthotics in managing deformational plagiocephaly.

Cups

What they claim to do: Developed by Dr. Rogers, these are concave cups that babies sleep in from birth to prevent flattening.

Do they work? Yes.

Downside: they need to be adjusted frequently by a licensed orthotist to allow for head growth.

How long are they needed? Once the baby rolls out of them they are not needed! This is a relatively new treatment and one that can be utilized well before there is a problem. And, it eliminates the development of the flattening to begin with.

Resources:

Cranial Technologies: Plagiocephaly and Helmet Informationl

Children’s Hospital Baby Head Suture Disorders

BACK TO SLEEP Campaign

(Originally posted March 2007; Updated December 2009)

Common and Technical Names:

Poison Ivy: Toxicodendron rydbergii

Poison Oak: Toxicodendron diversilobum

Poison Sumac: Toxicodendron vernix

Plant Identification: see this link: Cornell Poisonous Plants Information Database)

What it is: Allergic reaction to urushiol oil from the poison ivy/oak/sumac leaves. The rhyme “leave three let them be!” can help kids remember to avoid clusters of three leaves together. 85% of kids can have allergic reactions to the oil.

Exposure Issues:

• Plants: poison ivy, oak and sumac leaves
• Non-plants: oil on toys and shoes that had been in contact previously with the oil; the oil can actually remain active for 1 year!

Typical Ages for Illness: any age in a susceptible person, someone who is sensitive to the oil

Typical Symptoms: rash and itching in the areas of skin in contact with the oil. This can be from direct contact with the plan or by fingers who touch the oil on the skin

Seasonal Issues: The plants are perennial but have different appearances as the seasons progress. See KidsHealth for great pictures of poison ivy through the seasons.

Incubation Period: rash typically starts 1-2 days after exposure to the plant oil

Diagnosis: by the distinctive appearance of the rash which has a bubbly look. For a typical appearance of the rash click here.

Symptom Duration: the rash can take 2 weeks to clear. It is not contagious.

Treatment:

Symptomatic! Stop the itch!!!!

• over the counter products such as calamine lotion
• oatmeal baths and lotions: Aveeno is the name brand to look for
• antihistamines such as benadryl or claritin
• 1% hydrocortisone cream to small areas 2 times a day but do not use to large areas of the body or the face, or more frequently, without consulting your pediatrician
• local cold compresses

If these simple measures do not work and your child is very uncomfortable, call your pediatrician for further advice.

Exposure Prevention:

• Teach your children to recognize the poison ivy plant.
• Wear long pants, long sleeves, gloves and boots when in suspect areas.
• Use barrier creams such as Ivy Block.
• Remove plants if necessary (this should be done with caution—do not burn the plants since inhaling the smoke can lead to very serious reactions).

Call Your Pediatrician if your child has:

• wide spread areas of rash
• rash near the eyes or mouth
• any areas or the rash that appear infected, have frank push or appear red or angry looking, are tender, have red streaking, or the child has a fever

Internet Resources For Parents

American Academy of Dermatology Poison Ivy/Oak/Sumac Page

Children’s Hospital Boston Information on Poison Ivy and After Care Instructions

Lucile Packard Children’s Hospital

Internet Resources for Kids and Teens

American Academy of Dermatology Pesky Poisonous Plants Page

KidsHealth Information for Kids on Poison Ivy

KidsHealth info for Teens on Poison Ivy

Q) Dear Dr. Gwenn,

Thanks,
YP

A) Dear YP:

Vomiting in toddlers is always alarming. Although your child is well appearing, it is still possible he has a mild stomach virus. Food poisoning is a consideration with acute vomiting although this has gone on for a while. Other considerations in this setting are reflux or even allergies. I’ve seen a number of children who have such significant post-nasal drip they throw up due to the amount of mucous they swallow.

The first step is to help your son feel better and make sure he doesn’t get dehydrated. Push clear fluids and reintroduce solids slowly following theso-called BRAT diet – breads, rices, applesause and toast…essentially, very bland foods! Also, touch base with your pediatrician to get not only more guidance but to start discussing what may be the actual underlying cause of this situation. An office visit will likely be needed to accomplish that. And, since your pediatrician knows your child well by know and your child’s history, he or she can better advise you on what may be occurring. Once an office evaluation is done, your pediatrician can advise you if any further testing is needed. Often wtih children the diagnosis of vomiting is apparant from the history and physical but because the GI tract is a plumbing system, sometimes we need xrays to peer inside.

For all vomiting situations, seek medical care immediately if your child can not keep anything down, especially fluids. Children can become dehydrated quickly. Sometimes we have to give the children bowel rest and use intravenous fluids to keep them hydrated and safe while we let the work up progress. Other symptoms to call for with vomiting include vomiting green material or blood, fever, or abdomial pain.

Dr. Gwenn

Technical Name: otalgia

NickName: ear pain

Causes: ear pain is a symptom that doesn’t always mean ear infection.  The most common causes of ear pain include:

• Ear infection
• Ear irritation of ear canal
• Fluid in ear building up pressure
• Foreign body in ear canal
• Pain from the  mouth or neck

To learn more about the anatomy of the ear, click here.

Diagnosis: examination by a doctor will determine the actual cause.

Treatment: for all causes of ear pain, treating the pain early on is the most important factor. The definitive treatment for the pain will be dependent on the actual cause. Here are some considerations:

1. If a foreign body is present such as a bead, do not go after it, a doctor can remove it for you in the office. However, this is not something always easily done in a pediatrician’s office and may require either an emergency room or visit to an Ear/Nose/Throat specialist.
2. Ear Canal Infection/Irritation: ear drops are usually prescribed
3. True middle ear infection: this is also dependent on the cause. If viral, it will clear with time. If bacterial, most will clear with time in older kids and 10-20% will need an antibiotic. The standard of care today is to treat the ear pain for 2-3 days and start an antibiotic at that point if ear pain is persisting. Your pediatrician can guide you more specifically based on your child’s age, ear exam and history. Children under 2 years of age are still treated with antibiotics in the United States.

Other Treatment Issues:

What should I do if my child has ear pain in the middle of the night?

Give Tylenol or motrin and call your doctor for advice the following day. If you have been given ear drops for pain the past, these are ok if you ear is not draining. Never put drops into a draining ear without a doctor evaluating the ear first.

What should I do if my child has ear pain during normal business hours?

If your child is over 2, I’d suggest you give a dose of Tylenol or motrin and gage your child’s response. Knowing that an antibiotic will not be utilized in most case for a few days, you have time to watch and wait. However, if your child appears ill or markedly uncomfortable, if the ear is draining pus or blood, or if high fever is present, call your pediatrician’s office for advice.

Resources for more information:

Ear Pain Info from Children’s Hospital Boston

Antibiotics vs  Waiting from WebMD

Swimmer’s Ear (KidsHealth)

Middle Ear Infections (KidsHealth)

Flying With Ear Infections (KidsHealth)

Foreign Bodies in Ears and Nose

What is an ear infection?(For Kids from KidsHealth)