III Child Topics


Althought flu season is typically not found during the summer we leave this here as a reminder we typically start our flu vaccine clinics shortly after Labor Day.  We DO recommend seasonal flu vaccine for all our patients and family members, especially those in high risk groups.

A very good and basic discussion of Influenza can be found on:


In addition the Center for Disease Control has a more comprehensive discussion which you can find at https://www.cdc.gov/flu/


Tips to Stay Healthy During Cold/Flu Season

Vomiting ( Nausea and Emesis )
Pink Eye/Eye Discharge 
Sore Throat 
Head Lice 

Tips to Stay Healthy During Cold/Flu Season

Top five essential things you can do to avoid getting sick and, importantly, avoid infecting others. These critical tips are widely agreed upon by the World Health Organization, the U.S. Centers for Disease Control and Prevention, and other health experts.

1. Wash your hands.
The best thing anyone could do right now to avoid swine flu, experts say, is to wash their hands. It sounds like a stupidly simple response to an overwhelming situation, but nearly compulsive hand-washing helps prevent the spread of this airborne respiratory disease. It's the droplets from coughing and sneezing that spread the disease. These get on our hands. And then everything we touch is infectious.
How you do it is important:
- Use warm or hot water if you can.
- Lather up and rub not just your fingers and palms but also under the fingernails, around the wrists and between the fingers for as long as it takes to sing "Happy Birthday" twice, or the ABCs, once.
- Rinse well.
It is important to wash your hands before eating and after using the bathroom, but also after using a tissue or covering your mouth when you sneeze or cough, sick or not. So yes, that's a lot of hand-washing. Basically, think of how often you would wash your hands if you worked in an emergency room or operating room. Wash your hands that often and that thoroughly.

2. Cover your mouth when you cough or sneeze.
The way you spread influenza is with droplets that come out of your mouth or nose, so we recommend the classic shoulder or crook-of-the elbow sneeze. Better that the droplets are on your arm or sleeve – and then after coughing or sneezing – WASH YOUR HANDS.
Surgical face masks are an option for keeping your droplets to yourself, but they don't keep your hands clean and there is no consensus in the health care community on whether face masks are advisable for everyday use. Studies have shown that most people use masks incorrectly or inconsistently, so these other tips are more practical and realistically beneficial.

3. Stay home.
If you're sick, stay home- plain and simple, no exceptions! Try to muster the energy to wash your hands after you use tissues so you don't reinfect everything you touch afterward. This helps you recover, and protects your loved ones.

4. Don't touch your face.
Try, try, to keep your hands out of your mucous membranes - your eyes, nose and mouth - direct routes to the bloodstream that allow a virus to bypass the protective barrier of the skin. Few of us succeed at this fully. Frequent hand washing will help us when we forget, and touch accidentally.

5. Avoid sick people
It's a good idea to avoid close contact with other people who are sick. The flu virus tends not to float in the air. Instead, once dispersed, the liquid droplets tend to settle on objects that doctors call fomites - things that people touch that can pick up a virus. Examples include coins, hand rails, door knobs, common household and office objects. Smooth objects transmit microbes more than rough or porous ones. So, for instance, coins would allow one to pick up more virus than paper money. And again, if your children are sick with fever and cough/sore throat KEEP THEM OUT OF SCHOOL, so that well children have the freedom to attend without fear. Encourage your children to wash hands at school, send them with hand sanitizer, and make sure classrooms are equipped with soap, water, towels and tissues.

Vomiting ( Nausea and Emesis )

Think of vomiting as your child's way of purging the body of the ills it is encountering. Typically, a viral gastroenteritis (AKA "stomach bug" or "stomach flu") is the most common reason your child will vomit. And depending upon your child's age, there are certain guidelines that can be followed in order to hopefully maintain adequate hydration (see below for symptoms of dehydration), which is really the primary concern of vomiting. Because when dehydration becomes too severe, it can become serious and impact the body's ability to function efficiently. But bear in mind, most of the time, it really is no more than an aggravating experience for both you and your child.
So with the goal of maintaining adequate hydration and slowing down the vomiting process, here are some guidelines you can follow:
Infant younger than 6 months of age:
  • Give about ½ ounce of an oral electrolyte solution (e.g. pedialyte) every 15 minutes or so. Try to avoid water unless we tell you otherwise as the salts in the electrolyte solution help to replace what is being lost from the vomiting process.
  • Slowly increase the amount of solution your infant is taking if the vomiting has not reoccurred. For example, after two hours of tolerating the ½ ounce, ok to try maybe ¾-1oz every 15 minutes or so and then gradually increase throughout the day.
  • If after 8 hours of this hydration process without any vomiting, ok to return to either formula and/or breastfeeding. But start slowly…if breastfeeding, stick to 5-10 minute feeds every 2 hours and if formula feeding maybe begin with no more than an ounce at a time. 
  • If vomiting occurs during this rehydration process, wait about 30-60 minutes before beginning the process once again.
  • But with any infant under two months of age and back-to-back vomiting episodes, call us at Boulevard Pediatrics for immediate care and instructions. 
 Infants 6 months to 1 year of age:
  • For the most part, pretty similar directions as for the younger infants, other than volume amounts can begin a bit higher. 
  • What often is helpful in this age range are the flavored popsicles from the oral electrolyte solutions.
  • If after 8 hours of this hydration process without any vomiting, ok to return to formula/breastmilk as mentioned above…just remember to start slowly. And for infants who are on solids, ok to begin slowly with some of the bland foods…bananas, cereals, soft crackers.
  Children 1 year of age and older:
  • As above, but larger initial volumes of clear fluids can be tolerated…begin with ¾ ounce every 15 minutes and gradually increas from there. Some clear liquids include ice chips/water, flavored oral electrolyte solutions (e.g. pedialyte), or the popsicles as mentioned above.
  • After 8 hours of no vomiting, ok to start the mild, bland foods….as above, as well as mashed potatoes, bland soups, chicken broth.
  • Sometimes we will prescribe an anti-vomiting medication but only after being evaluated in the office.
  • And for those wondering about milk products, probably best to avoid until a day or so after the vomiting ceases.
So what are some symptoms of mild to moderate dehydration?
  • Dry mouth.
  • Decreased tears.
  • Decreased wet diapers or no urination in an older child for 6-8 hours.
  • Slightly sunken in soft spot on the infant's head.
  • Fussier than normal.
And some symptoms of severe dehydration?
  • Drier mouth…even sticky looking inside.
  • Wrinkled or doughy skin.
  • Decreased alertness.
  • Sunken eyes or sunken in soft spot in an infant.
  • More sleepy and even limp appearing.
  • No urination in 8 hours for an infant and 12 hours in a child. 

And when should your child be seen?  If there is refusal of fluids or if vomiting continues, we want to see your child. Also, if there is any abdominal pain not consistent with a viral "stomach bug", projectile vomiting in an infant less than 3 months of age, vomiting following head injury, vomiting bright green fluid, vomiting blood or coffee ground emesis, or anything else that concerns you about your child, please have your child be seen immediately.

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Colds, AKA upper respiratory tract infections, are the most common illnesses your child will encounter. In fact, once your child enters daycare/preschool, you can expect an average of 8 colds each year usually occurring 2-3 days after exposure and lasting anywhere from a few days to a couple of weeks. Some of the more common symptoms your child may have include a runny or stuffy nose, sore or scratchy throat, sneezing, coughing, and even a low grade temperature. And with the nasal discharge, it can be watery or that thick yellow or green color. Furthermore, please realize colds are quite contagious, particularly during the first couple of days after symptoms appear and they can spread via person-to-person contact, airborne particles, or a contaminated surface.
 So what can you do to help your child with a cold? Well, it's first important to realize colds are caused by viruses (and most commonly by rhinoviruses) and antibiotics will not be helpful because they are used for bacterial infections and not viruses. But some of the supportive care measures you can employ include:
  • Elevating the head while sleeping.
  • Humidified air (we prefer cool mist humidifiers) to loosen the nasal secretions.
  • Maintaining good hydration and getting good rest.
  • Using nasal saline drops and bulb suctioning the nose periodically.
  • Chicken soup? Well, although the research is limited, it is known that chicken soup has an amino acid, cysteine, which has mucous thinning properties…so we say, it's worth a try.
But please don't forget the most recent recommendations regarding over-the-counter (OTC) cough and cold medications that state they should not be used for children less than 4 years of age secondary to no real data supporting its effectiveness and the concern of over-dosing.
When should you bring your child in to see us? Well, first and foremost, if you have any concern of your child's well-being. But other guidelines on when to bring in your ill child include:
  • Shortness of breath and/or difficulty breathing.
  • When the coughing worsens.
  • Increased tiredness…lethargy.
  • Cannot maintain good hydration status.
  • A sore throat with a pretty good amount of pain when swallowing.
  • Fever persisting for more than 3 days or a fever not responsive to medical intervention and cooling measures.
  • Ear pain. 
And is there anything to be done to prevent colds?
  • Although it may appear obvious, avoid those who have a cold and things they may have touched...utensils, cups, tissues.
  • Good hand washing.
  • Cover your nose/mouth prior to sneezing/coughing…have your child cough into his/her elbow, not hand.
  • And for those wondering about zinc, vitamin C and Echinacea, there still exists no solid research supporting their use in children to prevent colds. 

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Acting as an important reflex to protect your child's airway, there exist many reasons why your child may cough. Some of those reasons addressed elsewhere include the signature seal bark-like cough of croup, the whistling type of cough of wheezing, or just the typical cough you might hear with the common cold. 
However other reasons for your child's cough include allergies, allergic rhinitis-where the cough develops from post-nasal drip, gastroesophageal reflux disease (GERD)-somewhat of an insidious presentation as there may not be any other presenting symptoms, sinus infections-colds that linger for at least 2 weeks (if not longer) and often worsen as the nasal cavity becomes filled with mucous, and even pertussis  (whooping cough)-where the child will have coughing spells that end with the classic "whoop"…often having its greatest impact on infants. But fortunately, we have a pertussis vaccine that begins at 2 months of age as part of the DTaP vaccine (which also includes diphtheria and tetanus). In fact, there now exists a pertussis booster vaccine for both adolescents and adults.
Most coughs worsen during the night, particularly related to the horizontal position your child sleeps in, but other coughs may be worse during the day as the climate or physical activity your child encounters may have a negative impact (e.g cold air or exercise-induced asthma or wheezing).
And while some coughs do not require immediate attention, please come in to see us if any of the following occur:
  • Difficulty breathing or working harder than normal.
  • Any shortness of breath or stridor ("harmonical" breath sound upon inspiration).
  • The cough is associated with a high fever.
  • Any change in color (typically blue) around the mouth.
  • Any blood noticed with the cough.
  • If wheezing is noted and no asthma care plan already exists with your physician.
  • The classic "whoop" of pertussis is noted.
  • Any infant who has been coughing for a prolonged period.
 So what can you do at home to help your child with a cough?
  • If your child has asthma, initiate the care plan as previously discussed with your pediatrician.  If no plan is in place, come in for an immediate evaluation.
  • As mentioned in the croup section, if the seal bark-like cough begins, bring your child into the bathroom after the steam from a hot shower encases the room.  The steam will help your child relax.  If no improvement is seen, have your child be seen for an immediate evaluation.
  • Purchase a cool-mist humidifier for your child's room.  The moisture can often be very helpful.
  • Keep your child well hydrated and maintain good rest.
  • Use saline nasal sprays to deal with some of the nasal congestion.
  • And as there is some research supportive the use of honey prior to bedtime in children 2 years and older, a trial of 2 teaspoons of honey with the caveat of never giving honey to children less than 1 year of age secondary to the risk of infantile botulism.
And don't forget the most recent recommendations regarding over-the-counter (OTC) cough and cold medications that state they should not be used for children less than 4 years of age secondary to no real data supporting its effectiveness and the concern of over-dosing.
 Interestingly enough, croup (AKA laryngotracheobronchitis) is not actually a specific virus but rather a description of a disease state. It is marked by a harsh cough often sounding like a seal bark and can be caused by a variety of organisms, including parainfluenza, human meteapneumovirus, adenovirus and even influenza. The reason for the croupy cough and sometimes-associated stridor (high-pitch breathing sound upon inhalation) is the swelling that occurs around the larynx (vocal cords) and trachea (windpipe). Younger children are most susceptible to this illness secondary to their small airways and because the symptoms often worsen at night, this illness can be a very scary experience for both the child and the parents.
 Most cases of croup usually are not serious and can be treated at home. Home measures include exposure to humidified air (whether it be from a humidifier or taking your child into a steam-filled bathroom) and even some cool night air (wrap your child up and walk outside for a few minutes) and, of course, drinking plenty of fluids. However, if symptoms do not respond to home measures, an immediate evaluation by a physician is warranted as possible medications may be needed including steroids and/or epinephrine (delivered in a mist-like form).
 And other reasons to immediately see us in the office or, if at night, the local ED or urgent care:
  • Impressive stridor (the high-pitched inspiratory breathing sounds)
  • Drooling or any difficulty swallowing
  • Any extreme irritability or agitation
  • Difficulty breathing
  • Around the mouth, nose bluish hue…perioral cyanosis
  • Or a fever approaching 104 F
A body's normal core temperature (one that is most accurately taken rectally) is 98.6 degrees F but a variety of factors (including age and general health) can influence a body's normal temperature. It is even common for a temperature to be slightly lower in the AM then rise in the late afternoon and for strenuous exercise to slightly increase a body's core temperature. But when a core body temperature is greater than 100.4 degrees F, a fever exists; however, it is possible for lower values to indicate a fever depending upon the child. 
 When your child has a fever in response to an illness, its occurrence is actually a beneficial thing as it is during this time frame when there is an increase in white blood cells, antibodies, and other agents (e.g. cytokines) that fight the infections and cause an increase in the body's core temperature. So please keep in mind when a fever occurs, it is your child's way of trying to rid the body of the illness or infection it is encountering…which again, is a good thing. Consequently, it is not always necessary for a fever to be treated if your child is playful and in good spirits but please read on for more specifics on what exactly to do as it relates to your child's age and actual temperature. 
 As far as the best way to measure your child's fever, there are 5 different methods we would like to share with you:
Rectal: up until 3 months of age, the most accurate way of measuring your child's temperature. Also, this is something you will see our staff do when the younger infants present for ill visits.
Oral: best to use no earlier than 4-5 years of age.
 Ear: often employed for our older infants and children. It tends to run a bit lower than the rectal temperature but can give us a good idea of where things stand.
 Axillary: an OK method when greater than 3 months of age, however, not as accurate as the rectal measurement.
 Temporal: measuring across the forehead, something we use in our office as long as the infants are greater than 3 months of age.
 Now as far as what to do and expect if your child has a fever, let's break it down by age range:
 0-4 weeks of age: for anything >100.4 degrees F rectally, this requires an immediate evaluation, whether it be to our office or after hours, to an urgent care facility or emergency room. Ultimately, expect an admission for evaluation of blood, urine, and cerebrospinal fluid (CSF…obtained via a lumbar puncture…to look for meningitis).
 4 weeks-3 months of age: for anything>100.4 degrees F, again, an immediate evaluation is needed but further care varies based on the evaluation and any diagnostic testing performed.
 3 months-6 months of age: evaluate immediately for any fever > 102 degrees F, any fever lasting > 3 days or sooner if your child is fussy/irritable, fever appearing at the end of an illness, or any rash not noted before the fever began.
6 months-2 years: please come in for an evaluation if the fever is greater than 104 degrees F, any fever lasting greater than 3 days, when the fever follows an illness or when no viral symptoms are noted (i.e. no runny nose, no cough, no vomiting, no diarrhea).
 Now remember, with older children (even in the 1-2 year old age range), a fever does not necessarily need to be treated. If your child is in good spirits and playful and maintaining good hydration (drinking fluids and urinating plenty), fever treatment is not absolutely necessary. But if your child has a fever (no matter the number) and just not feeling good, ok to take the necessary steps to reduce the fever with the goal of bringing the temperature closer to 100-101 degrees F range. 
 Some non medication fever reducing measures include removing excess clothing, cool compresses to the forehead, armpits, and/or groin area, and lukewarm baths. As far as the medications (AKA antipyretics), the medications include acetaminophen-Tylenol and ibuprofen-Advil/Motrin). Some points to keep in mind include Tylenol may be given every 4 hours but never more than 5 doses in 24 hours (and never give below 3 months of age unless instructed by one of us) and Advil/Motrin may be given every 6 hours (but never using in infants less than 6 months of age…and more often closer to one year of age). We also prefer you not to interchange between the two medications but if one doesn't seem to be effective, ok to use the other.
 And never ever use aspirin to control a temperature in children secondary to its association with Reye's Syndrome…a condition which can affect children who have a viral infection. This has the potential unfortunate outcome of liver failure and even death.

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Pink Eye/Eye Discharge

Pink eye (AKA conjunctivitis) can be caused by a variety of reasons.  Some of the more common causes include:
Bacteria: often cause a green/yellow or mucus-like discharge and the white of the eye and inner eyelids will usually be red. The discharge often causes the eyes to be stuck together. Treatment typically involves using antibacterial eye drops or ointments. And yes, it usually is very contagious and the primary reason why day cares, preschools, and schools alike will send your child home when it is a concern.
Viruses: like bacteria, are an infectious cause of pink eye where the eye is quite red and tearing with some white discharge is often noted. Antibiotic eye drops/ointment may still be used secondary to the concern of having both a bacterial and viral cause of the pink eye simultaneously.
Allergies: eyes will typically be red and itchy and often associated with a clear discharge. Treatment measures are typically two-fold: allergen avoidance and topical anti-allergy eye drops. Of note, occasionally other allergy medications (both oral and intranasal corticosteroids) may also be used.
Environmental irritants: think of the smoke lingering in the air after a fire or the dust that occurs with house renovations.
Corneal abrasions: which usually follows a scratch (often seen with those who wear contact lenses) and can cause tearing, redness, and eye pain.  Photophobia (light irritation) can also occur as well.
And so what to do when your child has pink eye/eye discharge? Even before calling the office, certainly ok to wipe away any discharge with a warm moist cloth. Expect to bring in your infants and young toddlers as there can often be an ear infection associated with infectious related pink eye. For older children, it may be possible to arrange for a phone consultation with one of our physicians but again, please contact our office for further direction.  However, if there is any concern of a corneal abrasion, an immediate evaluation is in order, and if necessary, with a pediatric ophthalmologist. Also, if inadequate response to treatment measures after 3 days or any visual problems and/or eye pain, an appointment with a pediatric ophthalmologist is also in order.
And a few comments about blocked tear ducts:  Blocked tear ducts are quite common in the newborn/infant population. In this age group, these ducts (which help to drain the tears from the eyes into the nasal cavity) can often become kinked and ultimately clogged. With no room to pass through the ducts, the tears often well in the corner of the infant's eye and may occasionally become infected. Some things you can do at home include wiping away the drainage with a clean, moist cloth, massage the tear ducts (although there is some debate as to the effectiveness of this measure) in a circular fashion downward in between the corner of the affected eye and the nose a few times throughout they day, and if you are breastfeeding, ok to express 1-2 drops of breast milk (secondary to its antibiotic properties) and apply them to the corner of the affected eye a few times throughout the day. But if these are not helpful or confirmation is what you seek, please come see us for further evaluation and care. Typically, a baby with outgrow these blocked tear ducts, but occasionally further evaluation and treatment by a pediatric ophthalmologist may be required if the tear duct remains blocked as the infant approaches 1 year of age.

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Sore Throat

The differential diagnosis behind your child's sore throat can be quite extensive. It obviously includes infectious causes (e.g. strep throat, other bacteria, and a multitude of viruses), post-nasal drip from an upper respiratory infection (i.e. a URI or cold), symptoms from allergies, gastroesophageal reflux disease (AKA GERD), or even some freaky traumatic event to the neck region. And pending the cause of your child's sore throat, the management will obviously differ. So while we ignore some of the more rare causes of sore throat for the time being and focus in on some of the more common ones, we hope to educate everyone on the best management pending the underlying etiology for your child's sore throat.
Strep Throat: Although a multitude of strep bacteria exist, the one we are referring to here is Group A streptococcus bacteria (AKA Strep pyogenes). The presentation of strep throat usually is with fever and sore throat (including difficulty swallowing) but without the cold symptoms (e.g. cough and runny nose) you would see from a viral cause. Abdominal pain and headache may accompany the symptoms and even some neck pain (from the swollen lymph nodes in the neck region) may occur. If one were to look inside the mouth, besides a red throat, there may be tiny red spots (petechiae) on the soft or hard palate and even the whitish patches (exudates) on the tonsils may be noted. When a rash accompanies strep throat, we call it Scarlet Fever but treatment is the same for both. In fact, treatment for strep throat usually involves a 10 day course of antibiotics (although sometimes we may use a 5 day course of zithromax). The reason treatment of strep throat is so very important is the complications from strep can be quite significant. In fact, besides the development of an abscess in the tonsillar region or inflammation of the kidney (poststreptococcal glomerulonephritis), a cardiac complication can also occur…rheumatic fever. Rheumatic fever occurs when nodules form in either your child's joints, skin, or muscles, but most concerning is when they form on the heart muscle and the heart valves. This can lead to permanent scarring of the valves and, well, you probably can get an idea of how serious this might become. Problematic valves can ultimately lead to heart failure. So if any of the symptoms above (particularly without the cold symptoms) are seen in your child, please bring him/her in to see us. 
Post-nasal drip from an upper respiratory infection: So often the reason for your child's sore or irritated throat. What occurs here is the runny nose from your child's cold is basically going down the back of your child's throat…tickling or creating a scratchy feeling as it goes and ultimately creating an irritating cough.  Now as I know many of you are aware, there is no specific antiviral medicine for colds. It is basically supportive care. So, depending on your child's age, either suctioning or blowing of the nose, pushing the fluids, and maybe a popsicle or two, the only other that may be tried is an antihistamine (e.g. benadryl or zyrtec). But if unclear it is a postnasal drip triggering the throat irritation, we certainly encourage you to discuss with one of us before trying a medication on your own.
GERD: Simply put, just think of the stomach acid flowing back up the esophagus (the tube that connect the throat with the stomach). The persistent flow of the stomach acid can generate an extremely irritated throat and even some hoarseness, but along with these symptoms, one may also have the feeling of heartburn or a sour taste in the mouth. Treatment measures include over-the-counter and prescription medications…including antacids (Tums, Maalox), H-2 blockers which block acid production (Pepcid, Zantac), or even proton pump inhibitors with also block acid production (Prevacid, Prilosec, Nexium). Sometimes other medications may be tried but if ultimately these measures fail, surgery may be the only option. 

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More often than not the first time parents are told their child is wheezing, the typical question that immediate follows is "does that mean my son has asthma?"  And while a simple yes or no answer is what the parents are looking for, it is important to realize many factors are involved as to whether a child will ultimately have asthma.  And although your pediatrician may often have some suspicion about a first time wheezer ultimately becoming asthmatic, it is important to emphasize just because a child wheezes, it does not necessarily point to a lifetime of asthma.  In fact, only 30% of children less than 1 year of age who do wheeze, go on to develop asthma.

But let's take a step back for a moment and clarify this concept of wheezing.  Simply put, wheezing typically follows constriction of the lower airways of the lungs...that is, the bronchioles.  In its milder form, wheezing may sound like a whistle when a child breathes out (the expiratory phase of breathing).  Now, the patho-physiology behind wheezing is quite detailed but as with any medical condition, think of two factors playing a role in why your child might wheeze.  Firstly, if mom and dad are asthmatic or a significant family history of allergies and/or eczema is present, then a genetic predisposition for their child to wheeze may exist as well (something researchers spend a great deal of effort trying to determine).  Secondly, think of the environment we live in…think of all those viruses/colds and environmental allergens (grass, dustmites, exposure to smoke, and even cockroach carcasses) we come across on a daily basis…any of which can trigger an inflammatory response in the lungs leading to the constriction process mentioned above.

And some other reasons your child might wheeze?  Gastroesophageal reflux disease (AKA GERD or reflux), vocal cord dysfunction, and any foreign object accidentally swallowed that ends up in the airway.

And one last bit of insight for the parents of a child who may be wheezing?  It may not be wheezing you are hearing but rather upper airway obstruction noises (i.e., all that mucus from a cold stuck in the nasal cavity that creates that whistling sound).  But if there is any concern your child might be wheezing, please come see one of us at Boulevard Pediatrics.

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Earaches are often the most common reason for coming to the office. Now most are aware of the traditional ear infection (AKA middle ear infection or otitis media) where fluid buildup occurs behind the ear drum (AKA tympanic membrane), but keep in mind there are other reasons why your child's ear may be hurting…some of which will be shared here. But probably best to begin with a brief description of the 3 different parts to the ear...the outer ear, middle ear, and inner ear. The outer ear includes the part of the ear you can see and the ear canal. The middle ear houses the eardrum and 3 tiny little bones...so very important in the hearing process. And think of the inner ear as the nerve "center" of the ear. And while ear infections can occur in each of the three different parts of the ear, the two more often seen in children include:
Middle ear infection (otitis media): As mentioned above, probably one of the most common reasons for coming to the office. The typical story usually involves cold symptoms for a few days and then in some children, there is a predisposition for fluid (which includes bacteria) to buildup behind the ear drum. It is that fluid buildup that creates the pain or discomfort for the child. As far treatment, below 2 years of age, an oral antibiotic is typically used (anywhere from 5-10 days). When older, we will often try to hold off on antibiotic use and begin with pain control and supportive care (Tylenol/motrin and possible ear drops to ease the pain).
Outer ear infection (otitis externa or AKA swimmer's ear): This typically follows moisture buildup in the ear canal...hence the name, swimmer's ear. Often seen during the summer when children are swimming or children with long hair who do not dry there hair after showering and moisture remains in the ear canals long after done swimming. Particular bacteria enjoy this type of environment, and ultimately, lead to a rather painful ear. Often, the pain from an outer ear infection is far more debilitating than from a middle ear infection. Something a parent can check for at home is pulling and tugging on the ear…if any pain, a pretty good indicator this is a swimmer's ear.
Two other reasons to consider when your child complains of an earache or you are suspicious of ear pain in your child who is unable to localize the pain for you include:
Teething: When infant teeth break through the gums, particularly the molars, you may see your child grab or pull at the ears. This is referred ear pain and although many parents are concerned about an outer ear infection, it is the teething causing the ear pain. Unfortunately, it is sometimes difficult for parents to distinguish between a middle ear infection and teething as other teething symptoms include a low grade fever, runny nose, and fussiness…very similar to the cold that may precede an ear infection. A visit to the office will help to clarify between the two.
Foreign body: You might be very surprised to know what can end up in your child's ear…beads, legos, sand, and even insects. So if any concern that is the case, please come in to see us.

Head Lice

So what exactly are lice? Lice are parasites which can be found anywhere on the head, although favorite places include around the ears and near the neckline in the back. They enjoy and need to feed on human blood throughout the day to survive. There are 3 forms of lice: the egg (AKA the nit), the nymph, and the adult. The eggs are laid by the adult near the base of the hair shaft where they then firmly attach. While these eggs may be difficult to see…and often look like dandruff…they then hatch about 8-9 days later. Nymphs are the immature lice and after feeding on human blood for about 10 days or so, become adults. Adults have 6 legs and are often grayish-white to tan in color and also require human blood to survive as they will die within 1-2 days after falling off a child's head.
Who gets lice? Really, just about any child can but the numbers obviously increase in those who attend preschool/elementary school and obviously household members of infected children. And just so you know your child is not alone, some estimates have 12 million cases occurring annually in the U.S in the 3-11 year age range. Because they cannot fly, head lice spread by direct contact with the hair of an infested child…head-to-head contact. Spread via contact with clothing or hair-care items (combs, brushes), while not impossible, is considered to be rather unlikely.
What to expect if your child has lice? Typically, a child infested with lice will be somewhat uncomfortable secondary to the itching. Furthermore, because lice are more active at night, getting a good night sleep may be tough. Lesions…which can become infected…are often noted on the head secondary to the intense scratching.
How do you diagnose lice? Find one live nymph or adult louse (but remember adult lice move quickly) and you've made your diagnosis. The use of a magnifying glass with a fine-tooth comb in a well lit room may aid in making your diagnosis. With nits, it becomes a bit tricky as if you find them attached within ¼ inch of the base of a hair shaft, an infestation probably exists. But if nits are greater than ¼ inch from the scalp and no live nymphs or adult lice are seen, it usually indicates an old infestation and treatment is not warranted. Best advice, if you're not sure, then come in and see one of us.
And what about the treatment for lice? Well, consider it to be a 3 step process which involves killing the lice, ridding the hair of nits, and preventing their spread. 
So how best to kill lice? Well, a variety of treatment types exist…gel, shampoo, cream rinse and mousse…and nearly always, a second course of treatment is required. Two of the over-the-counter (OTC) medications include:
1.    Pyrethrins (brand names include Rid and Pronto among others):  As they only kill live lice and not the nits (AKA the eggs), a second treatment occurs 7-10 later. As they are usually in shampoo form, application time is usually for just 10 minutes before rinsing out. Unfortunately, resistance is more common these days. Also, if your child is sensitive to ragweed, treatment with pyrethrins is not recommended secondary to the concern of an allergic reaction...although there is some debate surrounding this.
2.    Permethrin 1% (brand name Nix):  Approved for children above 2 years of age, this cream rinse is applied after shampooing with a non-conditioning shampoo. It is left on for about 10 minutes and because it, too, kills only the live lice and not the nits, reapplication occurs 7-10 days later as well. But bear in mind, the residue from this cream is designed to kill the newly hatched lice (unlike the pyrethrins).  But following the theme of pyrethrins, resistance is now being reported.
As far as some of the prescription medications, I offer you three of the more commonly used ones:
1.    Permethrin 5% (brand name Elimite): Now some of you may recognize this is as the cream used for scabies treatment. Although there is some debate on whether it is more effective then permethrin 1%, there has been definite anecdotal reported success. With this cream, it is left on overnight and then washed off in the AM.
2.    Malathion 5% (brand name Ovide):  This lotion had been off the U.S. market for a period of time then reintroduced earlier this decade. It, too, is left on overnight and then washed off in the AM. Repeat use in 7-10 days is typically recommended. The concerns surrounding this produce are that it has a high alcohol content…making it quite flammable…and the risk of respiratory compromise if ingested. 
3.    Lindane 1% (brand name Kwell): Important to begin by saying it has central nervous system side effects if used improperly and seizures have been reported with its use. Application time is only 10 minutes with reuse 7-10 days later. Because resistance has been reported for quite some time and the above-mentioned health concerns, we certainly try to avoid its use.
But remember with whatever medication that is used, please follow the directions as outlined on the box or on the prescription label. And just a couple of words on the home remedies many of you are probably already aware of…mayonnaise, olive oil, petroleum jelly, herbal oils...although certainly ok to try, they have yet to be scientifically proven to work. But for those hoping for a natural treatment resolution, go ahead and give it a go…just lather it in and leave it on the hair overnight with a shower cap on top. 
Now as far as combing out the nits, a few important points to keep in mind: Go ahead and use the special comb as it can make it more effective in removing the lice. Be patient…both you and your child…as this process can take quite some time. Spend the same amount of time daily for about 2 weeks before feeling comfortable you have resolution. And certainly ok to call upon one of the local agencies to come to your house and assist with the lice picking but remember a fee is involved.
Lastly, here are some basic tips in preventing lice from spreading:
  • Check everyone else in the house for lice…don't overlook anyone.
  • Wash all clothes, towels, hats, bed sheets in hot water and dry on high heat.
  • Vacuum things that cannot be washed…furniture, carpets, fabrics…anything your child may have been in contact 1-2 days before starting treatment
  • For items that cannot be washed…toys, stuffed animals…put in a plastic bag for two weeks (more than enough time to kill off the lice).
  • Soak combs/brushes in boiling water for at least 5 minutes.
  • Avoid head-to-head contact as this is the most common way for lice to spread.  
  • And even though it is much less common for lice to spread in this fashion, we still recommend avoiding the sharing of combs/brushes, hats/coats/scarves. 
And please remember no matter how annoying and embarrassing lice may be for your child, there are no significant health consequences from acquiring it and it doesn't incriminate one's personal hygiene or home cleanliness. The goals are simply to treat in a timely manner and prevent its spread.
This typically late fall/wintertime respiratory virus can sometimes cause critical wheezing in our infants and young toddlers. In fact, respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and pneumonia in children under 1 year of age here in the United States. It can also seriously impact those with an underlying hyealth condition such as cardiac or pulmonary disease as well. With adults, it typically manifests only as a cold, albeit a significant one. A few key things to know about RSV include:
How is RSV spread?  It is spread via a respiratory route and contact spread…sneezing, mucus, touching contaminated persons or surfaces.
How do I know if my child has RSV? Initially a child of any age with RSV has cold-like symptoms with abundant nasal mucus. Fever is typical in the younger children. While older children and adults usually stop there, younger babies may then progress to a chesty cough which may include you hearing some whistling on inspiration and expiration (wheeze). On occasion, a child with severe RSV can turn blue (cyanotic), breathe very fast, vomit from the force of the cough or just act very ill.  Obviously, your child needs to be seen immediately if any of these characteristics occur.
Can RSV be prevented?  Yes, to some extent.  Changing our wintertime behavior can prevent spread:
  • If you have a cold, DO NOT visit any newborns, preemies, or toddlers.
  • If you have a cold, do not attend functions where there may be newborns, preemies or toddlers.  
  • Wash your hands frequently during the winter - especially if those around you have colds! RSV can exist on hands for 30 minutes, and on surfaces for up to 2 hours. So if you work, go to school, or casually stroll in a market and touch a cart, you can get RSV. 
  • Don't share beverages, food, or kisses with those who have colds or if you have a cold yourself. 
  • And for premature infants or those infants with an underlying medical condition, they may be eligible for a monthly monoclonal antibody (synagis) to help prevent them from acquiring RSV.  Please discuss with one of us to discuss if your child may be eligible as unfortunately, there exist strict criteria for its use.
Is there treatment for RSV?  Treatment is supportive in general – lots of fluids, moist humidified air, bulb suctioning.  If a child is droopy or achy from fever, fever medication may be warranted.  Cold medications serve no purpose and should be avoided.  Wheezing children may be helped with inhaled medication (xopenox/albuterol), but only if recommended by your healthcare providers.