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Monday, June 26, 2017

Neutropenia... What?

It is recommended to screen for anemia (low red blood cell levels) around one year of age. Our office orders a complete blood count (CBC), which checks for red blood cells, white blood cells, and platelets - the main components of our blood.

One relatively frequent abnormal lab we see (especially during the winter months) is a low absolute neutrophil count (ANC). Neutrophils are a type of white blood cells that fights bacterial infections. When their numbers get too low, it can increase the risk of serious bacterial infections. While some people have low ANCs that cause significant immune deficiencies and can lead to infection, the most commonly seen low ANC we see are brief dips after a viral infection. A low ANC is called neutropenia.

Photo source: Wikimedia. Blausen.
The large majority of kids with neutropenia have only mild drops in their ANC and are not at significant risk of illness. In general the more severe the drop, the more significant the infection risk.

Most causes of neutropenia are due to infection, drugs, severe malnutrition or immune disorders. The most common cause of neutropenia we see is after an infection. In most cases this type of neutropenia quickly resolves without any treatment. Some viruses, such as hepatitis B, Epstein-Barr, and HIV, are associated with prolonged neutropenias. The drugs that can cause neutropenia are not commonly used medications and routine testing for neutropenia would be done when those medications are used. Vitamin B12, folate, and copper deficiencies are very uncommon in children, but can lead to abnormal blood counts.

There are three levels of neutropenia:

  • Mild neutropenia: The ANC ranges between 1000-1500/μL
  • Moderate neutropenia: The ANC ranges between 500-1000/μL
  • Severe neutropenia: The ANC is less than 500/μL
    • Mild: ANC 1000-1500
    • Moderate: ANC 500-1000
    • Severe: ANC less than 500

  • Mild neutropenia: The ANC ranges between 1000-1500/μL
  • Moderate neutropenia: The ANC ranges between 500-1000/μL
  • Severe neutropenia: The ANC is less than 500/μL
  • Since most mild cases of neutropenia self-resolve, it is not usually anything for parents to worry about. I used to recheck all of these, but found that many kids needed several rechecks because they always had a mild viral infection and they never got significantly sick. I have changed my personal protocol because if kids start getting sick, they will end up being rechecked and if they're healthy, there was no need to recheck.
    • If a child is overall healthy and growing well, the level is only mildly low (above 1000) I do not recheck the level -- though if your doctor wants to recheck it (or if you want it rechecked), that is appropriate to do.
    • If the level is in the mid-range (500-1000) or if the child has had problems with recurrent infections or growth, I will usually recommend a confirmation (repeat test) and possible further evaluation. 
    • If the level is in the severe range (less than 500), it should be rechecked and the child should be closely monitored due to high risk of severe bacterial infections.
    • Some physicians recommend repeating a blood count with any fever for a year in kids who have had any degree of neutropenia, so you'll have to talk to your child's doctor for a plan.

    What symptoms might happen if the ANC is low?


    Most children with a temporarily and mildly low ANC will have no symptoms and need no treatment. Children with chronically low ANCs will have more infections that require antibiotics, such as pneumonia, skin infections (abscesses, cellulitis) and lymph node infections. They might also have chronic gum disease, mouth sores, or vaginal or rectal ulcers. A common cold or cough is NOT from a low ANC, since these are viral illnesses and a different type of white blood cell targets viruses.


  • Frequent infections
  • Serious respiratory infections, including pneumonia or sinus infections
  • Skin infections (e.g. cellulitis, abscesses)
  • Multiple serious infections (e.g. meningitis, bone infections)
  • Lymph node infections
  • Gum disease
  • Mouth sores/ulcers
  • Vaginal, urethral rectal ulcers
  • When do we worry?


    The level of ANC as well as the cause both determine the risk level of an overwhelming infection. An example would be when people are immune suppressed from chemotherapy, they are at very high risk of bacterial infections. On the other hand, an otherwise healthy person with a mildly low ANC is not more likely to get a bacterial infection than another person with a normal ANC.

    We are concerned if the child has recurrent infections, poor growth, or a very low level. Each case must be evaluated by the person who ordered the test and who has recently seen your child.

    What treatment is done for a low ANC?


    Most children do not need any specific treatment. They are monitored for recurrent infections, especially infections that require antibiotics. They are also monitored for growth, since if a body is chronically sick, it often doesn't grow well.

    Each infection that requires antibiotics is treated and blood counts might be checked to see how low they are at the time.

    In children who have a chronically low ANC, I usually refer them to a hematologist (blood specialist) to evaluate why they have it and if it requires a special treatment that stimulates the bone marrow to make more neutrophils.


    For more information:

    Benign familial leukopenia and neutropenia in different ethnic groups.

    Sunday, June 11, 2017

    Dry Drowning - What Parents Need To Know

    I thought about titling this one "We're drowning in dry drowning phone calls" because we are getting many worried calls about dry drowning, but that's overly dramatic and I hate headlines that make things seem like the sky is falling...



    I had never heard of dry drowning until social media picked it up a couple of summers ago. Maybe I did as a resident, but since I've never seen it, I'd forgotten the term. Either way, it isn't very common at all, but it is an emergency when it happens, so it's good that we all know that it can happen. People also use the term secondary drowning and some experts differentiate the two by whether or not water actually gets into the lungs, causing swelling of the lung tissue, or if water irritates the vocal cords, causing them to spasm and close off. Either situation is potentially life threatening and they have similar symptoms. Note: Please see the addendum at the bottom. Several articles have emerged since the original writing of this post that clearly indicate there is no such thing as dry drowning.

    One of the reasons I think so many parents are worried is that it is common for kids to go under water: in the tub and in the pool. Many get water in their mouth or complain that it went up their nose. Few actually get any into their lungs, which is where it can cause problems. How can you know when you need to worry?

    Most of us recall a time we coughed briefly after inhaling liquid, and we were fine. So when is it worrisome? It's when the water that gets into the lungs causes inflammation within the next day or two. This inflammation makes it hard for the lungs to work - the air tubes are swollen, so air can't get through. Treatment is giving oxygen, sometimes with a ventilator (breathing tube and machine) until the inflammation goes down.

    Symptoms you need to recognize and act upon by taking your child to an ER:


    • Cough: If your child has coughing for a minute or more after being in water, he's at risk. This indicates that the child is trying to clear the airways. If water got down there and they cough most up, some can remain behind and lead to inflammation over time. Watching your child carefully for the next 3-4 days is important. This can be hard to recognize initially, so a complete evaluation is important if any other symptoms develop.
    • Difficulty breathing: Anyone who is struggling to breathe needs further evaluation. Signs can be rapid breathing, sucking in the ribs or the stomach, difficulty talking, or even a look of fear from difficult breathing.
    • Near drowning: If your child had to be pulled out of the water, he should be evaluated in an ER. Even if he seems fine afterwards. The reaction is delayed, so they can seem to be 100% better and then go downhill.
    • Behavior changes or confusion: If a child is confused, lethargic** or has a change in ability to recognize people, he should go to the ER. Serious illnesses can present with a change in mental status, including significant infections, concussion, heat exhaustion, brain tumors, and drowning. The ER doctor will ask what else has been going on to help identify the cause of confusion.  **Many people misuse the term lethargic. Lethargic isn't the same thing as being tired after a long day. The medical definition is "Relatively mild impairment of consciousness resulting in reduced alertness and awareness; this condition has many causes but is ultimately due to generalized brain dysfunction."
    • Vomiting: Vomiting after a day at the pool can be due to infection (from swallowing contaminated pool water), food poisoning (from food left in the heat too long) or dry drowning. It's best to check it out in the ER.

    What will happen in the ER?

    Many parents don't want to go to the ER because of high co-pays. We try to keep kids out of the ER as much as possible. But some issues are better taken care of in an ER. Most offices don't have the equipment or staff to manage these issues well. Dry drowning can be life threatening, and the evaluation and treatment should start in the ER. I cannot say exactly what the doctor will do, since that will depend on your child's symptoms and exam. There is no specific treatment for this, only supporting your child's airway and breathing as the swelling goes down.

    • If the doctor thinks your child may have swelling of the airways, he might order a chest x-ray to look for pulmonary edema (lung tissue swelling). 
    • An iv might be started to be able to give adequate fluids, since your child might not be up to drinking well. 
    • Oxygen levels will be monitored and extra oxygen might be given. 
    • Since the swelling worsens before it gets better, if there is a strong suspicion of dry drowning your child will be admitted for further observation.
    • Some kids need help breathing and are put on a ventilator (breathing machine) until the swelling goes down.

    Prevention is important!

    As with many things, we should do all we can to be sure our kids are safe around water. This includes the bathtub and toilet as well as swimming pools, lakes, and ponds. 

    • Childproof your home when you have little ones who might play in a pet water bowl or the toilet. 
    • Teach your kids water safety. Swimming lessons can help them learn skills. Tell them to never try to dunk each other. They shouldn't pretend they're drowning because it might distract a lifeguard from a true emergency. 
    • Learn infant and child CPR.
    • If you have a pool or pond at home, be sure there is a fence limiting access from your house.
    • Watch your kids closely and keep them within reach when they're in water until they are strong swimmers. When they are strong swimmers you can let them swim outside your reach as long as lifeguards are present. 
    • Learn what distress in the water looks like. The movie depiction of drowning with a lot of yelling and thrashing around is not what usually happens. If someone can verbalize that they're okay, they probably are. Drowning victims can't ask for help. There is a video linked to this page of what to look for with drowning that shows an actual rescue. From this site, signs of drowning:
    • Head low in the water, mouth at water level
    • Head tilted back with mouth open
    • Eyes glassy and empty, unable to focus
    • Eyes closed
    • Hair over forehead or eyes
    • Not using legs – Vertical
    • Hyperventilating or gasping
    • Trying to swim in a particular direction but not making headway
    • Trying to roll over on the back
    • Appear to be climbing an invisible ladder

    Addendum:

    I just read this post that gives references regarding drowning definitions. It appears I didn't forget learning about dry drowning in medical school. It isn't really a thing. The symptoms listed above that I recommend getting evaluated are still concerning symptoms, but they might be from another cause. Check this out: On "Dry Drowning"

    Another: Drowning in a Sea of Misinformation: Dry Drowning and Secondary Drowning

    Monday, May 22, 2017

    New Juice Guidelines!

    The American Academy of Pediatrics is releasing new guidelines for introducing and giving fruit juice today.


    Juice that comes from fruit is not the same thing as eating fruit. It's missing the fiber and even the feeling of fullness that comes from eating foods rather than drinking. Too many kids drink excessive juice, which fills them with empty calories and can contribute to obesity and tooth decay.

    How much juice should kids have?

    • Juice is not recommended at all under 1 year of age in the new guidelines. 
    • Toddlers from 1-3 years can have up to 4 ounces of 100% juice a day. 
    • Children ages 4-6 years can have 4-6 ounces (half to three-quarters of a cup). 
    • Children ages 7-18 years can have up to 8 ounces (1 cup) of 100% fruit juice as part of the recommended 2 to 2 ½ cups of fruit servings per day. 


    General tips and tricks:


    • Offer only 100% juice if you're giving juice at all. Fruit flavored drinks are not the same thing as juice.
    • Water is always healthy! If your kids want it flavored, cut up fruit and put it in the water. There are many recipes online to get ideas, but kids don't need anything fancy - just put cut up pieces of their favorite fruit with water in a glass container. Put the container in the refrigerator for 2-4 hours and then pour the infused water into their cup without the fruit (which could pose a choking risk). The infused water will stay fresh in the refrigerator for up to 2 days.
    • Some kids like to start the day with a frozen water bottle. Simply put a 1/2 to 3/4 full water bottle in the freezer overnight - don't fill it too much because ice expands! Add a bit of water in the morning to help it start melting so it's drinkable when they want a sip. Adjust the amount of water to freeze as needed depending on how insulated your water bottle is.
    • If your kids demand more than the recommended amount of juice for their age per day, water it down. By mixing water (or sparkling water for a bit of zip) with juice, you decrease the amount of sugar in every serving. You can give 1/2 the recommended daily maximum amount of juice with water twice and still stay within the daily limit. 
    • Never let kids drink juice out of a bottle.
    • Never put kids to bed with juice. They should brush teeth before bed and be allowed only water until morning.
    • Offer only pasteurized juice. Unpasteurized juice can cause severe illness.
    • Give kids real fruits and/or vegetables with every meal and snack.
    • Make smoothies! Putting fruits and vegetables in a blender to make a smoothie is a great way to give the full fruit or vegetable instead of juice. Consider adding plain yogurt**, chia, flax, oats, nuts, and other healthy additions to increase the nutritional components of the smoothie! **Flavored yogurts often have added sugars. Look for just milk and cultures in your yogurt. 
    • Most juice boxes have more than a day's supply of juice. Don't use juice boxes. Offer juice in cups so you can limit to the age appropriate amount. 
    • Organic juice is not healthier than other juice. Many parents presume it has less sugar or more nutrients, but it doesn't.
    • Vegetable juices may have less sugar and fewer calories than in the fruit juice, but are often mixed with fruit juices so you must read ingredients. They also lack the fiber of the actual vegetable, so eating the vegetable (or pureeing veggies into a smoothie) is healthier. 
    • Beware of labels that look like juice but aren't 100% juice. The label might say "juice cocktail," "juice-flavored beverage" or "juice drink." Most of these have only small amounts of real juice. Their main ingredients are usually water, small amounts of juice, and some type of sweetener, such as high-fructose corn syrup. Nutritionally, these drinks are similar to most soft drinks: rich in sugar and calories, but low in nutrients. Avoid them.
    • Sports drinks are not healthy substitutes for water. They are sugar-sweetened beverages that contain sodium and other electrolytes. Unless one is doing high intensity exercise for over an hour (such as running a marathon, not playing in a baseball tournament), water and a regular healthy diet provide all the calories and electrolytes we need.
    • Water's the best drink for our bodies. Buy fun reusable water bottles and challenge your kids to empty them throughout the day. The old rule of "8 cups a day" is outdated, but we should get enough water (from the water content in foods + drinks) to keep our urine pale. We need more water when it's hot, when we exercise, when we're sick and when the air's really dry. Once we feel thirsty we're already mildly dehydrated, so drink water to prevent dehydration.

    Sunday, April 23, 2017

    Itchy, sneezy, puffy - All signs of allergy. What can you do?

    It's allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors. This is an update to a previous blog I wrote on the subject, since there are many more medicines now available over the counter.




    Symptoms of Allergies: 

    Allergies can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes. Some kids get a crease across their nose from wiping. Others get purple circles under their eyes called allergic shiners. These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

    Treatments: 

    It is best to treat before the symptoms get bad. It is easy to monitor pollen counts online to know what's out there and start treatment before symptoms make you (or your child) miserable. Treatments include medicines and limiting exposure.

    Medications:

    I don't want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help. Types of medicines:
    • Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others. In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits. You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help. Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. Insurance companies rarely cover the cost of antihistamines these days.
    • Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn't needed. If you need a decongestant initially, you can use one with your usual antihistamine. Most decongestants on the market are ineffective. If you ask the pharmacist for pseudoephedrine, it is available behind the counter. It was replaced by phenylephrine years ago due to concerns of methamphetamine production, but works a little better than phenylephrine. Decongestants do NOT fix a cold, they only dry up some of the mucus. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age. 
    • Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better. Most insurance companies don't cover prescription allergy eye drops well, so you might want to check your formulary before asking for a prescription. This is usually available on your insurance website after you log in. Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye. 
    • Singulair (Montelukast) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. Once a person has been on montelukast for a couple weeks, they usually don't need an antihistamine any longer. It is available only by prescription, so make an appointment to discuss this if your child might benefit.
    • Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

    Limiting Exposure:  The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

    • Wash hair, eyelashes, and nose after exposures -- especially before sleep. They all trap allergens and increase the time your body reacts to them. I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses. (Note: I have no financial ties to Nasopure... I just love the product and website!)
    • Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.
    • Wash towels and sheets weekly in hot water.  
    • Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting. 
    • Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them. 
    • There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners. 
    • Keep the windows closed. Sorry to those who love the "fresh air" in the house. For those who suffer from allergies, this is just too much exposure!  
    • Keep pets out of bedrooms. If you know a family member is allergic to an animal, don't get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal. 
    • If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts. 
    • Keep smoke away. Smoke is an airway irritant and can exacerbate allergy symptoms. Remember that the smoke dust remaining on hair, clothing, upholstery, and other surfaces can cause problems too, so kids can be affected even if you don't smoke near them.  

    What if all of the above isn't helping?
    • Maybe it's really not allergies. 
    • Allergies to things other than foods are rare before 2 years of age.
    • Viruses can cause very similar symptoms to allergies. 
    • Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don't find it very helpful for environmental allergens because you can't avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn't take long to see patterns. Testing is important if allergy shots are being considered.   
    • Need help tracking allergy symptoms? There's an app for that! Here's one review I found of allergy apps. I don't have any personal experience of any, so please put your favorite in the comments below to help others!
    • Wrong medicine or wrong dose. 
    • Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.
    • Some kids outgrow a dose and simply need a higher dose of medicine as they grow. 
    • Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment to discuss if this is an option for your allergy sufferer.

    Wednesday, March 15, 2017

    Hearing Loss

    Most of us associate hearing loss with old age, but it is increasingly common for children and teens to suffer from mild to moderate hearing loss. Nearly 15% of kids have hearing loss according to the CDC. Hearing loss can be due to many things that are difficult to control, such as heredity, infection, and medications. In kids and teens it is oven due to a preventable cause: noise.


    Where does the excessive noise come from?


    Even young children are exposed to more loud noises through toys, television, and gaming devices than children of years past.

    Widespread use of ear buds for prolonged periods can take its toll on hearing. Unlike the bulky headphones used when I was a child, earbuds deliver sound directly into the ear canal without any sound buffering in between. Most often the earbuds are used with iPods and other mp3 players are low to mediocre quality, so they are unable to transit the bass as effectively. Many kids turn the music up to hear the bass. If others can hear the music coming from ear buds, they are too loud!

    Loud concerts or sporting events can also expose our ears to excessive volumes for a prolonged period of time.

    Not all excessive noise is from kids being undisciplined - some kids are helping out the family or trying to earn extra cash by mowing lawns or using power tools, which puts them at increased risk.

    How much is too much?


    According to the Centers for Disease Control and Prevention (CDC), being exposed to more than 85 decibels (dB) of sound for eight hours can damage your hearing. At 105 dB, hearing loss is possible after a mere 5 minutes.

    If you're like me, that means nothing because how much is 85 dB? There is a great chart of common sounds and how loud they are on this page from the CDC. There are also several free apps available for download on smartphones and tablets - search "sound meter" or "decibel" and read reviews before downloading. Take advantage of these -- and because it's in the phone, kids might actually have fun playing around with them and learning about their environmental risks at the same time!

    Signs of hearing loss


    One early sign of excessive noise is ringing in the ears, but most people with hearing loss never realize it's happening because it's slowly progressive. If you notice your child asking "what" more often or complaining that the television is too quiet when others hear it well, it is a good idea to have their hearing tested.

    Consequences of hearing loss 


    There are many potential consequences to hearing loss:

    • Learning - you have to be able to hear the lecture. 
    • Behaviors - if directions and instructions are missed, a child might incorrectly be seen as misbehaving. 
    • Friendships and social skills - if a child can't follow a conversation they aren't easy to talk to or play with.
    • Job availability - many jobs require hearing at a certain level. 

    Prevention


    Talk to your kids about the risks of their habits that involve loud sounds. Unfortunately kids won't always take parental advice to heart because they have a feeling of invincibility, but studies show if they learn about hearing loss they are more likely to use protection. Even more so, what their friends are doing alters their behavior. Teach not only your kids, but also their friends. If they're all going to a loud event, consider giving them all ear plugs. Once hearing is damaged they can't gain the hearing back, so prevention is key.

    Ways to protect include:
    • Wear hearing protection (earplugs) when mowing the grass and attending loud events, such as concerts or sporting events.
    • Turn down your music! Some music players have alerts when the volume goes too loud, but those can be ignored if the child doesn't understand why it's important to lower the volume. If others can hear the music you're listening to through earbuds, turn it down.
    • Lower the maximum volume setting on your iPod or mp3 player. To do this, go to "Settings" and select "Volume Limit" under Music. Set it at about 60% of the full volume, that way you can't accidentally turn your music too high.
    • Use big headphones instead of earbuds. They offer more external noise cancelling, which allows the music to be heard better at lower volumes. They are also physically further from your eardrum, which helps.
    • If you must use earbuds, use high quality buds that transmit bass if you are tempted to turn music up to hear the bass.
    • Follow the 60/60 rule: No more than 60 minutes of listening at a time, and no higher than 60 percent of maximum volume. If you go under "settings," you can actually set your iPod for maximum volume setting of 60 percent, so you can't accidentally turn your music up too loud.
    • Higher pitched sounds have greater potential to damage your ears than lower pitched sounds. Turn down the volume when a high-pitched song comes on.
    • Try not to fall asleep with earbuds or headphones on. The time of exposure matters and why waste sleep time damaging your ears? 
    • If you need "white noise" to fall to sleep, put together a playlist of soft songs or sounds and have it play at a low volume from a speaker on your bedside table. Use your clock's "sleep" function, which will automatically turn off your music after a set amount of time to ensure the music doesn't end up playing all night long, which saves energy in addition to your hearing.
    • As always: model these behaviors for your children. If they see you mowing the grass with loud music blaring in your ears, they will grow up to do the same. If you wear ear buds many hours of the day, they will see that as a normal and acceptable behavior. 

    What happens that hurts our hearing?


    Keep the volume down – Too loud and too long can damage your hearing shows a man listening to music. Below it the music soundtrack and volume levels are shown. The video then breaks to showing what happens to the hair cells in our ear with these volumes, which makes the damage more understandable because you can see it happening. 

    Resources:


    CDC's Hearing Loss main page

    Sunday, February 19, 2017

    Flat heads in babies

    We have significantly decreased the risk of SIDS by placing babies on their backs to sleep, but have seen a rise in flat heads due to their positioning. Prevention of the flatness involves several positioning strategies.
    Supervise tummy time when Baby's awake!

    It's important for babies to sleep on their back, but they tend to have their head facing one direction or another. They should alternate which side they face, but many babies have a stiff neck and favor looking to one side. Think of when you wake with a stiff neck - probably from positioning overnight. Many babies are in the same position for quite awhile at the end of pregnancy - of course they're stiff!

    If Baby's neck is stiff, you can massage his or her neck and shoulder muscles gently and then slowly move the head right and left (chin to each shoulder) and side to side (ear to shoulder). Don't quickly force the head movement, but think of what you do if you have a stiff and sore neck. The more frequently you stretch it out, the better it feels, right? I recommend stretching Baby's neck with each diaper change (before the change or after you wash your hands!) until it isn't stiff for several days and Baby moves his or her head easily without your help.

    Start supervised tummy time early on - the longer you wait to start, the more Baby might resist it. I see so many parents who are hesitant to put Baby on his or her stomach. Concerns range from the umbilical cord stump still being on and bothering the baby (it won't) to spitting up will worsen (test it out, for many babies it's actually better) to "I thought babies should never be on their stomachs" (only when sleeping or not supervised).

    Tummy time is an important time for baby to develop muscle strength. It needs to be supervised, but it can be a fun time to interact with Baby. Lay face to face and talk to Baby, encouraging him or her to look up. Grab a brightly colored object and move it around for Baby to watch. Enjoy your play time.


    For more information on issues related to stiff necks in babies and how to treat the stiffness, see this Torticollis information.

    AAP article on how to prevent flat heads in babies.

    Saturday, February 4, 2017

    Rashes in kids... a few case studies for parents

    I am not a dermatologist, but I see rashes all the time. Some are easy to identify, others I'm not sure what the cause is. In general physicians are taught to treat the symptoms of a rash. The standard dermatology lecture in a nutshell is: If it's wet, dry it. If it's dry, wet it. If it itches, use steroids. If it's infected, use antibiotics.

    I'll go over a few made up case studies -- each one is a conglomeration of kids I've seen.

    Case 1

    Parents bring Itchy in for a well visit but mention that her skin has rashes on her elbow creases and behind her knees. Sometimes she scratches them to the point where they bleed. They've tried applying a pink fragrant lotion that they got as a baby gift, but she says it burns and didn't help.

    Advice for this family would not include which of the following?

    1. Use the lotion more often since the skin is dry
    2. Stop the lotion because fragrant lotions can worsen this condition
    3. This type of dry skin can be related to allergies and asthma, having one makes it more likely to have another
    4. Controlling the itch is important because scratching worsens the rash

    The answer is #1. This rash is most likely eczema, a fancy term for dry skin. It often develops in infants but improves as a child gets older. It is more common in kids with allergies and/or asthma. It can worsen with exposure to irritants (such as a fragranced lotion or soap) and allergens (food allergies and seasonal allergies). I've often heard this called "the itch that rashes". Scratching damages the skin, which allows water to escape, which dries the skin more, leading to more itching. This itch/scratch cycle worsens the rash and can lead to secondary infections. This can be a very frustrating condition because it will come and go for years in some kids. It's important to avoid irritants and use proper skin care. For more treatment, visit Dry Skin / Eczema / Atopic Dermatitis.

    Case 2

    Parents bring their infant in for her well visit and ask about a rash that's been there "for awhile" but doesn't seem to bother Baby. They aren't sure when it started. They can't recall any new soaps, lotions, foods, or other potential triggers. They describe it as red spots and they aren't sure if they're changing over time. Baby is eating well, gaining weight well, sleeping well, and not fussy. On exam, they show me the rash on the abdomen and arm, but I cannot see any red spots. 

    What further questions might I ask and what advice might I give?


    1. If this rash would be on your own skin, how would you treat it?
    2. Treatment of the rash should be based on symptoms, and since there are no symptoms, no treatment is needed
    3. Monitor for signs of itching, fussiness, fever, poor feeding, and other concerns
    4. All of the above


    The answer is #4 and yes, I see this non-existent rash all the time. It's not just my old eyes that can't see it -- I hear from pediatrician friends about this phantom rash too. I know parents worry more about their children than they worry about themselves, but sometimes they can realize the unfounded concern when I simply ask what they would do if this rash was on their own skin. Most say they wouldn't worry about it. Enough said. 

    Case 3

    Parents ask about a rash that appears sometimes after their school aged child showers. It doesn't itch or hurt. It is always on the chest and abdomen and sometimes on the legs. It looks like red splotches. They've tried various soaps and shampoos, but changing them doesn't seem to affect the rash. It isn't present on exam because it only happens after showers and lasts less than 30 minutes. They are concerned because it returns so frequently.

    My advice to parents includes which the following?

    1. Treatment of a rash should be based on symptoms, and since there are no symptoms, no treatment is needed
    2. Use only cleansing products made for babies since your child is obviously sensitive to something
    3. Turn down the temperature of the water in the shower to see if the rash "resolves"
    4. 1 and 3
    The answer is # 4. Again, I've been asked this type of question more than once. It also falls into the category of "What would you do if you had this rash?" Most parents would admit they wouldn't do anything since it didn't cause any problems and was brief. If they really think about it, they probably have had this "rash" after a hot shower. It's just flushed skin. If you enjoy a hot shower, it's okay if your skin flushes a bit.


    Case 4

    Mom brings Kiddo in because her nails are growing "funny." They have a horizontal crack and the tips are peeling off. They don't seem to hurt or bother Kiddo.

    What further information would be important to know?
    1. Was there any trauma to the nails?
    2. Has your child been sick in the past 2 months?
    3. Does kiddo use nail polish or fake nails?
    4. Does your child pick at her nails regularly?
    5. All of the above.
    The answer is #5. The answer is usually in the patient history with this one. I've seen a number of kids with peeling nails recently because we had hand, foot, and mouth in the area about a month ago. Not all kids with that infection lose their nails, but it can happen. For more on this, including pictures, see Four Cases of Onychomadesis after Hand-Foot-Mouth Disease. Other causes of peeling nails include trauma and nail picking, nutritional deficiencies, nail products, chemical irritants, certain medications, infections, and chronic diseases. 

    Case 5

    Mom brings Snotty in because he's had a runny nose all week. On exam, he's found to have what mom thought was dried mucus under his nose, but the underlying skin is red and it's actually more of a crusting, not mucus. 

    Treatment of this includes all except:
    1. Using rubbing alcohol to rub off the crust
    2. Antibiotic ointment
    3. Washing the area
    4. Avoid touching the area
    5. Oral antibiotics
    The answer is #1. That would hurt! This is a classic case of impetigo. Impetigo is a bacterial skin infection. It often happens when the skin is damaged (in this case from Snotty wiping his nose constantly) and if bacteria from the nose or mouth get into the skin. It can be treated with prescription topical antibiotic ointment in most cases, but some cases require oral (by mouth) antibiotics. Wash the area gently and soak crusts with warm wet cloths to help remove the crust. Complete removal of the crust isn't necessary though - that will happen naturally as the infection resolves. Touching the area can spread the infection, so avoid touching it and wash hands well after touching it!