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Saturday, October 27, 2012

Itchy Bottom? Is it Pinworms? What to do?


Pinworms have been around forever, but most people rarely give them a thought until they hear of a child at school or daycare with the infection or their child has symptoms. And yes, this idea came out of a recent phone call from an anxious parent, so they are in our daycares.

Pinworms are usually harmless but disturbing. Signs of infection are typically an itchy bottom at night. This is because the worms that are unnoticed while in our guts come out at night to lay eggs. Occasionally the worm will migrate to the vagina in girls, causing vaginal itching and discharge. Severe infections can lead to weight loss, but this is not typical. Rarely a small white thread-like worm is seen in the stool. (If you see this without other symptoms, bring it in to your doctor to be sure it isn't just a thread or other object.)

Pinworms can infect those who unknowingly touch the eggs on bedding, food, or other surfaces, then touch their mouth. Eggs can live on surfaces outside the body for up to two weeks. The eggs are swallowed and then hatch in the small intestine. The worms mature in the colon, and the female worms go to to the surface to lay eggs at night. This causes intense itching at the anal area, which can lead to a secondary infection from broken skin.  The scratching also allows the eggs to get under fingernails and then transfer to family members when they get onto household objects.  Pets don't carry pinworms, so don't blame your dog.

Testing for pinworms can be done at home. Before bed put a piece of clear tape on the anus of your child. Be sure it touches the skin of the anus so it can collect any eggs that are laid overnight.  In the morning remove the tape and look for small white eggs on it. (You can also touch the tape to the anal skin first thing in the morning, before toileting, but overnight might be more reliable if the child can sleep with the tape.)

Treatment of pinworms: 
Vermox is a prescription medication that stopped production this year and is not available any longer. Some pharmacies might still have some in stock, but a prescription is needed for these and without knowing the stock of any particular pharmacy, I don't recommend searching for it. 
An over the counter medicine can be purchased for each non-pregnant family member over 1 year of age and 25 pounds. Treating family members helps decrease the risk of infecting from each other, but is not universally recommended. If repeated infections occur, then all household members should be treated to treat a potential unknown carrier. Anyone who shares bedding should definitely be treated with the first round of treatments. 
If you are pregnant, talk to your OB about treatments.
There are no medicines approved for infants, but symptomatic infection is rare in this age group. Infants do not have the ability to scratch their bottoms, so they are not likely to spread an infection on the rare chance they are infected. If they do touch their bottoms during diaper changes, be sure to wash their hands!
Call your pharmacy before making the drive to ask if the medicine is in stock.
Two name brands are Reece's Pinworm Medicine and Pin-X. They might have to special order it.  It is okay to wait a few days before treating or you can call other pharmacies.
Be sure to get enough to treat all eligible family members twice. Follow package directions for dosing and repeat the dose in 2 weeks to decrease the risk of re-infection. Remember the eggs can live on surfaces up to 2 weeks, so reinfection is possible during that time!

To help with the itching, an oral antihistamine can be given per package directions.  You can also apply hydrocortisone to the anal area up to twice a day.

In addition to the medicine: clean toilet seats, bathtubs, bed linens, and other surfaces. Vacuum carpets and upholstered furniture. Wash clothing in hot water if the fabric allows (especially underwear!)  If pants will not tolerate hot water, avoid wearing them for 2 weeks and keep them separate from recently worn clothing. Keep fingernails short and clean so eggs aren't carried under nails.  Shower and rinse the anal area first thing in the morning for 3-5 days after the medication is given. Encourage everyone to wash hands frequently, especially before and after eating and touching the eyes, nose, or mouth!

What about school or daycare? If a child has (or might have) pinworms, they do not need to be kept out of school or daycare.

When to see your doctor: If the anal area is excessively red, bleeding, or the itching doesn't stop within a week after treatment, bring your child in for an exam to be sure pinworms are the problem. Antibiotics might be needed to treat a secondary infection.

Saturday, October 20, 2012

Ear Piercing - What's right for one isn't the answer for all!

I am often asked by parents when I think it is the right time to pierce ears on children. I have never read a scientifically based report on the best time - and never expect to! This is very much a parent / family decision.

Parents Magazine online recently posted Ear Piercing for Kids to address some of the common questions and answers. Some of these answers have scientific basis-- such as the type of metal-- most do not.

There is not one age that is "best" to pierce an ear. Many people go through life without ears pierced. Some cultures pierce ears in the newborn period. Some families have a guideline of 7 or 10 years old. Some kids want their ears pierced, but cannot due to sports that will not allow studs in during practice/games/competitions and new studs cannot be removed. Seasons overlap, so there is no 6 week period allowing studs to remain in place. (Some sports will allow studs to be covered with a band aide, but not all, so be sure to ask your team's rules before piercing!)

What is right? It depends on your culture and goals.

I have my personal opinions and fears.

I have seen infants pull earrings out, so I very much worry about damage to the earlobe and the choking risk of any jewelry on infants. My worry is not so strong to refuse to pierce infants-- I have many patient families who prefer to pierce ears in infancy for many reasons, and for many it is culturally based. I want to support other cultures, so have not tried to dissuade these families and most infants do very well with it. And if I do it for one, I should do it for all, right?

The infection risk mentioned in the article above for the first couple of months makes sense, but to stop that risk at 6 months seems premature to me. My reason: at 6 months babies spend a lot of time with their hands in their mouths, then they grab their ears. The mouth is a germy place, and to put the saliva all over the freshly pierced ear seems a risk to me.

On a technical note, I am more nervous piercing infant earlobes than bigger kids. Older children who want their ears pierced will usually sit still-- scared maybe, but still.  Infants must be held and they are typically crying when held. A small variance in positioning on a small earlobe can grow to a more noticeable difference as the earlobe grows. Bigger earlobes are easier to mark and position earrings symmetrically. I think this is a big issue for me because I do not like the angle of my earring holes. (This is why I rarely wear earrings. I had mine pierced initially at about 6 years, I think. They got infected and I had to let them close and then they were later re-pierced. I am not sure if the original hole made the 2nd piercing more difficult or not, but the angle makes the earrings too upright for my liking.)

The more I type, the more I think I should start trying to talk families into waiting...

What do you think?


Tuesday, October 9, 2012

Eye Exams for All Children!



I often find that when I tell parents to start taking their children to the eye care specialist, the advice is not followed. Even at the 3 year well visit when I suggest a free screening, so I know it isn't always about the cost. We are all busy. I get that. But our eyes are important, and many pediatric eye conditions have much better outcomes if addressed early.

I was excited to see an article, No Child Too Young for Eye Exam in Pediatric News, thinking posting it would help parents. But after reading it, it was a bit technical, and written for physicians. So I thought  I'd break it down and explain why eye checks by an eye care specialist is so much more than a vision screen at school or the doctor's office. (I have stopped recommending vision screenings in my office - though they are still offered- because if insurance limits to only one screen per year, I want it done by someone who looks at the entire eye. See the second scenario in Middle Man Payment Plan for more.)

First, what do I mean by seeing an eye care specialist? Eye care specialists include Ophthalmologists and Optometrists. Ophthalmologists are physicians who went to medical school to obtain an MD (Medical Degree) or DO (Doctor of Osteopathy) degree and then did their residency in opthalmology. They can do eye exams as well as treat problems medically or surgically.  Optometrists go to school specifically to diagnose and treat eye conditions. Their degree is OD (Optometry Degree). They focus on routine eye care and vision correction. Both of these specialists can have specific areas of expertise and may or may not treat kids, so always be sure they have experience with kids the ages of your children.

In the article referenced above, Dr Sherry Boschert discusses myths of eye problems in children. These myths:

1. My child is too young for an eye exam. Not true. Ophthalmologists are routinely consulted in the Newborn ICU to see newborns for various eye concerns. Thankfully they don't have to be able to tell if view #1 or #2 looks better... even at my age, this is very difficult! Eye doctors can be specially trained to evaluate a newborn's eyes adequately.

2. Tearing must be due to a blocked tear duct. Many infants have blocked tear ducts, which causes the eye to water often. Since it is so common, it is most likely that your child with a tearing eye has a blocked tear duct. But... if it comes with pain or light sensitivity there might be more going on like a scratch on the eyeball or increased pressure within the eye.

What is a blocked tear duct? Just as it sounds, the tube that drains tears from the eyes into your nose become blocked. Tears are made in glands in the eyelid, cross the eye to moisturize it, then drain into the nose. With the drainage tube blocked, tears well up in the eye and it looks like the eye is crying. Usually this self-resolves by about 9 months of age, and parents can help by massing the area of the tube several times/day. It can lead to matting and drainage from the eye, but without redness or pain does not require any other treatment the first 9 months of life.  If it persists longer or if it leads to a discolored swelling below the eye we refer to an ophthalmologist (eye surgeon) for treatment.
Corneal abrasion is the medical term for scratch on the eyeball. How does this happen? Babies keep their hands near their face often and can get a fingernail in the eye accidentally. Often parents do not know what happened, but baby suddenly cries uncontrollably and won't open the eye. Older kids might be able to tell you that something went in their eye or they simply complain their eye hurts. They might have one area of redness (as opposed to pink eye where the entire eyeball is red). These scratches can be seen in our office with the help of special dye and a black light (Kids think this is pretty cool!) and are treated with antibiotic eye drops and close follow up. Severe trauma should be seen by an ophthalmologist. 
Glaucoma is not common in babies and children, but it is something that needs to be treated emergently by a pediatric eye surgeon (ophthalmologist). These babies appear to have beautiful big eyes, but they are caused by increased pressure within the eye. This pressure must be released to avoid permanent vision damage and treat the associated pain.  

3. All red eyes are contagious. Red eyes can be from viruses and bacteria (the reason schools/daycares kick kids out at the first sign of a red and/or goopey eye), but they can really be from many causes:

  • viral conjunctivitis = pink eye from a virus. This is typically red and watery, but no mucus discharge. It usually comes with other typical "cold" symptoms. It is contagious, but like all viruses, no antibiotics help. 
  • bacterial conjunctivitis = pink eye from a bacteria. These eyes are red with yellow discharge. Antibiotic eye drops do help contain this from spreading as well as treat the infection.
  • allergic conjunctivitis = pink eye from allergies - typically itchy and watery, sometimes red eyes and sometimes a very thin mucus discharge occurs. A careful look at the inner eyelids will show small bumps. These can be treated with typical oral allergy medications or eye drops for allergies (available OTC). Eye doctors will use steroid eye drops for very bad cases, but these should be used with the direction of eye specialists who can check eye pressures to follow potential side effects.
  • other illnesses - I commonly see reddened eyes with "sick" kids (Strep throat, upper respiratory infections, etc) who don't meet criteria for a true conjunctivitis.
  • irritants - shampoo, smoke, chlorine, or other things entering the eye can irritate it and cause it to temporarily look red. Many of these require a flush of the eye. If pain or redness persists, they eye should be completely evaluated to be sure there is no damage to the eye surface.
  • foreign bodies in the eye - sand, eyelashes, and other objects can irritate the eye. If unable to remove them safely at home, the primary care provider can help. If pain persists after removal or if they eye remains red more than 6-8 hours after removal, the PCP should evaluate for infection or abrasion.
  • stye - These are bumps in the eyelid, near the eyelashes. If they are deeper within the lid they are called chalazions. They don't usually cause the eye to look red (except the bump itself) but I include it here because I see many kids for "pink eye" diagnosed at daycare, that have no pink eye, just a stye. These can be helped with a warm compresses. I do not feel these need antibiotics or eye drops but the author mentions those as a treatment option. If they grow large enough to cover the pupil or if they last longer than 3 months, an ophthalmologist might need to remove them.
  • tired kids often have red eyes, usually parents notice this pattern
  • injury - see corneal abrasion above
  • sunburn - yes, the eyes can suffer sun damage just like your skin. Wearing sunglasses with UVA and UVB protection and wide-rimmed hats can help prevent this (as well as cataracts, macular degeneration, and other issues). If blistering or severe pain, these should be evaluated by an optometrist or ophthalmologist.
  • hemorrhage = bleeding within the eye. This can be common after birth or with coughing or vomiting due to sudden increased pressure within the eye. They self resolve. 
  • episcleritis = inflammation of part of the eye covering. The white of the eye can look pink or purple, the eye hurts and is sensitive to light, and it may tear. It typically self-resolves, but an eye specialist can help with the diagnosis.
  • pinguecula and pterygium = small growths on the surface of the eye from various causes. An eye specialist can help with diagnosis and management, though typically no treatment is needed.
4. Children outgrow crossed eyes. Many children appear to have crossed eyes due to a wide nasal bridge, and they do "outgrow" this as their face shape matures. This is called pseudostrabismus and is not a problem with the eye.  It can be demonstrated in the photo at the top of this page. The right eye appears to cross in, but if you note the light reflex on the pupils, it is in the same location on both eyes. Truly crossed eyes would show the light reflex on different parts of the eye. This is caused from vision problems, eye muscle problems, or even in rare cases brain masses, and none of those go away without proper treatment. Your child's primary care provider can help determine if it is a "real" eye crossing or "pseudo" eye crossing, but an eye specialist can do a more thorough exam and determine treatment and follow up requirements. If you have pictures that show your child's eyes crossing, bring them to your appointment.

5. A bump on the eye will go away. See also "stye," "pinguecula,"and "pterygium" above. In addition to sties and chalazia, hemangiomas (collections of blood vessels), lymphangiomas (collections of lymph tissues) and dermoids (cysts) can cause masses around the eye. These should be followed by a pediatric ophthalmologist. Rhabdomyosarcomas are cancerous tumors that also require immediate treatment.

6. One eye is bigger, but it's a family trait.  An eye specialist should always evaluate the eye urgently if one seems bigger than the other. There are many causes, and many need emergent or urgent treatment.

7. Glasses worsen a child's prescription.  I have heard this often from parents, worried that the glasses prescribed to their child will worsen the vision over time. This is not only incorrect thinking, but opposite of what sometimes happens. Children's eyes and nerves are developing, and early vision correction will often improve vision over time. And they can see better to avoid injury, learn better, and in general see the world better!

8. Abnormal light reflexes are just a bad picture.  When a child's "red eye" looks more white, it can be simply the angle of the lighting or the child's eye pigments, but it can be a signal of eye tumor, cataracts, or abnormal eye shape (which leads to vision problems). Never ignore this! If your child's eyes don't look right in a picture, bring the picture to an appointment with an eye care specialist.

9. Different colored eyes are cute. This can be normal, but if eyes are a different color (either left vs right or colored stripes or rings within the same eye as in the picture) a vision check by an eye specialist is a good idea.

photo source: http://en.wikipedia.org/wiki/File:Heterochromia_Blue_Orange.png

10. Parents don't know best. What an obvious myth!

Saturday, October 6, 2012

The Limping Child

A limp in children is a fairly common problem that has many causes.  Many of these causes are not dangerous, but all limping children should be evaluated by a health care provider to be sure there isn't anything more serious requiring treatment.  Our office has recently seen a surge of limping kids from various causes, so I thought I'd review many of them here. They are in order of body location, but symptoms of all may include a limp. This list is not comprehensive... although it is long, there are other causes I have left off. I have linked many of the causes to more information, just click on the diagnosis name.

Fever, weight loss, poor feeding, or night sweats suggest infection or malignancy and should be evaluated as soon as possible. History of trauma of course increases the likelihood of traumatic injury and if stable, can wait overnight to avoid an ER trip, but if any gaping open skin, excessive bleeding, disfigurement, or excessive pain warrants immediate evaluation and treatment.

Hips:

Developmental dysplasia of the hip involves the abnormal formation of the hip socket and a flattening of the top of the thigh bone (femur).  Babies who are born breech, especially females, are at increased risk. Family history and some genetic conditions also can show a predisposition to this condition. All babies are routinely screened with a hip check during their physical exam until they are well into walking. Sometimes even with a shallow hip socket the exam can appear normal, so high risk infants are often sent for hip ultrasounds (sonograms) or x-ray (if over 6 months). If this condition is recognized, these babies should be treated by a pediatric orthopedic surgeon. 

Transient synovitis (also called toxic synovitis) is found in children 3-10 years of age. It typically follows an infection. They have pain in the hip and don't want to move the hip in its full range of motion. It self-resolves in about a week. Non-steroidal anti-inflammatory medications can help with the pain. Although it resolves without treatment, a thorough physical exam by a medical provider is important to evaluate for other causes. 

Septic arthritis, on the other hand, is an acute infection of the hip joint. This is a very serious condition because without treatment the hip joint (or other affected joints) is destroyed by the infection.  Several bacteria can cause this type of infection, so culture of the pus is obtained and antibiotics are required. Classically these infants and children hold their leg at a flexed position and don't want to move the leg. This helps reduce the pain by giving the hip joint as much open space for the pus to decrease the pressure and relieve the pain.

Legg-Calve-Perthes disease is found in males more than females, typically 4-10 years of age. It is usually on one side, and results from an interrupted blood supply to the top of the femur (thigh bone). This leads to a flattening of the top of the femur and cysts in the bone. Physical therapy, casting, traction, or surgical correction are various treatment options, depending on age and severity. Pediatric orthopedists are consulted to manage the treatment of this process.

Slipped capital femoral epiphysis (SCFE) tends to occur in early teen years, males more than females, and obese children are at increased risk. It often happens in both hips and is caused by pressure on the growth plate at the top of the femur (thigh bone).  Pain can be felt at the hip, thigh, or knee. It can be sudden or gradual. It requires surgery to pin the top of the bone (above the growth plate) in line with the rest of the bone, so pediatric orthopedists are consulted to treat this condition.

Knees:

Osgood-Schlatter disease is fairly common in athletic teens. Knee pain is caused from traction on the growth plate on the tibia (one of the shin bones). Pain is felt directly below the knee at the top of the shin bone. Many people have a boney bump that doesn't hurt after growth is complete and the growth plate is no longer present. Rest, ice, and non-steroidal anti-inflammatories are the treatment.  Unfortunately symptoms can last for several years until growth is complete, but it is not a concerning process for overall bone health. 

Sprains involve stretched or torn ligaments. Often a popping sound is heard at the time of injury and pain is immediate. Swelling from fluid behind the kneecap is common. The knee can seem unstable and weight bearing is painful.  Strains are a tear of the muscle or tendon. Symptoms are similar to sprains but also involve bruising. For more information on both sprains and strains see KidsHealth.

Tendonitis is an inflammed tendon. It is a common overuse injury. Pain or tenderness with movement of the joint or walking is noted. Rest, ice, wraps, elevation of the leg, and anti inflammatory medications can help. Physical therapy to strengthen muscles to support the knee is recommended for most of these overuse injuries, but surgery is sometimes required.

Meniscal tears are common sports injuries from sudden change in speed or side to side movement. Tenderness, tightness, and swelling of the knee are noted. Initial treatment is the same as the tendonitis treatment above, but surgery is required for large tears.

Osteochondritis dessicans (OCD) occurs when a piece of bone or cartilage breaks off the bone and causes long-term knee pain. It often occurs with swelling, inability to extend the knee fully, stiff knee, and popping of the knee. Treatment involves casting and sometimes surgery.

Feet and Ankles:

Tarsal coalition is a condition where 2 or more bones are joined in the midfoot or hindfoot. Pain in the midfoot or a spastic or fixed flatfoot are symptoms. This is a congenital (birth) condition, but symptoms don't develop until late childhood or adolescence. It is sometimes found incidentally on xray for another issue. Conservative treatment involves splinting, and surgical correction is also available.

Plantar Fasciitis is pain in the bottom of the foot or heel pain. Tight calf muscles or Achilles tendons often are associated with this. It occurs in toe-walkers, overweight people, people who wear shoes without sufficient support, and athletes who fail to adequately stretch.  Stretching, non-steroidal anti-inflammatory medications, and heel inserts often help relieve pain. Physical therapy can be helpful.

Achilles Tendonitis is an overuse injury of the Achilles tendon. Runners and jumpers are often affected.  Pain tends to worsen with time, especially after running or jumping. It is treated with rest, ice, wrapping, elevation of the foot, anti-inflammatory medicines, stretching, and shoe inserts.

Sprained ankles are very common. They happen when the ligaments of the ankle get stretched.  Elevation of the foot, ice, non-steroidal anti-inflammatories, and rest help it heal. 

Bones:

Fractures (see also fractures) after injury are not always easily identifiable in young children who are not able to state what happened. Initial xrays might appear normal if there is only a subtle fracture. If limp persists, follow up xrays in one week can show signs of a healing fracture more readily than the initial fracture.

Overuse injuries and stress fractures are becomming more common as younger kids are getting into more highly competitive sports. X-rays may be normal or show mild changes. If history of training and pain/limp is consistent with stress fracture, MRI or bone scans might be required to show bone injury.

Bone tumors can originate in the bone or from other cancers metastasizing to the bone. Leukemia involves production of abnormal blood cells in the bone marrow, and leg pain is often a common finding. Bone pain, fracture from mild trauma, and other symptoms of the primary cancer are all presenting signs.

Leg length discrepancy can cause a limp that typically does not hurt. Most of these can be managed with shoe inserts to "lengthen" the short leg. Surgery is sometimes recommended.

Multiple joints:

Arthritis can affect a single or multiple joints. Morning stiffness that gradually lessens as the day progresses and the joint "warms up" is common. Swelling might be minimal or great. Family history is often a clue, but some kids have no family history of arthritis. Other symptoms, such as rash, fever, eye changes, are possible.

Abdominal and back issues: 

Constipation, appendicitis, abdominal muscle (psoas) abcess, tumors in the abdomen, inflammation of the disc spaces in the vertebral column, and tumors of the spinal cord are other possible causes of limp or refusal to walk. History and exam will help to identify these causes.

Muscles:

Hamstring strain happens when muscles in the back of the leg stretch and tear.  Sudden thigh pain, sometimes with a popping sensation and bruising, are symptoms. Treatment involves rest, ice, wrapping the muscle, elevation of the leg, and non-steroidal anti-inflammatory medications. 

Quadriceps contusion happens after a hit to the muscles of the thigh. Rest, ice, wraps, elevation of the leg, massage, and non-steroidal anti-inflammatories can help relieve pain. Physical therapy can be initiated when swelling is decreased. Slow return to sports is important to allow complete healing.

Post-viral myositis is muscle inflammation after an infection with a virus. Affected kids will have severe pain in the calf muscles, typically within a couple of days of a resolving viral illness (often influenza, but other viruses too). This is a condition that resolves over about 10 days, but medical providers should help with the evaluation of this to be sure the kidneys are not involved. If the urine is very dark it should be evaluated immediately.

And one more thing...

A cause of leg pain that doesn't cause limp is Growing Pains.