Thursday, December 27, 2012

Top 10 Posts

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There are many Top 10 lists at the end of the year. Since I've been running low on blog ideas and short on time with the holidays, I thought I'd do my Top 10 blog posts.

What started as a quick project has sent me down memory lane, since most posts are triggered by an event (or series of events) that make me want to write about the topic. I'm adding a bonus #11 because it is one of my favorites and I am feeling nostalgic.

11. Potty Training is one of my most personal blogs, describing my own potty training parent moments. Sorry kids!

10. Walk In Clinic Etiquette was written in part because of my frustration of the many options of urgent cares, some with good treatment, others with less than ideal treatment. It also highlights some of the issues our walk in clinic providers deal with regularly.

9. Fever is... one of the biggest worries of parents. There are so many real fears but also a lot of exaggerated fear. My attempt to set the record straight.

8. Cut the cord... Give them the World! My thoughts on parenting to allow kids to grow to be independent and productive adults.

7. Parenting when you're angry: Keep Cool We've all been there.

6. Oh, what a (sick) season! This is one of my newest posts. Tips on what to do if your family gets what's going around are still pertinent.

5. Itchy Bottom? Is it Pinworms? What to do? We had a number of pinworm calls from worried parents and I wanted to help our phone nurses out since the treatment options are confusing to parents.

4. Got Milk? Cow, Coconut, Soy, or Almond? Questions on milk alternatives are common for kids with dairy allergy or family preference.

3. Ear Wax: Both Good and Bad Ear wax is another common frustration to parents. When to leave it and when (and how) it should be removed are discussed.

2. Car Seat Confusion and Booster Boo Boos I love that this has been so widely read. It is such an important topic. Please share this one!

1. New Guidelines for Treatment of Strep Throat This surprised me as the most read post. I'm glad people are interested in reading things like this. I hope it decreases the demand for unnecessary antibiotics and educates people about why we do some of what we do in medicine.

One final "bonus" blog update. Pediatric Partners joined Team Mighty Maxwell (March for Babies) in support of Dr. Ratliff's son. Max remains at Children's Mercy. He continues to require help breathing with a ventilator but his doctors are trying to slowly decrease the amount of help he needs. He has had surgeries to help reduce pressure in his eyes and is seeming to be happier overall. For more updates, check out his CaringBridge page.

Tuesday, December 18, 2012

Oh, what a (sick) season!

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This cold and flu season has started early and hit hard! The number of kids we are seeing with severe illness, such as prolonged fevers (over 5 days over 101.5F) and difficulty breathing, are not typical for this time of year. On more than one occasion we have tried to admit a sick child, only to be told there are no available beds. While we are familiar with this in January, this started in November and is more common this month. I feel the need to review a few helpful tips.

What are we seeing right now? A bit of everything. Fever. Vomiting. Diarrhea. Strep throat. Influenza (fever, cough, sore throat, body aches). Bronchiolitis (from RSV and other viruses). Pneumonias. Asthma flare ups. Sore throats from viruses. Whooping cough. Mild colds and coughs. Basically, if you ask if it's going around, chances are the answer right now is "yes".

Wash hands and surfaces! First and foremost is control of spreading infection. You never know when someone is shedding a virus before they feel sick. If you are taking care of sick kids, you are at risk of getting sick along with them. Wash hands and surfaces often. Don't share food and drinks, even with your family! Avoid touching the eyes, nose, and mouth. These are where germs enter to make you sick! When's the last time you cleaned your phones and keyboards?

Fever can be a good thing. We worry in infants under 3 months, those who are immune compromised, or those that are not up to date on vaccines ~ they should always have a medical exam with fevers. If a fever lasts longer than 3-5 days kids should also be seen. For everyone else, we treat symptoms, not the thermometer. If a child is playful at 101F, no need to treat other than pushing fluids and watching carefully. Usually by 102F kids start feeling body aches and feel better with treatment. Watch your child's symptoms, don't worry about the actual degree on the thermometer. Use either acetaminophen or ibuprofen, but most pediatricians don't recommend alternating. Follow dosing charts for weight, and if weight is not known, use age. For dosing charts, see our Medication Dosing page.

Stay home if sick. Again, this is paramount for controlling the spread of all the germs. Don't try to mask symptoms with a fever reducer so you can send kids to school or you can go to work. Stay home and rest!

Never underestimate the power of water. If there is vomiting, an electrolyte drink in small volumes frequently is best. For most colds and coughs, simply drink more water. If there is congestion, runny nose, or cough, add water to the air with a vaporizer or humidifier while you sleep. Even if you have a home humidifier, using an additional one in the bedroom helps. Use saline in the nose. Drops are okay for infants. Older children and adults can learn to flush the nose with saline. Check out Nasopure for tips on learning how to do this and videos to see that it's not as bad as it sounds. (I am not associated with or paid by Nasopure. I just like their product.)

Antibiotics don't make viruses go away any faster. Please don't ask for a prescription if cold and cough symptoms just started within the past 10 days. Unless there is an identified infection requiring antibiotics, they won't help. Even some things we often treat with antibiotics don't need them. Many ear infections and sinus infections are viral and will resolve without antibiotics. At your office visit ask about the need for antibiotics if your child has one of these infections.

We cannot make any diagnosis over the phone. As descriptive as you are on the phone, there is no substitute for examining a child. I encourage people to go to their medical home as often as possible and use other urgent care centers or emergency rooms for true urgent/emergent needs. Going to the same office for sick visits helps to track infection rates to identify kids who might need another treatment, such as ear tubes for frequent ear infections. Even if you get good care elsewhere, it is hard to keep track of dates they were sick and which medicines were used. With most pediatricians open extended hours these days, it is usually possible to be seen by someone you know and trust in a familiar setting.

Some illnesses need multiple visits. I know this is time consuming (and expensive with many insurance plans) but illnesses progress, symptoms change, and exams change. Just because your child was seen a day or two ago and it was "just a cold" doesn't mean it won't progress into an ear infection, pneumonia, or dehydration over time. Unless your child is really sick, you don't need to bring them in at the first sign of a runny nose or fever. Try home therapies first. Coming in early doesn't stop the progression of illness. Preventative antibiotics are not recommended, even if your child has a history of frequent ear infections.

We are in the middle of a whooping cough epidemic. Unfortunately whooping cough can mimic mild colds at the beginning, but the cough can last for several months if not treated in the first couple weeks. A small percentage of people who have been vaccinated still develop whooping cough, though it may be milder it is still contagious. If you child has been exposed to whooping cough and develops any cough, visit your doctor for evaluation and treatment. If your child develops a cough that is followed by a whoop or a cough followed by vomiting, he or she should be evaluated for whooping cough. Be sure kids and all care givers are up to date on vaccine. Typical pertussis vaccine is given at 2, 4, 6, and 12-18 months, 4-6 years, and 11 years. If not given at 11-12 years of age, the Tdap should be given to all teens/adults once. Get vaccinated!

Our influenza season has started earlier than usual and is predicted to be a bad season. Flu vaccines are the best prevention against influenza, so yearly vaccination for all over 6 months of age is recommended. We gave more influenza vaccine than ever in our office this season, but we are out of stock. If your family has not been vaccinated, check with your health department and other locations offering flu vaccines.

If you need information on treating specific illnesses, use our tips on Illnesses and Symptoms, but please see someone at your usual physician's office as well if you are concerned. 

Sunday, December 16, 2012

Violence... I think parents can help prevent from home

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I, like most of you, am horrified by the event's of last week's shooting. I have read countless articles in the aftermath about talking with kids, safety in schools, gun control, and even mental health services needing to improve.

I keep wondering if there is something each parent can do at home to help the future.

Violence in the media is constant. It is becoming more graphic and violent. Children do not have the ability to separate fantasy and reality, which makes them more vulnerable to altering behaviors depending on what they are exposed to. Until the last part of our brain matures during adulthood, we have not fully developed self control, emotional regulation, and judgement. So for those of you who think your children or teens are mature, they are still developing important parts of their brain!

If we limit exposure to violence, would it help prevent violence? If children are exposed to less violence at home and in the media, can we cultivate a society of people who can work through conflict in a civil manner?  It's been shown in study after study that violence exposure leads to violent behaviors. What about the opposite? Model positive behaviors and limit negative exposures to encourage healthy development of behaviors.

Research shows that the more violent video games kids play, the more violent they become. Very young children exposed to aggressive acts on television will be more aggressive with their play. There is even long term effects from early exposures. A study showed that men who were high TV violence viewers as children were significantly more likely to be physically aggressive with their spouse and to be convicted of a crime at three times the risk of other men. Women with high TV violence exposures as children were four times as likely as other women to be physically violent.

Parents: you can't "take back" early exposures. Don't wait until you are worried about your child/teen's behavior. Prevent it!

Some limits to violence are more difficult to enforce than others.

If kids live in violent homes, they are vulnerable on many levels. Recognizing these at risk kids and helping their situation improve or remove them from the situation is very difficult. There are free online resources to help (use a safe computer if you are at risk!) Even if you are not in an abusive situation, learn to recognize signs that someone is. You could save a life! SafeHome provides education and assistance for those in need in the Kansas City area.  The Hotline is a nationwide hotline that also has educational information on its website. 
When our children are at other homes, we don't always know the parenting styles or supervision as we do at home. Get to know the parents of your children's friends. Let them know your expectations of what your child can/cannot watch or play. Talk to your children and teens about what they do elsewhere. 

Easier fixes involve the media. (Note: I didn't say easy. I said easier.)

Remove the televisions and other electronics from bedrooms. They cut down on sleep (sleep deprivation adds to poor decision making and behaviors) and allow private, unsupervised viewing. 
Parents should screen what their children watch and play for age appropriateness. I have heard many parents say something to the effect of "He's always been around shows like this, and is not scared. He loves to watch them." Why is he not scared, if his age would typically be scared? Is he already desensitized? That scares me. Check out free on-line reviews from a reputable site, such as Common Sense Media, before deciding if something is appropriate for your child. Choose appropriate times that do not allow younger children to be exposed.
Listen to the music your children and teens enjoy and check out their reviews on Common Sense Media. Many songs promote partner violence, fighting, and sexual violence. Songs have a way of getting into our head. Fill their brains with healthy lyrics, not brainwashing songs that promote any form of dangerous behaviors!
Set maximum times children and teens may have screen time. The American Academy of Pediatrics suggests no more than 10 hours per week for children over 2 years of age. No screen time is recommended for children under 2 years. Remember that screen time includes television, movies, video games, social media, and all other things on a screen. 
Learn the technologies your children are using. If your child or teen is playing online, you need to learn how to set parental controls and monitor what has happened on line.

I am not advocating that families should never enjoy an age- appropriate movie or video game. We actually went to see The Hobbit last night. Although it is PG-13, I read reviews and decided that it was appropriate for my 11 year old. She has a strong sense of reality vs fantasy and was able to sit through the show without being scared at all. (She felt it was "boring" and too long.) It wouldn't be good for all 11 year olds though, and I don't think I would have taken her much younger. Point: parents must know their child, have the facts, and make educated decisions. Don't just say "yes" because it's easy!

And finally, the best parent is an active parent. Participate in activities with your children. Build up their self confidence. Talk to them about what's on their mind. Show them you care. Set limits and stick to them. Give healthy physical contact (hugs, high five, back pat, tickles) often, no matter how old they are, unless it makes them uncomfortable. Tell them you love them. Be their rock.  


"Impact of Media Violence Tips." Reviews and Ratings for Family Movies, TV Shows, Websites, Video Games, Books and Music. N.p., n.d. Web. 16 Dec. 2012.

"The Teenage Brain-- Why Do Teenagers Think Differently than Adults?" The Teenage Brain-- Why Do Teenagers Think Differently than Adults? N.p., n.d. Web. 16 Dec. 2012.

"Childhood Exposure To Media Violence Predicts Young Adult Aggressive Behavior, According To A New 15-Year Study." Childhood Exposure To Media Violence Predicts Young Adult Aggressive Behavior, According To A New 15-Year Study. N.p., n.d. Web. 16 Dec. 2012.

"The Impact of Media Violence on Children and Adolescents: Opportunities for Clinical Interventions | American Academy of Child & Adolescent Psychiatry." The Impact of Media Violence on Children and Adolescents: Opportunities for Clinical Interventions | American Academy of Child & Adolescent Psychiatry. N.p., n.d. Web. 16 Dec. 2012.

"Media Violence." Media Violence. N.p., n.d. Web. 16 Dec. 2012.

Tuesday, December 4, 2012

Stepping outside my comfort zone

Getting ready to start in our party scene!
This past week I was on vacation from my day job to be an active parent.

Sometimes we need that.

I really had to step outside of my comfort zone for this parenting act -- being in the cast of Clara's Dream (a version of The Nutcracker).  Parents often do things we never thought we would for our kids.  We intentionally put our nose to a probably dirty diaper to be sure it needs to be changed. We forego sleep to take care of kids. We take care of their needs before our own routinely.  They change us in many ways for the better.

For years my daughter has loved to perform on stage for theater and dance. She has asked on several occasions for me to audition for "family shows" where they allow parents of students to be in the cast. Each time she has asked, I answered with a firm "No".  I have never acted or danced. I prefer one-on-one conversations, not large groups - and definitely not the stage!

Several months ago she asked and I actually considered it. I had already requested vacation for that week due to show week always getting crazy with time constraints. Rehearsals were later in the evenings, so they wouldn't interfere with work. As I thought about it, I considered the joy of being an active part of her favorite activity and put away my fears of being on stage.  (Of course the fear returned each time we were called backstage to line up for the scene- but it was too late to turn back then!) It was an act of faith because I had never seen the show and knew little about what I was signing up to do.  I figured parents would mostly be "background" people and didn't realize we would learn dance steps and actually be a part of the scene. No, I didn't have to do ballet - just a Victorian ballroom style dance.

It was fun to be a part of my daughter's life in a way that will always have a special memory. Call it working mom guilt, but I want to make special memories in addition to daily quality time.  Quality time is not spent watching tv with kids, but doing things together.  Some things are small, like taking a walk or playing a game. Some things are more memorable because they are unique.

Not only did I get some great times with my daughter, I also met a number of fun people in the process.  Spending so much time with other parents of dancers was a great bonding experience in itself. And I got to know some of the students and teachers my daughter works with on a regular basis at dance classes.  It is always a good idea to know the people that hang out with the kids!

So when your kids ask you to do something and your first thought is "no way", take a moment to think about it. You might just change your mind and grow with your child!

Bow time... my "German son" is blocking me.
To be in your children’s memories tomorrow, you have to be in their lives today.  – Anonymous

Wednesday, November 28, 2012

Know Your Insurance Formulary

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When kids with a chronic illness (migraines, asthma, ADHD, acne) need a first-time prescription, I often ask the parents to look at their formulary first. This upsets some parents because they want to start something today, but I refuse to play the phone tag game for the next week.

What do I mean?

Most diseases have more than one medication that can be used to treat the condition. Many of these medicines are very expensive, and insurance companies put them in various tiers depending on how much they pay for the medicine.  The more they are contracted to pay, the higher the tier, resulting in a higher copay for the consumer. This varies from company to company, so what someone with a prescription plan from Company A has different costs than someone with a plan from Company B.  Even different plans within company A vary.  High deductible plans add in even more confusion because your cost depends on how much you've already spent.

I saw a formulary for one company recently that the medicine was generic tier for those under 18 years, but over 19 years it needs a prior authorization. Huh? The condition doesn't change with the birthday. The medicine is approved for both age groups. Why they have that prior authorization requirement is a puzzle to me.

I simply can't keep all the plans straight. Ideally electronic records would link to each insurance plan's formulary and let us know immediately how much a prescription will cost, but they don't.  Even pharmacies can't give the cost until they "run it through".  There are simply too many insurance plans.

So if you think you will need a long term prescription for a long term problem, I simply ask that you do your homework first. The insurance company won't tell me what your plan says. You must ask.  When we know the formulary, we can discuss the best option to begin treatment.  When 2 medicines have equal risks and benefits for a condition, we will choose the least expensive. If the lesser expensive options don't work, we may end up on a higher cost medicine. At that point other things have been tried and the cost is more acceptable.

Without the formulary, what tends to happen is I write for Drug A. When the parent goes to the pharmacy to pick it up, it is too much money, so they call use to change. Of course they don't know what to change to, so I change to Drug B.  Same story.  Turns out, it will be Drug E that is the lowest tier. Parents are frustrated with me for not giving the "right" one, but I am blind. Drug A was cheapest on the last plan I wrote a script for. Who knew yours is different?  This leads to too many trips to the pharmacy and phone calls back and forth. Everyone is frustrated and time is lost. It is faster to spend some time in advance finding out what to try first!  Please.

Believe me, this is frustrating for all of us. I wrote about my personal experience with formularies in Health Insurance Woes.  As an update to that, we are now using a mail order pharmacy. It is still much more than our last plan, but better than local pharmacies.

Saturday, November 17, 2012

Is an apple a good bedtime treat?

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As parents we try to get as many fruits and vegetables in our kids as they will take, so when Junior asks for a bedtime snack, it is tempting to allow a piece of fruit. Sounds healthy, right?  Surely better than ice cream...

An apple is healthy and can be a great part of a healthy snack, but kids (and adults) shouldn't have a high carbohydrate snack before bed without some protein and / or fat.


When we eat, our body senses the increase in blood sugar and sends out insulin to store the sugar in cells for future energy. An apple (or other fruit) is high in carbohydrates (sugar) and low in fat and protein. Sugars and can be quickly stored, lowering the blood sugar pretty fast unless there is fat or protein to stabilize it.

Fats and proteins are more complex to digest.  They must first be converted into smaller molecules before insulin can store the food for energy.  This allows a more gradual fall of the blood sugar.

Why is this important at bedtime?

We always have some sugar in our blood, ideally 70-100 mg/dl, but rising after eating and falling when fasting (not eating).  Normal sugar levels give our cells energy for all they need to do. We go for many hours without eating again when we sleep all night. If the insulin level is still high after storing all the easy to store carbohydrates but there aren't more molecules from the breakdown of protein or fat around to start storing, the insulin lowers the normal blood sugar to unsafe levels.  This is especially dangerous at night because one early sign that the blood sugar is too low is tiredness, which is unnoticed when asleep.

Diabetics should be especially aware of this response because their body does not regulate insulin normally, and they can suffer from severe low sugar if too much insulin is given without the proper balance of nutrients.

It would be extremely uncommon for a person with normal sugar management to have serious consequences of low blood sugar (such as coma or seizures) from this apple before bed, but without a good sugar level, the body will not get the most benefits of sleep: restoration of the body and growth in children.

So what's my recommendation for that bedtime snack? Go ahead and give that apple-- with a glass of milk, yogurt, peanut butter, cheese, or other food with protein.

And ice cream isn't all that bad as far as a snack that won't lower blood sugar too much... it just has less nutritional value.  So as a fun treat when kids are eating enough fruits and veggies the rest of the day and have gotten exercise and not an overabundance of empty calories, it's okay to have an ice cream once in awhile.  After all, it's made from milk, so not all bad!

Which reminds me of this great Bill Cosby clip: Chocolate Cake  (Who says we can't have a little fun when talking nutrition?)

Saturday, November 3, 2012

Taste a Bite Without a Fight

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Here's another blog inspired by a facebook question:

Megan Brower Lynberg My 2.5 year old son is super picky and I swear he looks at certain foods and decides not to eat them. I know most parents have the try it rule, or just one bite, but we can't even get him to do that most times. Any suggestions on how to implement that? Or should we just let it go and know that for the most part he gets a balanced diet and hopefully he'll branch out as he gets older?

Picky eating is synonymous with most toddlers and school aged kids. I smile inwardly when parents boast that their one year old will eat anything, unlike "other kids" who are picky, as if the other parents did something wrong.

It is between 15 months and 3 years that kids who used to eat anything go through phases of pickiness. I say phases, because sometimes it is a favorite food one week, only to be "yuck" the next week.  I knew this when my kids were young, so I took pictures of my toddlers devouring things like broccoli, so I could show them later that they did, in fact, love it.  (It didn't help.)

Overall the two biggest food groups kids dislike, vegetables and meats, are two of the most nutritious, so parents fret about how to get the nutrition in.  My general advice: parents decide what foods are offered, kids decide how much they eat.

My kids learned "Taste a bite without a fight" at daycare. Why silly rhymes work, I don't know, but sometimes they do.  I usually advise to enforce a bite after 3 years.  Before this age, they might just be too young to fight the battle yet. They simply don't know how to follow rules until about 3. I have heard of parents turning on the tv so the child mindlessly eats what the parent puts in his mouth. Don't do that! It sets up so many bad eating habits!!!

Until the taste a bite rule can be enforced (and even after that) I like to use hidden foods as nutrients. We are having pumpkin french toast this morning-- pumpkin puree added to the eggs/milk. This is not much vegetable, but more than they would get from a bowl of cereal or standard french toast. If this is done with many meals, it all adds up. Find foods your child likes, then "tweak" to fit in needed nutrients.
Vegetables and fruits can easily be pureed and put into sauces, casseroles, smoothies, and ground meats (meatballs, burgers, meatloaf).  Put a can of beets into the blender with your spaghetti sauce for a funky colored sauce. If your kids don't like sauce on noodles, try making pizza with a zucchini/carrot/beet jazzed up sauce. Some people just finely shred or chop. I find that puree works better because they don't see it and pick it out! There are many recipes for this online and in cookbooks for parents.  Check out my Pinterest Meal Ideas page for starters. (Not all ideas are healthy on this page... some are things I just want to try!)
Putting a cheese sauce over vegetables or offering a dunking sauce (yogurt, catsup, ranch dressing) makes it more acceptable to many kids. 
Add fruits and vegetables to breads or noodles. Most kids love the bread group. Banana bread, pumpkin bread, zucchini bread, spinach noodles, and more are all ways to add a little fruit or vegetable into something they will eat. Yes, they will get more sugar this way, but ...
Try a soup or stew. This is a great time of year to throw things in the crock pot in the morning and come home to the smell of dinner already ready!  
If it's meat he doesn't like (most don't at this age) use other forms of protein and iron (eggs, nuts, legumes, etc). Dairy helps with the protein, but has no iron, so don't only use cheese - a common food they love! You can also try meat hidden in casseroles or in fun forms, but remember there are entire countries of people who don't eat meat. Just make sure your kids are getting the nutrition they need.
Play with the food: make the food fun to eat by arranging into shapes. Use a cookie cutter for fun shapes. Arrange food into a face on the plate. There are many ideas of this online! 
Let kids help prepare the meals in an age/ability safe way, starting with washing vegetables, or arranging them on a plate. Start a garden next season so kids can see the food grow! 
A tip from my mother-in-law: kids will eat anything on a stick or fun appetizer sized! Make roll ups with a tortilla, cream cheese, lunch meats, spinach, or whatever sandwich fillings you use and cut into circles. Put a toothpick in small pieces of fruit or jazzed up meatballs (or load up fruit or vegetables on a skewer for a fun kabob).  

Read books that involve foods. I have put some ideas on my Pinterest Books page. Two of my favorites: "I Will Never Not Ever Eat a Tomato" by Lauren Child and "Green Eggs and Ham" by Dr Seuss. Use the books to stimulate ideas-- like making green eggs!

Above all, try to keep meal time pleasant. It should be a time the family gathers to talk, laugh, and enjoy one another. If the focus is a fight about eating, it is not serving one of the big benefits of eating together.  Work the nutrition in, but keep the meal itself fun!

Post suggestions of what has worked for your family. I always love to hear new tricks!  And if your child is really restricted in foods, talk with your doctor.  Sometimes it's more than just picky!

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:

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.


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.


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. 


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.


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.

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Sunday, September 30, 2012

Breastfeeding: Easier for Working Moms with New Insurance Rules

New moms often wonder if frozen breast milk will be as healthy as directly from the breast and if it's worth it to take time to pump at work. YES it is worth it!

Breastfeeding has been shown to keep babies healthy. So much so that many companies have started encouraging breastfeeding with pumping rooms and extra free time during the work day because they know it will decrease the unscheduled time off of parents home with sick kids. Unfortunately breastfeeding rates at 6 months (~60%)  and a year drop (~34%) considerably from those breastfeeding immediately after birth (~82%). As of August 1, 2012, breast pump supplies should be covered by insurance, which might make the $200+ price tag of a pump more appealing. Check with your insurance company for coverage. 

Moms often ask when they can start pumping and when it is too soon. If baby isn't latching well in the days after birth, you can start immediately. Pumping can help bring in milk more quickly, especially if baby isn't feeding effectively yet. If baby is feeding well and you want to wait until you need to start collecting a supply, then it is fine to wait. Babies should be introduced to a bottle by about 3-4 weeks of age. If you wait too long they often refuse it completely. If you don't have a milk collection yet, you can pump and give the fresh milk directly by bottle. Having another caregiver (Dad, Grandma, sitter) give the bottle often makes it more acceptable to baby. If mom's there they often want the "real thing".  

If you use frozen milk, you can defrost it in the refrigerator for up to 24 hours, then warm it in a cup of warm water. Never microwave or boil it. Not only can this make it too hot for baby, but it might also destroy some of the great properties of breast milk. For guidelines on milk storage, you can visit the La Leche League International Guidelines and

If you're struggling with breastfeeding, don't just give up! Work with your pediatrician and/or a lactation consultant. Help is available to make it possible for most mothers to breastfeed!

More help:

The La Leche League has compiled a list of FAQs and articles on breastfeeding for working mothers on their Working and Breastfeeding page.

If you need help working with supervisors to schedule a time a place to pump, the US Department of Health and Human Services, Health Resources and Services, and Maternal and Child Health Bureau has put together a very informative online guide which includes a sample letter to give to your supervisor.

Tuesday, September 18, 2012

New Guidelines for Treatment of Strep Throat

New guidelines for assessment and treatment of Strep throat were published in the Oxford Journals of Clinical Infectious Diseases this month.  They attempt to decrease the overuse of antibiotics to treat sore throats caused by a virus, since antibiotics are ineffective against viral illnesses. Streptococcus (AKA Strep) is a bacteria, and antibiotics do treat infections with Strep. (See Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America for the full report.)

While these guidelines are written for physicians and other medical providers, if patients understand the guidelines it can help them know what to do when they (or their children) have a sore throat.  Many parents presume Strep with every sore throat, but in reality only 20-30% of sore throats are bacterial in kids.  The large majority (70-80%) are from a virus and do not need an antibiotic. In adults the number of sore throats needing antibiotics is even lower - only 5-15%.  Nationwide, 70% of people who go to a medical provider with a sore throat get an antibiotic. This means many are treated unnecessarily.

Why do we treat Strep throat with antibiotics? In most cases Strep throat will be handled by the body's immune system over a relatively short time.  Without treatment most symptoms go away within a few days. Before antibiotics were available most people with Strep throat got better on their own. Unfortunately the Strep bacteria can affect the heart (rheumatic fever) or kidneys (streptococcal glomerulonephritis) or cause other problems if left untreated. Treating with antibiotics early can prevent some of these complications. Treating also decreases the time that a person with Strep throat is contagious, so helps stop the spread of illness to friends and family members.

Why do we want to avoid antibiotics if it is a virus? Antibiotics do not help the body get better or even feel better faster if a virus is causing the symptoms. They simply are ineffective against viruses. They do carry risks: diarrhea and allergic reactions are two relatively common issues. Overusing antibiotics leads to bacterial resistance, which means when someone is sick with a bacterial infection, several antibiotics might fail because the bacteria has become a "super bug" and less inappropriate use will cause fewer super bugs.

How can you know when to bring your kids in for evaluation? Strep throat and viral sore throats have a lot of common symptoms. Strep throat typically causes a sudden onset of one or more of the following: sore throat, fever, rash, headache, abdominal pain, nausea, vomiting, or swollen glands.  If there are "cold" symptoms such as runny nose, cough, hoarse voice, diarrhea, or eye discharge, it is more often from a viral upper respiratory tract infection, not a bacterial infection.  Children under 3 years of age are less likely to get Strep throat, but it is very common in school aged children.  The only way to know if it is Strep throat or not is to get a throat swab and test it.  A rapid antigen test is typically available in less than 10 minutes. If it is positive, treatment is indicated. If it is negative, a culture can be done to confirm Strep or no Strep.  This takes about 2 days. To prevent rheumatic fever, treatment should be started within 9 days of symptoms starting. Unfortunately treatment does not affect the kidney disease that rarely is a complication of Strep throat.  It is not an emergency to run in to the ER overnight for possible Strep throat, but do bring kids in if they have symptoms of Strep without viral symptoms. Also bring them in if their viral symptoms warrant evaluation in their own right (difficulty breathing, extreme pain, dehydration) or if you are unsure what is going on.

My summary of the guidelines:

1. Establish the diagnosis by swabbing the throat and doing a rapid antigen test and/or culture.  Do not treat "because it looks like Strep" because it usually isn't.
2. If the rapid antigen test is negative in children and adolescents, a back up culture is indicated. Adults do not need a back up culture unless Strep is highly suspected.
3. Blood titers are not recommended to check for current Strep throat infection because they reflect past infections. These are used to evaluate more chronic conditions.
4. Testing is not recommended if symptoms suggest a viral infection (cough, runny nose, hoarseness, oral ulcers). Falsely positive Strep tests can happen, and then an unnecessary antibiotic would be given with a virus infection.
5. Children less than 3 years of age do not routinely need to be tested for Strep because they are very low risk of complications of rheumatic fever, but the provider can test them if they have known exposure and symptoms of Strep.
6. Follow up throat cultures after treatment are not routinely recommended but can be considered in certain circumstances (if carrier status is suspected).
7. Testing or treatment of contacts of patients with Strep throat is not recommended if those contacts have no symptoms. (This means if Brother has a positive Strep test, there is no need to test or treat Sister if she has no symptoms. But... if she develops symptoms she should come in for a test.)
8. Patients with Strep throat should be treated with an appropriate antibiotic for an appropriate time. This is typically a penicillin (such as amoxicillin) for 10 days. For those with a penicillin allergy, cephalosporins or clindamycin or clarithromycin for 10 days is recommended. Azithromycin for 5 days at Strep dosing levels is acceptable for patients with allergies to other antibiotics.
9. Use of fever reducer/pain relievers, such as acetaminophen or ibuprofen, should be considered as needed. Aspirin should be avoided in children. Steroids are not recommended.
10. Patients with recurrent Strep throat at close intervals should be evaluated for chronic Strep throat carrier status with repeated viral infections.
11. Strep carriers do not require antibiotics because they are unlikely to spread Strep to close contacts and are not at risk of developing complications of Strep (rheumatic fever).
12. Tonsillectomy is not recommended to reduce the frequency of Strep throat.

Saturday, September 15, 2012

It's All In Your Perspective: Read Critically

As a mother of two middle schoolers, I know that school attempts to teach kids to read critically, but I don't think the population as a whole really catches on.

Headlines amaze me. I know they are trying to sell a newspaper or become the # 1 rated program on tv, but they spin stories so much it is sad. More than sad. They take advantage of our gullibility. They enrage people or get them riled up and then people share misinformation. This has happened time and again with many health issues. Just watch Oprah or Dr Oz. (For those who trust Dr Oz, see the bottom for links expressing my concerns.)

Recently some parents (more than one family, don't think I am singling anyone out here) have read a recent headline and want to stop a lifesaving drug for their children. No joke. They worry more about the drug that their child is thriving on because of one headline.

Asthma drug may stunt growth permanently is the title of a NBC News story.  Makes you think the poor asthmatic kids will never be able to perform in life because they are too short. Personally I would rather my child breathe comfortably while running, playing, and living regardless of how tall he/she will be, but really you need to look more closely than the title. (And many people only read headlines, so wouldn't read that the total difference was 1 cm = 1/2 inch. Not 1/2 foot or anything that really is significant in my humble opinion. Few jobs will require another 1/2 inch of height.)

Medscape is an online medical journal I follow. The title of their story about the same research: Pediatric Corticosteroids Have Minimal Effect on Adult Height.  If you are a headline reader, you will have a much different opinion about this life-saving asthma prevention medicine.

No wonder sometimes parents worry so much about things that we as physicians seem to "ignore" or not understand your concerns. We aren't concerned based on the way we have interpreted the research. Hopefully we can explain why we are not concerned, but often times emotions scream louder than statistical analysis information. I have blogged on this before in Decisions Parents Make: Use all the facts.

Please read information critically on your own. Think over what you read. Get additional information from other sources if it is a big issue to you. Think some more. Then make a decision you can stand firm in and not regret. Please.

For more:
Science-Based Medicine's blog: For shame, Dr. Oz, for promoting Joseph Mercola on your show! and Dr. Oz promotes quackery... again

Tuesday, August 21, 2012

Ear Wax: Both Good and Bad

Ear Wax Removal NOT Recommended
We make ear wax, also known as cerumen. Many people are annoyed by wax buildup, but it has a purpose! Wax grabs all the dust, dirt, and other debris that gets into our ears. It also moisturizes the ear canal ~ without it our ears become itchy. It even has special properties that prevent infection. That's all good stuff, so don't be too frustrated with a little wax!

Most often the wax moves from the inner part of the ear canal to the outer edge of the canal on its own.  It is amazing to me how our bodies are put together so perfectly: it is designed so the wax is made deep in the canal, then skin cells and wax migrate to the outer edge of the canal, taking with them debris! Some people naturally make dry wax, others make wet wax. This can be due to genetics and other factors. The important thing to remember with this is how your wax tends to build up and how to best keep it from building up.

If wax builds up it can cause pain, itching, ringing in the ear, dizziness, decreased hearing, and infection.  Inappropriate cleaning with hard and/or sharp objects (such as an cotton swabs or paperclips) can increase the risk of infection or even perforation of the ear drum.  Even special cotton swabs made "safe for ears" can push wax deeper and cause a solid collection of wax plugging up the canal.

How can parents help babies and kids keep their ears clean?

Routine bathing with clean warm water allowed to run into the ear followed by a gentle wiping with a cloth is all that is needed most of the time. 
Ear drops made for wax removal with carbamide peroxide can be put in the ear as long as there is no hole in the ear drum or tubes.  The oily peroxide acts to grab the wax and bubble it up. Then rinse with clean warm water and a soft cloth (see syringe tips below). If there is excessive buildup, daily use of drops for 3-5 days followed by weekly use of the drops to prevent more buildup is recommended. (For particularly stubborn wax, using drops 2-3 times/day for 3-5 days initially can help.)
Make your own solution of 1:1 warm water:vinegar and gently irrigate the ear with a bulb syringe.  
Mineral oil or glycerin drops can be put in the ear. Let a few drops soak for a few minutes and then rinse with warm water and a soft cloth. 
Occasional use of a syringe to gently irrigate the ear can help. Using the bulb syringe:

  • First, be sure it is clean! Fungi and bacteria can grow within the bulb ~ you don't want to irrigate the ear with those!  While they can be boiled, they are also relatively inexpensive and easily available, so frequent replacement is not a bad idea.
  • Use only warm water /fluids in the ear (about body temperature or just above body temperature is good). Cold fluids will make the person dizzy and possibly nauseous! If using drops first, put the bottle in warm water or rub it between your hands a few minutes (as if rubbing hands together to warm them, but with the bottle between the hands). Don't overheat the fluid and risk burning the canal!
  • Have the child stand in the tub or shower.
  • Pull up and back gently on the outer ear to straighten out the canal.
  • Aim the tip slightly up and back so the water will run along the roof of the canal and back along the floor. Do NOT aim straight back or the water will hit the eardrum directly and can impact hearing. 
  • Don't push the water too fast ~ a slow gentle irrigation will be better tolerated. If they complain, recheck the angle and push slower. If complaining continues, bring them to the office to let us do it to be sure there isn't more to the story.
  • Refill the syringe and repeat as needed until the wax is removed. 
  • Use a soft cloth to grab any wax you can see and dry the ear when done. Some people like to use a hair dryer set on low to dry the canal. Just be sure to not burn the skin! 

If wax continues to be a problem, we can remove it in the office with one of two methods:
After inspecting the ear canal carefully with an otoscope (or as I call it with the kids: my magic flashlight), we can use a curette (looks like a spoon or a loop depending on provider's preference and wax type) to go behind the wax and pull it out.  This is often the fastest method in the office, but is not always possible if the wax is too flaky or impacted into the canal leaving no room for the curette to pass behind the wax.  It should only be done by trained professionals... don't attempt this at home!
If the wax is plugging up too much of the canal, the canal is very tender, or if the wax is particularly flaky and breaks on contact with the loop, we will let the ear soak in a peroxide solution then irrigate with warm water. This process takes longer but is better tolerated by many kids and they think it is fun to "shower their ear".  We often must follow this with the curette to get the softened wax completely out. 
My biggest tips:
Not Safe!

  • Never use cotton tipped swabs, pipe cleaners, pencils, fingernails, or anything else that is solid to clean the ear! (Note: I still don't recommend them if the package says "safe" ~ they aren't!)
  • Don't put liquid in the ear canal if there is a hole in the ear drum (tubes are included in this). Pus draining from the ear is a sign that there might be a hole.
  • Ear candles are not a safe solution. Burns are too big of a risk!
  • The ear canal is very sensitive, especially if wax buildup has been there a while and has caused an infection of the skin in the canal.  Anything put into the ear can increase any pre-existing pain. 
  • If the skin is friable from prolonged wax and/or infection there is often bleeding with cleaning. If you notice this at home, your child should have the ears evaluated in our office. We will look for holes in the ear drum, scratches on the skin in the canal, and signs of infection needing antibiotic.
  • Some people who suffer from itchy ears can help themselves by NOT cleaning their ears so much!
  • Earwax usually can be left alone. Only try to clean it out if there are signs of problems with it (ear pain, ringing in the ears, decreased hearing, etc). If kids don't tolerate removal with the methods above, bring them in for us to take a good look. There might be more to the story that needs to be addressed. 
  • If there is significant ear pain, pus or bleeding from the ear, or an object in the ear, bring your child in to the office to have us assess and treat.


In January of 2017, the American Academy of Otolaryngology-Head and Neck Surgery Foundation issued updated AAP-endorsed guidelines regarding wax buildup. Check out this list of Do's and Don'ts from the guidelines.