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Appendicits (PedsPathforParents)

20 Feb

What is the appendix?

The appendix is a little tube that hangs off part of the intestine.  It doesn’t appear that it is good for anything except making surgeons money by getting infected and needing to be taken out.

Screen Shot 2013-02-18 at 11.12.29 PM

What is appendicitis?

As with anything, -itis means infection or inflammation.  So, appendicitis, is infection in the appendix.

Appendicitis can happen at any age but is most likely to happen in older children and teenagers.  It is the most common cause of emergency abdominal surgery in children.

How does appendicitis happen?

  1. Most commonly, appendicitis start because the opening gets blocked (poop, food particles or an enlarged lymph node can do this).
  2. Because of the blockage, bacteria go crazy in the tube causing the infection.
  3. The infection can thin the walls of the appendix and make it more likely to pop.

What are the symptoms of appendicitis?

  • Belly Pain-the pain usually start under the belly button and move down to the lower right side
  • Vomiting
  • Fever
  • No Appetite-a child who feels like anything probably doesn’t have appendicits

How do you diagnose appendicitis?

Appendicitis can usually be diagnosed by the story and the exam but often we do CT scans and ultrasounds to confirm the diagnosis.

How do you treat appendicitis?

Appendicitis is treated by surgeons by removing the appendix.  This can often be done with a scope to decrease the amount of scarring and to get your child back on their feet quickly.  If the appendicitis is simple, the surgery is to simply remove the appendix.  Sometimes, the the appendix will have ruptures and require more surgery to remove the infected fluid from the belly.

RSV-What’s in a name? (PedPathforParents)

6 Feb

Do you think it’s RSV?  This time of year, I hear this question often in my office.

My answer might surprise you: “I don’t care.”

Let me explain why.

RSV is a virus.  It’s short for respiratory syncytial virus (but you don’t and shouldn’t care).  It causes a disease in young children (especially those less than 2 years) called bronchiolitis.

Bronchiolitis is a disease of the lower respiratory tract which causes children to wheeze.  They are wheezy because their small airways have swelling and junk (mucous and cells from the lining of the airway) in them.

The smaller airways are similar to the area where a child with asthma has issues (which is why they wheeze).  The difference is that children with asthma have a squeezing down of the walls of the airway (which is what a breathing treatment reverses).  This is why breathing treatments in children with bronchiolitis usually don’t work.

Bronchiolitis is not just caused by RSV.  There is a long list of viruses that can cause the same symptoms:

  • RSV
  • Rhinovirus (usually a cause of the common cold)
  • Parainfluenza
  • Human metapneumovirus
  • Influenza (Flu)
  • Coronavirus
  • Human bocavirus
  • Human polyomavirus

I’ve decided that people are more scared of something they can put a specific name on…let me explain with 2 hypothetical scenarios…

#1-I have a baby in front of me that I have admitted to the hospital is breathing incredibly hard, can’t eat, is puking up mucous and looks really sick.  I come in the next morning to talk with the family with some new test results, “Well, the RSV and flu tests are negative.”  Mom says, “Thank God it’s not RSV.”

#2-I have a baby in my office who is smiling and playful, is eating great with lots of wet diapers, and has mild nasal congestion but no difficulty breathing.  Mom says, “I want you to admit me to the hospital because my baby tested positive for RSV at the walk-in this morning.”

The point is, your baby can be sick with RSV and they can be fine with RSV.  They can be very sick with any of the other causes of bronchiolitis despite testing negative for RSV.

What are the symptoms of bronchiolitls?

Typically the child starts with runny nose and cough.  This will progressively worsen over a few days and possibly develop into difficulty breathing and difficulty with eating.  The symptoms typically last a total of about 5-7 days with the worst day being the day in the middle.  It is not uncommon for the cough and runny nose from bronchiolitis to last 2-3 weeks

How do we treat bronchiolitis?

In most children, treatment is done at home and consists of sucking snot (click here for more advice on this) and counting wet diapers.  This isn’t very fancy but, unfortunately, until someone invents TamiRSV we don’t have anything more specific.  As far as wet diapers go…I am looking for a wet diaper about every 6 hours.

Who goes to the hospital?

Getting admitted for bronchiolitis is usually based on 2 things: dehydration, severe difficulty breathing or low oxygen levels.

A child who can’t eat because they are breathing fast and is puking because of all the mucous that is draining into their belly is at risk for dehydration.  Unfortunately, the only way to fix this is to put them in the hospital for IVF until they are able to drink better.

A child who is having severe difficulty breathing also needs to be observed in the hospital.  Unfortunately, babies with severe bronchiolitis can get tired from all the heavy breathing they are doing and this can progress to needing ICU care.  It is best to have those babies who are breathing that hard in the hospital so that they can be monitored closely by people who know what they are looking for…

Babies with bronchiolitis often need extra help keeping their oxygen level up by getting extra oxygen.  We monitor these babies closely and I put them on oxygen for severe difficulty breathing or if their oxygen level is less than 90%.

Summary

  1. Bronchiolitis stinks, it makes kids sick and I don’t have much to offer.
  2. Whether it’s RSV or not often doesn’t matter.
  3. Watch for difficulty breathing and decreased wet diapers.

Sorry, It’s “Just” a Virus (PedPathForParents)-Why Doesn’t My Child Need an Antibiotic?

2 Feb
Wait! They may not need it after all!

Wait! They may not need it after all!

Have you ever wondered why you don’t need antibiotics for a viral infection?

Would it hurt anything if your doctor went ahead and prescribed one anyway, “just in case”?

What is a virus?

Viruses are small organisms that (unlike bacteria) cannot live on their own.  They can only live inside the cells of another organism (plant or animal).

How does my child get a virus?

Viruses can be spread by many different routes…

  • Blood sucking insects (mosquitoes-West Nile Virus)
  • Coughing or sneezing (flu, colds)
  • Fecal-oral transmission (eating poop, hopefully indirectly…see post on stomach viruses)

Why doesn’t my child need an antibiotic when they have a virus?

The main reason…they don’t work.

Antibiotics are designed and discovered because they work on specific parts of bacteria.  They are usually made to work on the cell wall or membrane that surrounds the bacteria.  They can also work to block a bacteria’s ability to make proteins or DNA.

Because viruses do not live on their own, they have very different coverings and because they rely on the cell to reproduce themselves, the ways in which antibiotics work do not affect viruses.

So, the next time you bring your child to me and wonder why I don’t give you an antibiotic, it’s because I don’t think it will work.  Sometimes, I feel like I get this look that a family thinks I’m withholding the magic bullet from them that would suddenly make their child better.  Believe me, I’m not.  I hate to see your child suffering almost as much as my own and I have no desire or incentive to prolong that in any way.

Why don’t we start an antibiotic, just in case?  What could happen?

Allergic reactions can be simple, like simple rashes, but they can progress to difficulty breathing and even death.  Severe allergic reactions like this are very rare but if there is any risk and the treatment does not benefit your child, why take the risk?

Diarrhea with antibiotics can be simple with watery, more frequent stools.  Or, it can be worse with another type of infection called c. dificile that leads to profuse “foul-smelling,” bloody or mucousy stools that requires another type of antibiotic to treat that infection.  Ask anyone who’s experienced it in the past, I’m sure they’ll tell you, “No thanks.”

Another problem with overuse of antibiotics is antibiotic resistance.  This is a problem for the community as a whole.  We have begun to see more and more “super-bugs” that are difficult to treat because they have been exposed to antibiotics and have developed ways to fight off the attacks of antibiotics.

Antibiotic resistance is not just a problem for the community, it is also a problem for your child.  In a child with recurrent ear infections or sinus infections, I do not like to repeat antibiotics that have been used within a month.  As we increase in strength on the antibiotic pathway, we increase the risk of side effects.  So, using antibiotics when they are not necessary only adds more to this problem.

Summary

  • Viruses are different from bacteria.
  • Because they are different, antibiotics do not work on viruses.
  • Overuse of antibiotics increases risk of side effects and antibiotic resistance.

Stomach Bugs-Why all the Poop? (PedPathForParents)

28 Jan

“His poop is so nasty and there’s so much.  I brought a diaper to show you.”

“Umm, no thanks, I’ll take your word for it; you can just throw it away, but not in my trash can.”

So, why is that poop so nasty?  Why do the kids throw up first?  Why does the poop last so long and when do I need to come in?

The most common symptoms of stomach bugs are…

  1. diarrhea (most books say normal or “foul-smelling”)
  2. vomiting
  3. fever
  4. anorexia (don’t want to eat)
  5. headache
  6. abdominal cramps
  7. myalgia (sore muscles)

In other words…your child feels like crap (pun intended).

My child just had this last month…Why do they keep getting this?

Among children under 5 years, children have somewhere between 1-5 episodes per year.  So recurrent episodes are the norm and not the exception.

How does my child get a stomach bug?

It starts when they eat poop…. In fancy terms it’s called fecal-oral transmission.  It goes like this: some dirty/nasty kid touches their own poop, then they touch something else in the room, then your child touches it and puts their hands in their mouth.  Before you get too upset at the dirty/nasty kid, remember that your kid gets to be that kid next….

Why so much diarrhea?  Why does it last so long?

Image

This picture is a picture of the fingers that sit in the small intestine, ready to absorb food from your stomach.  The problem with stomach bugs is that the virus comes in and jacks up these things and causes them to push fluid into the intestine instead of absorbing fluids out…and this is why you find water in the diaper (…and on the floor, in the bed and everywhere else).

The good news is that this part just lasts a little while. The bad news is that on the 2nd-5th day after infection, these little fingers fuse together and make matters even worse.  It’s not until everything starts to heal on days 6-10 that you begin to see final improvement in the diarrhea (My apologies to those of you who found this post on day 2…).

How do I know this is something different or more than a stomach bug?

Here are some things to watch for that suggest things might be something other than a stomach bug and probably require a trip in to see me:

  1. Vomiting more than 24-48 hours (sooner if signs of dehydration-dry mouth, no tears, no urine)
  2. Diarrhea more than 1 week
  3. Blood or mucous in the stool

What do I do to help my child?

Keep your child hydrated. Use whatever fluids necessary at first and as vomiting improves move away from pedialyte/gatorade; the sugar will actually prolong the diarrhea.

I do not recommend treatment with anti-diarrheal medications.  They do not have studies in kids showing that they work. Additionally, they have been shown to prolong some types of diarrhea.

So, good luck with getting your child through his stomach bug. The most important take home point-Don’t bring me a diaper to see.

Ear Infection? But I Clean His Ears Every Day (PedPathForParents)

19 Jan

The dreaded ear infection…it’s the black box of going to the doctor.

I think my baby is pulling at their ears, I go in and there’s nothing there.

I go in for a check-up with seemingly nothing wrong, and my baby has an ear infection.  What the heck?

How Common Are Ear Infections?

They are the most common reason for visits to the pediatrician’s office and the most common reason antibiotics are prescribed.

Around 70% of children have at least one episode of AOM by one year of age, and 80 to 90% by two to three years.

So, What Causes Ear Infections?  

Is it having them out in the wind?  Is it getting water in their ears when they take a shower?  Is it not cleaning out their ears properly?

No, No and Don’t stick anything in your ear smaller than your elbow.

One way to look at the cause of infections is to look at risk factors:

  • Age (6-18 months)
  • Family history (likely due to changes in anatomy, but just because you had tubes doesn’t mean your child will need them)
  • Day care
  • Smokers in the house

Here’s the story of how an ear infection develops:

Screen Shot 2013-01-18 at 10.45.25 PM

Here’s the way I describe the process to my families…

  1. The inner ear constantly drain fluid into the throat through a little tube that drains down (see Eustachian tube above)
  2. Viral infections or allergies cause swelling and drainage that block the bottom of the tube.
  3. Due to swelling and drainage, the fluid cannot escape.
  4. Fluid builds up behind the ear drum which is a nice warm bubble bath for bacteria-very romantic.
  5. Bacteria get into this fluid and start reproducing.
  6. Surprise…Ear Infection.

The pressure caused by the buildup of fluid on the ear drum is what causes pain from the infection.

Young children are more likely to get infections because their Eustachian tubes are more flat and not angled down as much as adults.

 Screen Shot 2013-01-18 at 10.43.49 PM

There are multiple bacteria and viruses that can cause ear infections.  Some of these infections will resolve on their own, some will require antibiotics.

So, What Does All This Mean?

There’s not much you can do to prevent infections…ear muffs, ear plugs, q-tips and ear candling are not the solution to preventing ear infections.  I asked Dr Tidmore (ENT) about ear candling once and I loved his response, “I generally don’t recommend people putting things that are on fire in their ear.”  Plus, ear wax is made for a reason and aside from me needing to see the ear drum to see if there is an infection, the wax should just stay where it is.

One of the most common stories I see is a child who has an upper respiratory virus with runny nose, cough and/or fever that last a couple of days and seems to be getting better then develops a second wave of illness with fever, fussiness, runny nose and cough which is the ear infection.

The problem with this is that if the parent brought the child during the first few days, then they are hesitant to come back in because, “Nothing was wrong last time.”  This is one of the reasons why we often ask our families to wait a day or two with runny nose, cough and congestion who continues to eat and drink well because the majority of those illnesses are viral infections.

Hopefully, this post sheds some light on a subject that many are confused about.

Any questions?  What wives tales have you heard about what might cause ear infections?

Eczema-Just a Fancy Word for Dry Skin? (PedPathForParents)

8 Jan

Screen Shot 2013-01-07 at 10.57.50 PMA first post in a series I am starting called Pediatric Pathology for Parents…This is will be a series of posts about common childhood illness and basic descriptions of their underlying causes.

Eczema is also know is atopic dermatitis (atopy means allergy and dermatitis means skin inflammation).

Symptoms:

  • Dry skin
  • Itching (some people call eczema the itch that rashes)
  • Red and crusty lesions on cheeks and outside of elbows/knees (infants)
  • Thick scales on the insides of the elbows/knees (children)

Statistics:

  • 10% of children in the United States have eczema
  • 60% of people with eczema have symptoms before age 1
  • 85% have symptoms by age 4
  • 60% carry some symptoms into adulthood

Pathology:

There are basically 3 main categories when talking about the causes of eczema: skin barrier, allergy and genes.

Skin barrier-The skin is the primary barrier for your body from infection and things out there in the community which you could be allergic to.  One of the key factors for keeping the skin barrier together is keeping it well hydrated (moist).  Some people lose more moisture through their skin and cannot keep their skin as protected than others and this puts them at more risk for eczema.  Trauma to the skin by recurrent scratching also causes it to lose more water and have more risk of eczema (this is another reason why it is the itch that rashes).  This is why applying lotion to eczema actually makes the problem worse because the alcohol in the lotion leaves the skin drier than before.  I recommend putting Vaseline or Aquaphor on so thick that you can see it at each diaper change (as many times a day as you can think about it)

Allergy-Some people have a higher risk of developing allergies to substances that have passed through the skin barrier.  There are cells just under the skin that love to find new substances and cause a reaction.  This reaction leads to redness on the skin surface that you see with eczema.  Applying a steroid cream (over-the-counter hydrocortisone or stronger prescription strength steroids) twice a day will decrease your body’s response to these substances and break the cycle.  Do no apply the steroid for more than 10-14 days at a time or the skin will begin to thin and make the problem worse.

Genetics-Most people believe that eczema does have a genetic basis.  We do not know for sure which   genes are involved but there are several possibilities and research continues to determine which is the most likely one.  Sorry, I don’t have any suggestions to change your family or origin (even though you might want to for this or many other reasons).

Any follow up questions about eczema or what causes it?  If I don’t know the answer I will look it up for you.

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