Earring Alert

     If your daughter or son has a pierced ear, Turn the ear over and look at the back of the earlobe. It is common for children and adolescents who wear earrings to keep wearing the same earring for days at a time. In addition, they often continue to play with the earring by squeezing on it. The result of these two habits is that the back of the earring gets imbedded more and more deeply into the back of the earlobe. When you look at the earring back, you may only see a portion of it with the rest being imbedded in the earlobe. With one patient, I could not see the earring back at all – it was entirely imbedded in the lobe and it had to be removed surgically. If you see this is happening, remove the earring, clean the lobe with alcohol and give the ear lobe at least a day's rest with no earring. If it looks infected, see your caregiver.

     The way to prevent this is simple. The “earring rule” should be that anyone with an earring takes it out at night and leaves it out through the night. They should clean the post and the back with alcohol and wear a different earring the next day. It is fine to alternate between two different earrings – just don’t wear the same earring two days in a row.

Peanut Allergy

     In previous articles I have discussed food allergy in general, but of all food allergies in children, peanut allergy is one of the potentially most dangerous. Both peanut allergy and bee-sting allergy can be rapidly fatal and any child who is suspected of having either peanut or bee-sting allergy should be seen by an allergist – not just a pediatrician.

     About 1% of children under age 5 have a true peanut allergy. It was once thought that allergy to peanuts was a life-long allergy, but there have now been reports of some children who have “grown out of” peanut allergy. But, because it is so dangerous, only a qualified allergist should decide whether peanut consumption is safe for a child previously diagnosed as having peanut allergy.

    The serious reaction to peanuts involves hives, coughing, vomiting, change in voice, difficulty breathing and, finally, unconsciousness, shock and death. This is called anaphylaxis. It usually occurs immediately after peanut contact but can occur up to 2 hours after contact. In about 20% of cases of anaphylaxis, there is another reaction that occurs from 1 to 4 hours after the first – even if the first was treated. A child could be brought to the emergency room, treated and released only to die later at home. Even if a child had a mild reaction at his first contact with peanuts, later reactions can be more severe. A child with both a history of asthma and peanut allergy is at a greater risk for having a fatal reaction with peanut ingestion. Teenagers also have a greater risk for severe reaction than younger children.

     When a child has peanut allergy, the only way to avoid a reaction is to avoid peanuts. The child needs to be taught to only eat foods from home and never to share foods or eat anything else – especially “treat” foods someone has brought in for a special day. Labels need to be read carefully and the parents and the child need to be extra careful in restaurants where the waitress (even the cook) may not be aware of a peanut-product ingredient or peanut contamination from a work area. Most cases of peanut anaphylaxis come from ingestion of peanuts, but there are cases of reaction from contact with eating surfaces exposed to peanuts and there are also very rare cases of a reaction from inhaling peanut protein.

     Most cases of death from peanut allergy are a result of epinephrine not being given in time. Epinephrine is an injected medication and parents and children need to get over their initial fear of the injection. This takes practice along with a carefully written plan for schools and other caregivers stressing the importance of giving immediate epinephrine at the first sign of a reaction. Your allergist can supply an ”Action Plan” which outlines exactly what to do if an allergic child is exposed to peanut. The dose of epinephrine should be repeated if the child doesn’t rapidly improve after the first shot and 911 should be called immediately when epinephrine is given. There is no danger to giving an epinephrine injection. Waiting to give the injection can be fatal.

More On Potty Training

          A recent article in a pediatric journal caused me to want to expand my comments on potty training. Please refer back to my previous article.

      The first concern for parents is: “When should I start potty training?” Training is education and parents are the child’s primary teachers. You start teaching your child from the minute he is born. You start potty training as soon as the toddler starts using the words and connecting them to the action. You talk to him when you are changing his diaper: “You pooped”; “Mommies and Daddies poop in the toilet”. It is uncomfortable to sit around in your own stool and urine - if it was more convenient than toilets, we’d all wear diapers. The child is going to realize that fact someday and would start using toilets even if you never said a word to him about potties. You are simply helping him learn to use toilets a little sooner than Senior Prom. But, as I’ve said about breast-feeding and so many other parenting matters, don’t create a success/fail situation for yourself. Let it happen naturally. Most children learn to control their bladder and bowel by 3 years of age.

     Don’t push and pressure a child about potty training. Don’t force him to sit on the toilet if he is reluctant or afraid. He will watch you sitting on the toilet and naturally want to copy you. Let him. Pants on or pants off doesn’t matter. Don’t feel you have to offer rewards – toys, stickers, etc. The reward he wants most is your praise and you can give that freely.

     Problems with potty training begin when the child associates negative things with the process – when it involves fights, pressure or crying. However, the most common cause of problems is constipation because it introduces the element of pain. Constipation can develop for many reasons – a toddler could simply have a hard stool and then associate the sensation of stooling with pain and start to withhold. When he feels his bowels moving and the need to poop, he goes off into a corner, tightens his buttocks and legs and forces the stool back up. This causes the stool to become larger and harder and gives him even more pain when it eventually comes out which makes him even more afraid and continues the cycle.

     If a child has large, hard painful stools, stools that clog the toilet, recurrent abdominal cramps (especially after meals), streaks of stool in his pants or explosive bouts of squirting diarrhea, he probably has constipation. (see my previous articles on constipation and abdominal pain). Your caregiver should evaluate him and, if the problem is constipation, the cure is to get him on a laxative that makes his stools soft and keep him on it until he forgets that he ever had a problem with stooling. You forget about potty training until the constipation problem is totally resolved but don’t forget that problems with both constipation and potty training come and go. Relax. Soon you’ll have to figure out how to pay for college and that is a much bigger problem.

Sore Throat

     Sore throat is a common complaint in childhood and strep throat is one of the most commonly treated infections.  The “Grandma Fact” that is often repeated is that when you see white areas or “spots” on the tonsils, it is usually strep.  This isn’t true. Strep infection often causes bright red spots on the back of the throat and the roof of the mouth. When there is a lot of white material on the tonsils, the cause is usually mononucleosis, especially when the lymph nodes in the neck are enlarged and the fever lasts longer than 3 days..

     Sore throat that comes along with typical cold symptoms is usually viral and will resolve when the runny nose and cough resolves.

      However, a sore throat can be caused by a more serious bacterial infection. If a sore throat or strep throat has been treated with antibiotics, the fever and the pain should improve within 48 hours. If the fever and pain do not resolve or if they come and go, the infection may be more serious. If there is swelling on one side of the back of the throat but not on the other, especially if it moves the uvula (the “hangy-down thing” in the back of the throat) over to one side, the infection is worrisome. If, along with the pain in the back of the throat, there is pain in the neck or swelling in the neck, the child needs to be examined. This is also true if the outside of the neck is tender to the touch. Sore throat with pain on one side that goes up into the head or down to the shoulder can also mean a serious infection. Finally, a child having trouble swallowing, talking or breathing needs to be seen by his caregiver.

Meningitis: Viral, Bacterial and Fungal

     There is confusion about the different forms of meningitis. Any time “itis “ is added onto the end of a medical word, it indicates infection or inflammation. If your appendix is inflamed, you have “appendicitis”. If your tonsils are infected, you have “tonsillitis”. The meninges are layers of tissue that cover and hold in the fluid that surrounds the brain and spinal cord. Meningitis is an infection of these coverings. 

     The three most common organisms that cause infection in human beings are viruses, bacteria and funguses. Viruses are very small and cause infections like colds, chicken pox and influenza. There are only a small number of antiviral drugs that can treat these infections. Bacteria are larger and cause staph skin infections and strep throat and other infections that are treated with antibiotics. Funguses are larger still and cause yeast and fungal skin infections such as athlete’s foot. These are treated with antifungal drugs. Any of these three organisms can cause meningitis, but they do it in different ways.

     Viral infections of the brain and surrounding tissues are often referred to as encephalitis because they can affect the entire brain (“encephalo” refers to the brain). These viral infections can be mild or severe and are caused by viruses such as West Nile virus and equine encephalitis virus. They are injected into humans by mosquito bites.  Meningitis caused by bacteria is usually severe and often very contagious from one human being to another. There are vaccines available for some kinds of bacterial meningitis such as meningococcal meningitis. This was a common form of meningitis in college students living in dorms and recruits attending boot camp. Meningococcal meningitis is so contagious that even close contacts of the patient need to be treated with antibiotics.

      Fungal meningitis is very rare and usually only occurs in patients whose immune system is suppressed. The fungal meningitis infections that have occurred recently in this country were caused when a fungus contaminated a solution of steroids that were injected into the fluid around the spinal cord to control pain from other conditions. The fungus then grew and infected the coverings of the cord. This type of meningitis is not contagious from one human to another, but, as with all fungal infections, it can be very difficult to treat.

What Expectant Mothers Should Know Before Going To The Hospital

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Here are some basic things moms need to know before delivery:

1.     Allow feeding to begin naturally

     Nature knows that both the mother and the baby will be exhausted in the first days of the baby’s life. Healthy, term newborns have extra fluid and nutrition at birth and are often not hungry in the first 24 hours. Too often, mothers are pushed to feed the infant in that first day of life – the mother is told to wake the infant up every three hours to “try to feed”. A sleeping infant is not a hungry infant and waking him up only results in the baby fighting and crying until he is allowed to go back to sleep. The mother ends up crying and feeling like a failure because “my baby won’t latch on”. What both the mother and the baby need in the first day is rest. “Trying to feed” is not “feeding” – it is “trying”. If the infant latches on and sucks, wonderful, but if the infant fights, refuses to latch on or falls asleep, the mother needs to listen to her infant’s clues and stop trying. The baby is not going to starve. The mother will be forced to “try to feed” again in three hours and by that time the infant might be hungry and latch on and feed just fine. Gradually, over the first few days, the infant will become more alert, be more hungry and will feed more aggressively at regular intervals, but forcing feeding in the first day of life just creates problems for everyone.
Breast is best but formula is fine
     No one has to be reminded about the benefits of breast feeding, but for some mothers, it just doesn't work. Other mothers may find themselves with a hungry baby and a low breast milk supply and need to supplement with formula. Fatigue and stress are the quickest ways to shut down breast milk production and most new mothers have both. If your baby acts hungry after you've breast fed him, don't hesitate to give him formula until he acts satisfied. Don't worry about the myth of "nipple confusion". The baby's only confusion comes from wondering why mom isn't feeding him more when he is hungry.

2.     Never wake an infant after 10 pm

     If your baby is hungry, he will wake up and then you’re on duty to feed him.  But if a healthy, term infant is sleeping in the night, he is just fine and you should keep sleeping, too. As soon as you can, after getting home from the hospital, you need to move the infant out of your bedroom and into the nursery. Otherwise, you both keep waking each other up unnecessarily with tossing and turning.

3.     Don’t buy a lot of stuff

     Bottle warmers, sterilizers, and baby bathtubs make great shower gifts, but, in general, they just take up room and are worthless. The same goes for most “newborn” outfits that your infant will outgrow in about a day. Start with a good car seat, a solid crib (in another room) and 1 month to 2 month-sized clothes. Make sure you have gone over the car seat instructions fully and know how to install and remove it from your car before you need it.

4.     Know your insurance

     Know exactly what routine care will be covered, how long you will be allowed to stay and (God forbid) what is covered if you or your baby have a medical problem. If you are having a boy, be sure to find out what, if any, coverage there is for circumcision. It is impossible to find out this information on a weekend, so do it now.

5.     Talk with your doctor

     You and your doctor need to discuss what will happen on the delivery day. Talk about what will happen if you go past your due date or if your labor doesn’t progress. What are your views on induction, on spinal anesthetic and on C-Section? Have your doctor write out what you have decided on and sign it so you can have it with you if you are delivered by an on-call doctor.

6.     Check Bilirubin

     If your infant looks at all yellow in the hospital or at home, have the bilirubin checked. Don’t rely on someone’s opinion that “It looks O.K.” If the first test shows even mild elevation, have it checked again in a day or two to be sure it isn't rising. The test is easy, fast and safe and can prevent a serious neurologic problem.

7.     Plan for a 1 week vacation

     I knew mothers who planned to go to a family reunion or host a Christmas dinner in a few days after delivery. It always resulted in a disaster for everyone. Plan on a full week of doing nothing but resting, nesting and getting to know your baby after you get home from the hospital. If you had a C-Section, plan for a full 2 weeks of doing nothing.

8.     Take all advice with a grain of salt

     In the hospital, almost everyone who walks into your room will give you different advice. Doctors, nurses, and lactation consultants will frequently contradict each other. Even baby books aren’t consistent. Remember that everyone who tells you about babies is telling you about some other baby. Listen to all the different opinions but, most importantly, listen to your baby. Babies aren’t subtle and your baby will be very clear about what he likes and doesn’t like. That doesn’t mean you have to carry him all night just because he’ll cry if you don’t. It means that, as the parent, you get to decide what works for both of you, no matter what someone else says.