Friday, June 30, 2006

Undescended Testicle

Dear Lisa,

My son, almost 13 yrs old, just informed us that he has a testicle that is not descended, and does not know how long it has been that way. We got him right in to our doctor, and we have a consultation on a surgery this next month to move it down. However, at his age, how great is his risk of testicular cancer? And will they be able to tell during surgery if there is cancer present?

“Concerned Mom”

Dear “Concerned Mom”,

Cryptorchidism or undescended testicle is a condition where the testes fail to descend to the scrotal sac where they belong. Surgery is needed in order to prevent the consequences of undescended testes. An undescended testes is unable to produce mature sperm, which is thought to be due to the higher temperature in the abdominal cavity or inguinal canal. (1) Undescended testes are also associated with hernias and are a risk factor for Testicular Cancer. According to the American Cancer Society, about 14% of cases of testicular cancer occur in men with a history of undescended testes. The risk of testicular cancer is somewhat higher for men whose testicle stayed in the abdomen as opposed to one that has descended at least partway. (2)

Men from the age 15 to 35 years old are at risk for developing testicular cancer. This means that most testicular cancers occur between the ages of 15 to 35 and are less common in younger boys. Just because your son has a risk factor for testicular cancer doesn’t necessarily mean that he is going to get it. Actually most men with testicular cancer have no risk factors. (2) It is good that you discovered the undescended testicle and are taking steps to correct it. Your son would have been at more risk if the undescended testicle was left undiscovered and not corrected. Now that you know that your son has a risk factor for testicular cancer you and your son are at an advantage because you are aware of the need to look for signs and have him carefully monitored for the disease.

At puberty your son should be taught how to perform a monthly testicular self exam, looking and feeling for masses or changes in his scrotum and testes. He also should have a complete physical examination including a testicular exam by his doctor yearly. Usually the first sign of testicular cancer is a lump on the testicle. Nine out of ten men with testicular cancer find a lump on the testicle which is usually painless but may be uncomfortable. Other signs of testicular cancer include a fullness or ache in the scrotum, enlarged testicle, swelling in the groin area, lower back pain, or changes in the breast tissue such as pain, swelling or discharge. In some cases of testicular cancer there are no symptoms at all. The important thing to remember is that although most cancers develop in the undescended testicle, up to 25 % of cases develop in the normal or descended testicle. Therefore careful measures should be taken to assess both testicles, not just the undescended one.

In response to your question about cancer being found during surgery, unless your doctor mentioned that there was a concern, be assured that testicular cancer is not commonly seen in younger children. Additionally, in most cases of testicular cancer, one of the symptoms described above would have been noticed. If you have not discussed your concerns with your doctor it would be important to do so. The doctor who examined your child will be able to explain if there were any suspicious findings of your son’s physical examination. During a physical exam on a child with an undescended testicle , the doctor feels the testicles for any sign of swelling, tenderness, or lumps. The doctor also feels the child's belly for enlarged lymph nodes and would be able to reassure you if everything looks and feels normal. Generally speaking, if the surgeon sees suspicious tissue during an operation, a biopsy or sample is taken and sent to the lab for examination by a pathologist. The pathologist then examines the sample and determines if the cells are cancerous. You can ask your surgeon if he is suspicious of cancer and what his approach is.

Testicular Cancer is one of the most curable forms of cancer. According to the National Cancer Institute, the 5 year relative survival rate for all men with testicular cancer is over 96%. (2) The American Cancer Society is a great resource for information about testicular cancer as well as other types of cancer. For more detailed information about testicular cancer you can log on to .

(1)Vigneux, A., Hunsberger, M. (1994) Altered Genitourinary/Renal Function. In Nursing Care of Children. (2nd Ed., pp 1520-1521). Philadelphia: WB Saunders.
(2)Detailed Guide: Testicular Cancer. What are the risk factors for testicular cancer?American Cancer Society Website available at: Accessed June 2006.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Free Pediatric Advice Updated Daily

Thursday, June 29, 2006

Urinary Incontinence

Dear Lisa,

Nurse, for much of the past few years, my daughter, 20 has been wearing adult diapers for incontinence reasons. The problem has been resolved but she still insists on wearing diapers. Is there a psychological reason behind this? Should I seek professional help? Thank you.

Dear “Should I seek psychological help?”

Urinary Incontinence can be a very embarrassing situation for a child, especially if it persists into the teenage years. The stress of having to deal with the problem may have left your daughter emotionally dependent on the diapers, even though she does not need them anymore. My first concern would be that your daughter may still be having incontinence. She is a young adult now who is able to take care of herself, so it is possible that she still is having symptoms and may be too embarrassed to tell you. If your daughter in the past only had symptoms at night, I would be less suspicious that there is a physical problem. If your daughter had a problem with daytime incontinence as well as nighttime problems this may be indicative of a urologic problem or another medical condition. The good thing is that most children don’t have another problem and only less than 3 % of children with primary nocturnal enuresis (nighttime urinary incontinence) have urologic abnormalities.

You should talk to your daughter and explain to her that other conditions may lead to urinary incontinence and it is important for you to know if she is still having problems. If she is still having incontinenece, then certain medical conditions should be ruled out. Children with Attention Deficit Disorder and Sleep Apnea tend to be at risk for nighttime wetting. A child with Spina Bifida Occulta, which may present as a mole, dimple or hairy tuft on the lower back can lead to lack of sensation in the area leading to incontinence . (1) Other disorders of the spine including a tethered spinal cord or a mass can also lead to urinary incontinence. Constipation has also been associated with incontinence because a full rectum can restrict the bladder’s expansion and cause an automatic bladder contraction leading to incontinence.(1,2)

Some literature states that certain foods or additives have been implicated in contributing to urinary incontinence. These foods include caffeine, vitamin C, citrus juices, carbonated beverages, and sugar substitutes. (3) If you daughter is continuing to have incontinence it would be a good idea to keep a food diary to see if the episodes are related to the increased intake of items on this list. Medications may also be the culprit. Certain antidepressant medications and antihistamines may also cause wetting at night. (2)

If your daughter admits to continued symptoms an evaluation by a Urologist would be in order. If she already had a complete medical work up to rule out other causes for her urinary incontinence and she truly is no longer having symptoms then she will need help letting go of the diapers. Some children/young adults just need a little direction in regards to how to master this. Because she is a young woman it would be feasible to start by substituting a large sanitary napkin for the diaper. Each week purchase a brand that is smaller and thinner until she is using panty liners. This slow approach may be what she needs. If she is resistant to any change and insists on wearing adult diapers even though she doesn’t need them, then she may benefit from professional counseling by a trained Psychologist.

I wish you and your daughter well.

(1)Zacharycuk C. Psychosocial implications of nocturnal enuresis demand treatment. Infectious Diseases in Children.2006(Apr)72-73.
(2)Mercer, R. Dry at Night. Advance for Nurse Practitioners. 2003(Feb):26-30.
(3)Maizels M. Rosenblum D. Keating B. Getting to Dry: How to Help Your Child Overcome Bedwetting. Boston, Mass:the Harvard Common Press. 1999.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Website Updated Daily

Wednesday, June 28, 2006

Tongue Piercing

Dear Lisa,

My teenage daughter wants to get her tongue pierced. I want to give her information about the risks of tongue piercing since she’ll be 18 years old soon and plans to have this done.

“What are the risks of tongue piercing?”

Dear “What are the risks of tongue piercing?”

The risks of tongue piercing include severe swelling, difficulty breathing, infections of the mouth and throat, chipping of the teeth, damage of the dental enamel, difficulty chewing and talking, possibility of aspirating jewelry (dislodged jewelry can be breathed into the lungs), trauma to the gum, endocarditis (infection of the heart), hypersalivation (making too much saliva), and problems during medical emergency procedures .(1,2) In case of an emergency, healthcare providers may need to intubate a patient or put a tube in the airway to keep them breathing. Oral piercings may interfere with the procedure and make intubation more difficult.

It is a good idea to inform your daughter of the risks and potential complications of tongue piercing. Although she soon will be 18 years old and will no longer need your consent, she will still need to be informed of the possible side effects and potential complications so that she can make an informed decision. If she does decide to get her tongue pierced she should know that there can be a delay in healing time of oral piercings if she smokes. (3) If she has a cardiac valve defect or congenital heart disease, antibiotics will need to be taken before the procedure. Also, there is a risk of developing a bifid tongue, or a tongue that splits in half as the result of tongue piercing . (4) Until the site is healed avoidance of exposure to other person’s body fluids which may harbor bacteria is recommended.(5)

(1)Grassia T. Treatment of skin issues requires knowing the patient’s needs. Infectious Diseases in Children. 2006;(June):42.
(2)Friedel J, Stehlik J, Desai M, Granato J. Infective endocarditis after oral body piercing. Cardiol. Rev. 2003;11(5):252-255.
(3)Cartwright M. Body piercing: what nurse practitioners need to know. J. Am Aced Nurse Pract. 2000;12(5):171-174.
(4) Fleming, P, Flood, T. Bifid tongue a complication of tongue piercing. Dr Dent J 2005;
(5)Thiem L. Body Piercing, clinical considerations. Clinician Reviews.2005;15(1):30-34.

Lisa Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice for Teenagers

Tuesday, June 27, 2006

Fifth's Disease

Dear Lisa,

My son was diagnosed with Fifth’s disease. My doctor says I don’t have to worry about it, but the word disease sounds so serious. He has a rash on his body that was going away and now it is coming back again. I don’t think that they will allow him to go to camp. How long should the rash take to go away?

“What is Fifth’s disease?”

Dear “What is Fifth’s disease?”,

Fifth disease or Erythema infectiosum is typically a benign self limited illness that minimally affects children who have a normal immune system. It is called Fifth disease because it was the fifth disease named that looked like the Measles but wasn’t Measles. The symptoms of Fifth disease include a very short period of virus like symptoms which can include a sore throat, low fever, tiredness and headache. Usually these symptoms are so mild that they go unnoticed.

Following this, a child with Fifth disease will feel and appear fine for 1 to 7 days. At this point a “slapped cheeked” appearing rash will appear on the cheeks of the child’s face. Next a rash quickly spreads to the arms, legs, trunk and buttocks. This rash which spreads to the arms, legs and torso looks like a diffuse, pink, flat, lacey appearing rash. Usually it is not itchy but can be itchy in only 15 % of the patients. (1) The rash on the face usually goes away in about a day but the rash on the body typically persists for three weeks.

At times the body rash may seem to lessen and almost disappear and then reappear again in response to certain situations or triggers. These triggers include hot baths, exercise, emotional stress and sunlight. In most cases this waxing and waning of the rash could go on for a few weeks, but may occur for months. (2)

The good thing about Fifth’s disease is that once the rash develops, it is no longer contagious. Transmission of Fifth’s disease occurs the week before the onset of symptoms. Therefore since your child has the rash, he is no longer contagious and should not be prevented from attending camp. Fifth disease is spread by respiratory droplets; when a child sneezes, coughs or shares food or drinks with another child. It also can spread from a pregnant mother to her unborn child. This is a major concern because the unborn child can develop complications such as anemia, hydrops fetalis and spontaneous abortion.

Complications from Fifth’s disease are rare and include arthritis and aplastic crisis. Arthritis symptoms usually occur in older adolescents and adults. Only 8% to 10% of children affected will develop arthritis symptoms. (3) The type of arthritis that develops as a result to Fifth’s disease does not cause destruction of the affected joints and usually resolves in a few weeks. (4)

Aplastic crisis is the inability to make red blood cells which leads to severe anemia. Children with a history of diseases that cause anemia such as sickle cell anemia, spherocytosis, thalassemia, glucose-6-phosphate dehydrogenase deficiency, pyruvate kinase deficiency, chronic hemolytic anemia, iron deficiency anemia, or autoimmune hemolytic anemia are at risk for developing this complication.

(1)Adler, S., Koch, W. Parvovirus infections. I: Gershon AS, Hotez PJ, Katz LS, eds. Krugman’s Infectious Diseases of Children. 11th ed. Philadelphia: Mosby;2004:429-441.
(2) Leah C., Jenson, J. Erythema infectiosum (fifth disease). In: Jenson HB, Baltimore RS, eds. Pediatric Infectious Diseases. Principles and Practice. Philadelphia: WB Saunders Company; 2002:325-330.
(3)Mancini A. Erythema infectiosum (fifth disease). In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 3rd ed. New York: Mosby;2003:1064-1066.
(4) Young N., Brown K. Parvovirus B19. N Engl J Med. 2004;350:586-597.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice for Parents with Sick Kids

Monday, June 26, 2006

Lumps on the Neck

Dear Lisa,

My son has one lump on the lower back of his head more on the base right before the neck starts, about the size of the tip of my thumb, less than a nickel but more than a dime I think. Further down on the same side of neck still more on the side, he has two littler lumps, the size of the tips of my pinky. They are not external because you can’t see them just feel them and if he moves his head to the side you can see the smaller ones.

“Concerned not sure what to think”

Dear “Concerned not sure what to think”,

The lumps that you are describing sound like normal posterior cervical and occipital lymph nodes. Another words, lymph nodes in the neck area and at the base of the scalp. Everyone has lymph nodes scattered throughout their body. The purpose of a lymph node is to remove bacteria, foreign material and dead cells from the body. If you inspect the neck of a normal healthy child you may find lymph nodes which are rubbery in texture, painless, soft, mobile and round. The size of lymph nodes range from 1 to 25 mm (or 0.04 to 1 inch). (1) Therefore it sounds like the bumps you are describing are within normal range since a nickel is 20 mm or less than an inch. Many parents report seeing lymph nodes or “bumps in the neck” when their child turns his/her head sideways.

Since the lymph node size increases in response to infection or cell breakdown, it is important to check the area above the lymph nodes that you see in order to determine what is causing them to enlarge. Sometimes you may find something as small as a scratch or bug bite on the face or scalp. Other times a tick may be found on the scalp or behind the ear. A child with a throat infection, ear infection or rash on the scalp will have enlargement of the lymph nodes in the neck area. Therefore if your son has had a fever, decrease interest in eating, a sore throat, scratching of his scalp, waking at night or ear pain, it would be a good idea to have him checked by his health care provider to rule out a throat infection, ear infection or skin problem.

Sometimes the number or germs that enter the lymph nodes is so great that the body cannot remove or detoxify them fast enough. If this occurs the lymph node may become infected. Signs of a lymph node infection include warmth at the site, redness, enlargement of the lymph node, pain or tenderness with palpation (touch) or fever. If any of these signs occur your child should be evaluated by your Doctor or Nurse Practitioner.

Lumps that are hard, larger than 1 inch, painful, not mobile when touched, interfere with movement or associated with a skin rash may represent a different problem and should be evaluated by your Doctor or Nurse Practitioner.

(1)Tortora, G., Anagnostakos, N. Principles of Anatomy and Physiology. Harper & Row Publishers, New York. Fourth Edition;1984:520-521.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Website

Friday, June 23, 2006

Internet Safety

Dear Lisa,

I have a 10 year old daughter who is becoming increasingly interested in the internet. I am aware of the dangers of online predators and would like information about how I can prevent an encounter. What do I do if I find inappropriate information on the internet or if I am suspicious of a predator? Are there any warning signs that I should be watching for?

“Stopping Predators on the Internet”

Dear “Stopping Predators on the Internet”,

Unfortunately the same internet that we value as a source of information is the preying ground for sex offenders and child predators. It saddens me to report that based on a nationally representative sample of 1,501 children and teenagers between ages 10 and 17, 19% were the targets of unwanted solicitation during a 1 year period. Ten percent of the solicitations were defined as aggressive, where the perpetrator asked to meet somewhere. Twenty five percent of the children reported at least one unwanted exposure to sexual material the previous year and 8% of the images reported involved violence in addition to sexual content. (1) These alarming statistics reinforce the need for parents to monitor their children’s online activity and teach them the risks of internet use.

Children at highest risk for unwanted solicitations include girls, older teenagers, those using the Internet more frequently, those participating in chat rooms, those communicating with strangers online and troubled youth. There are some simple measures that you can take as a parent to protect your child from predators. It is recommended that Computers be placed in a common area, not in a child’s bedroom. It is more difficult for a predator to engage in a conversation and go unnoticed if the screen is visible to family members.

It is important to educate your child about internet safety, explaining to her that adults who may want to hurt her can disguise themselves as children who want to be her friend. Children may not understand that predators will lie and claim that they are a child of the same age and with the same interests. Some predators may send a fake picture of a child, claiming that it is their picture and then pressure your child to send their picture in return. Children need concrete guidelines specifically listing who they can instant message, who they can email and what sites they are allowed to go on.

It is not good enough to say, “Do not talk to strangers”. In my practice I found that children insist that they didn’t talk to strangers online, but when asked who they spoke to, parents were quite surprised with what their child had to say. The child’s definition of stranger and the parent’s definition of stranger were two different things. I’ve had children admit to talking with a friend’s uncle, a neighbor’s older cousin or a friend’s mother’s boyfriend. The children/teenagers do not realize that it is inappropriate because they do not view these people as strangers. In order to clarify who is an acceptable contact, parents should review email and Instant Message address lists regularly and maintain access to all online accounts.

Telling your child, “Don’t give out your name or address” is also not good enough. Predators may be more subtle and seek out information such as the name of a child’s team, the name of an ice cream store that they go to, or the name of their school. A child may give this information out not realizing that it can lead a predator to a place where they can be located. There have been many cases where I questioned an adolescent if they were aware that they shouldn’t give out personal information. They all answer insisting that they would never do this. Within seconds they admit to having a “profile” on the computer that includes not only their name, address, and interests but also their picture. They defend themselves by stating that they only send their profile to “friends”, not realizing that other people could gain access to this information.

Signs that your child may be involved with inappropriate internet activity include, turning off the computer or deleting the screen each time a parent walks into the room, unexplained gifts, packages received in the mail, and unfamiliar telephone numbers on the telephone caller ID. For more information about internet safety you can review the FBI’s Crimes Against Children Program publication, A Parent’s Guide to Internet Safety. (3)

If you think your child has been exposed to inappropriate internet activity or solicitations by a child predator you should report the incident to the National Center for Missing and Exploited Children (NCMEC) which is the federal agency in the United States that is responsible for receiving reports. Your internet service provider should also be alerted to any type of questionable online activity. The most important thing you can do is keep open communication with your daughter. It is important for her to know that she can come to you with any problem and know that you will be supportive and understanding. No matter what level of involvement your child may have had, it is important for you to reinforce that she is the victim. Unfortunately, 25% of the children and teenagers solicited reported high levels of stress after the solicitation incident and 17% of the incidents the children were very or extremely embarrassed. (1)

(1) Finkelhor, D., Mitchell, K., Wolak, J. Online Victimization: A report on the Nations Youth. Alexandria, VA: National Center for Missing and Exploited Children, Crimes Against Children Research Center; 2000:1-47.
(2)McColgan, M., Giardino, A. Internet Poses Multiple Risks to Children and Adolescents. Pediatric Annals. 2005;34(5):405-414.

(3) A Parent’s Guide to Internet Safety. Washington, DC: US Department of Justice, Federal Bureau of Investigation. Available at: Accessed June 2006.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice-Keeping Children Safe

Thursday, June 22, 2006

Peanut Allergy

Dear Lisa,

My 2 year old son has been diagnosed with a peanut allergy. I cannot begin to tell you how petrifying it is to think that something so simple as eating a peanut can cause him to have such a severe allergic reaction that he could die. Now that the initial shock is settling, I want to make sure that I am doing everything that I can to keep him safe. I am with him 100% of the time, I read all food labels, I do not have any peanuts in the house at all and I always carry his Epipen, no matter where we go. Is there anything that I am missing? What other precautions can I take to keep him safe?

“Petrified of Peanut allergies”

Dear “Petrified of Peanut allergies”,

I applaud you for your diligence and effort in educating yourself about your son’s peanut allergy. Having a child diagnosed with a peanut allergy is a very difficult challenge because of the unpredictability of your child’s health and feelings of helplessness due to the lack of control of such a potentially life threatening situation. Be assured that you are not alone, because the incidence of peanut allergies is on the rise. In 2002, studies reported that the prevalence of peanut allergy had doubled over the past decade. (1)

There are some additional measures that you can take that can help keep your son safe. The best way to prevent an anaphylactic reaction is to always read all food labels. If an ingredient list is not available it is best not to let your child eat it. No matter how many times you buy the same product, you should read the ingredient label every time. I have had patients that had an accidental ingestion because a food product regularly used changed its ingredient list with no other obvious change in the packaging. Therefore it is best to read the ingredient list every time.

Most parents of children with peanut allergies avoid Chinese restaurants because they tend to use nuts in their recipes, and peanut oil to coat their pans. The same pan that is used to make a dish with peanuts may be used to make your child’s food, and there is a good chance of cross contamination.

Cross contamination is also very likely in bakeries because residual nut crumbs may accidentally be left on a surface where your son’s cake is made. It is safer to buy a cake with an ingredient list attached. When dining out, it is necessary to be very assertive when explaining your child’s peanut allergy to restaurant workers. Do no be afraid to question their ingredient lists for different dishes and inquire about procedures to limit cross contamination.

When ordering meals from an Italian restaurants ask how their sauce is made. Peanut oil may be used to prepare the sauce or nuts may be used as ingredients in some dishes. Lastly, chocolate commonly includes nuts or nut oils as an ingredient. Typically, chocolate made outside of the United States is not recommended because of the likelihood that it may contain nuts and not necessarily list this on the label.

Carrying an Epipen with you is the right decision because you never know if an accidental ingestion may occur. Even if you don’t keep any peanuts in the home and you read all labels, cross contamination or errors in packaging may still occur. Actually, it is recommended to carry more than one Epipen at all times.

You may need more than one Epipen in case one fails, in the event the Emergency Medical Services takes a long time to get to you and because anaphylactic reactions may be prolonged and the dose may need to be repeated. (2)

If an anaphylaxis does occur, give the Epipen right away. A delay in administration of treatment can result in a fatal or near fatal allergic reaction. Contact Emergency Medical Services immediately. To expedite their arrival have someone wait outside ready to direct them to your child, leave lights on and doors left propped open. If you are alone, prop the door open with a chair to bring attention to the entrance.

It is a good idea to have the number of your house posted clearly, making sure that tree branches and shrubbery don’t obstruct the view of the number. If need be, you can have your address painted on the curb. I have dealt with many Emergency Medical Service employees who informed me that hardest part of their job is finding a house address.

It is also a good idea to contact the Emergency Squad Chief and inform him/her that you have a child with the diagnosis of a peanut allergy and the potential for anaphylaxis. You can also mail a profile to the station. Mailing a profile to the squad will serve to familiarize the volunteers and workers with the people in the community who have the likelihood of needing their service.

The profile should be clearly written or typed and should include your child’s name, date of birth, weight, address, allergy, recommended treatment, other medical conditions such as Asthma, the doctor’s name and telephone number.

It is very normal for a parent to become overwhelmed with all of this information. Food Allergy Support groups can be very helpful for parents. Support groups can provide a place to share ideas, gain information and provide emotional support. You can contact your local health department and/or hospital to find a support group in your area.

The Food Allergy Network is a great resource. You can find updated information about food allergies, research, legislation and warnings about errors in labeling of food products.

(1)Bassett, C. What to do when foods become allergens. The Clinical Advisor. 2005;Dec:43-48.
(2) Gray, J. New Guidelines reveal complexity of food allergy. Infectious Diseases in Children. 2006; April:10.

Lisa Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Advice for Parents- Keeping Kids Safe

Wednesday, June 21, 2006


Dear Lisa,

My 5 year old son snores really loud and sounds just like my husband. I’ve tried changing his position while he is sleeping and it doesn’t make a difference. Is this normal?

“Mother of a Snoring child”

Dear “Mother of a Snoring child”,

During normal sleep a child’s respirations become more shallow and the muscle tone of the upper airway decreases. As a result the airway becomes floppy which leads to upper airway resistance and in some cases snoring sounds. (1) Snoring may occur intermittently with a cold or allergies because the nasal passages become blocked with mucus. On the other hand, if a child has chronic or loud snoring, especially with pauses in the breathing, an evaluation for Obstructive Sleep Apnea is warranted.

Children with enlarged tonsils and/or adenoids, low muscle tone, obesity, Down’s syndrome, Cerebral Palsy, a large tongue, a small oral airway, small nasal airway or children taking sedatives are at risk for Obstructive Sleep Apnea. (2,3) Signs of Obstructive Sleep Apnea may include excessive sleepiness during the day, hyperactivity during the day, nocturnal enuresis (bedwetting), night time awakenings, Attention Deficit Disorder, restless sleep, poor school performance, mouth breathing, behavioral problems, loud snoring or stridor. (4,5,6)

If Obstructive Sleep Apnea is a concern, an Ear Nose Throat (ENT) Specialist can evaluate your child’s upper airway and determine if he is at risk. In order to better describe your child’s symptoms to the specialist it is a good idea to bring a camcorder videotape including visual and sound effects of your child’s nighttime snoring to the evaluation. In some cases an overnight test performed in a Sleep Lab called a Sleep Study may be ordered in order to better evaluate your child’s nighttime breathing pattern and rule out Obstructive Sleep Apnea.

(1)Rosen G. General Overview of Neuroanatomy and Neurophysiology of Sleep. Presented at: Pediatric Sleep Disorders Conference;May 31, 2002:Edison.
(2)Sleep Apnea. Clinician Reviews. 2006;16(6):25.
(3)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia, PA: W.B. Saunders Company. 1990:438.
(4). Picchietti, D., England, S., Walters, A., Willis, D., Verrico, T. Periodic Limb Movement Disorder and Restless Legs Syndrome in Children with Attention deficit Hyperactivity Disorder. Journal of Child Neurology.1998;13(12):588-594.
(5)Dahl, R., Pelham, W., Wierson, M. The role of sleep disturbances in attention-deficit disorder symptoms: A case study. J Pediatr Psychol. 1991;16:229-239.
(6) Kaplan, B., McNicol J., Conte, R., Moghadam, J. Sleep disturbance in preschool-aged hyperactive and nonhyperactive children. Pediatrics. 1987;80:839-844.

Lisa Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily

Tuesday, June 20, 2006

Predicted Height

Dear Lisa,

Is there any way to know what my baby’s adult height will be? My husband is really tall and I am wondering if my son is going to be tall too.

“How tall is he going to be?”

Dear “How tall is he going to be?”,

An infant’s height is influenced by its prenatal environment and gestational age (whether it was born on time or not). If your baby is in the 100 percentile for height at 6 months old, it does not necessarily mean that he will be in the 100 percentile for height when he is an adult. Height measurements under the age of two do not correlate with the predicted adult height of a child. Once your baby turns two years old there is a calculation that is used to predict adult height. Generally speaking, a child attains 50% of its adult height at two years old. Therefore, if you take your child’s height in inches at two years old and multiply it by 2, you will get his predicted adult height. For example, if your child is 35 inches at 2 years old, it would be expected that he will be 35 times 2 = 70 inches or 5 foot 10 inches as an adult.

There is a calculation called the Midparental Height Formula that many health care providers use to predict a child’s height. To determine a child's midparental height first you take the biologic father’s height in inches and add it to the biological mother’s height in inches. Take this number and subtract by 5 for girls or add by 5 for boys. If you divide this number by two you will get your child’s predicted height in inches.

For example if you want to figure out a baby boy’s predicted height, first accurately determine the biological parent’s height. If the mom’s height is 5 feet and 4 inches and dad’s height is 5 feet and 11 inches, you would first convert the height into inches. Since there are 12 inches in a foot, the mother would be 64 inches tall and the father would be 71 inches tall. Next take these two numbers and add them together, 64 + 71 = 135. Since the baby is a boy, add 5 to that number, 135 + 5 = 140. Divide 140 by 2 and you get 70. Therefore it is predicted that the boy will be 70 inches or 5 foot 10 inches when he is an adult. Depending on the child’s health and nutritional status, this value may vary 1 to 2 inches from the predicted height.

Have fun!

Lisa Kelly R.N.,P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice about Keeping Kids Healthy

Monday, June 19, 2006


Dear Lisa,

My daughter is 13 years old and she hasn’t gotten her period yet. All of her friends all so well developed and they all got their periods already. Should I be worried that something is wrong?

“Waiting for period”

Dear “Waiting for period”,

Normal healthy adolescent girls free from any chronic medical conditions usually start puberty between 10 to 11 years old. It is also normal for some girls to start puberty as early as 8 years old, or as late as 13 years old. (1) The change of a child’s body into an adult occurs in stages over the span of 3 to 4 years. There is a normal progression of events starting with darkening of the hair on the legs, widening of the hips and the onset of body odor as the beginning phase. Next breast buds develop as well as the development of sparse dark mostly straight pubic hair. Following this the pubic hair becomes darker, coarser and more curly and begins to spread. You will also see further enlargement and elevation of the breasts. During this stage a female enters a skeletal growth spurt which results in the attainment of 6-11 cm of height per year. When the pubic hair becomes more adult in type and approximately two years after the onset of breast development, menarche or a girl’s first period typically occurs. (1)

Physical examinations by your daughter’s health care practitioner are just as important at this stage of development as they were when she was just an infant. Annual physical examinations can monitor your daughter’s stage of development, screen for abnormalities and provide anticipatory guidance as well as reassurance regarding her sexual development. In particular, girls need to be checked regularly to rule out any skeletal deformities, such as Scoliosis which tend to occur at this time due to the increased velocity of skeletal growth. (2) In addition yearly evaluations can monitor for the development of psychological problems such as depression or eating disorders which may rear their head when a young girl’s body experiences so many changes.

If you notice that your daughter is following these normal steps of development be assured that the process takes time. If you haven’t noticed any of these normal changes or if the progression through these stages takes more than 5 years, it would be a good idea to contact your daughter’s health care provider for an evaluation.

(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York: Delmar Publishers Inc. 1984:438-440.
(2)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass: Year Book Medical Publishers, Inc 1990:80-85.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily

Friday, June 16, 2006


Dear Lisa,

My son is four months old and I am worried about sun exposure this summer. Can he use sunscreen?

“Preventing sunburn in babies”

Dear “Preventing sunburns in babies”,

It is recommended that children 6 months old and older have frequent applications of a sunscreen with an SPF greater than 30. (1) Specifically, reapplication should be done after water exposure. It is best for children under 6 months to be kept out of direct sunlight and to wear protective clothing. Particular attention should be paid to the head, forehead and face of infants which can easily burn and should be protected with a large brimmed hat.

If there is no way to keep an infant under 6 months out of the sun, then it is okay to put sunscreen on their exposed body parts, sparing the eye area. Prevention of sunburns in children is of paramount importance since half of a person’s total lifetime sun exposure occurs before 18 years old. In addition, Sun exposure causes more than 90% of all skin cancers. (2)

It is a good idea for caretakers to avoid wearing jewelry or watches when handling infants outdoors in the sun. When metal jewelry is exposed to sunlight for a length of time it can become hot enough to cause a burn if accidentally pressed against an infant’s bare skin. Those at risk for developing skin cancer include white race, fair skin, blond/red hair, light eyes, freckling, history of sunburns, melanocytic nevi, family history of melanoma and immunosuppresion.(3) Therefore , if your infant has any of these risk factors it would be prudent to keep him out of the sun.

(1)Tuchman, M., Weinberg, J. Why everyone’s skin needs to be examined. The Clinical Advisor. 2006(February); 33-38.
(2) Grassia, T. The earlier, the better for skin cancer prevention. Infectious Diseases in Children. 2006(May):56.
(3)Richards, C. Pediatric melanoma rates increasing. Infectious Diseases in Children. 2006(May):54.

Lisa Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice for Healthy Kids

Thursday, June 15, 2006

Sexually Transmitted Diseases

Dear Lisa,

In teaching my teenage son about sexually transmitted diseases and the wisdom in abstinence, he thinks the answer to everything is just wear a condom. I tried to explain to him that condoms are not always full proof. I want to give him the correct information. What are the chances of getting a sexually transmitted disease when wearing a condom? Do condoms protect you from all sexually transmitted diseases?

“Are condoms full proof?”

Dear “Are condoms full proof”,

It is important to teach our teenagers about Sexually Transmitted Diseases (STDs) because many of them become sexually active during middle and late adolescence. Boys and girls ages 15 to 19 years old have extraordinarily high rates of sexually transmitted diseases. (1) For example, more than 2.8 million cases of Chlamydia occur annually in the United States, mainly among 15-24 year olds. (2) In the United States, 6% of all 12 -19 year olds carry the Herpes Simplex Virus antibodies that indicate either active or latent infection. (3)

The good thing about your son’s response is that he understands the importance of condom use. The use of male condoms can help prevent STDs, particularly HIV, Chlamydia, Gonorrhea, and Trichomoniasis because they are transmitted by fluids on mucosal surfaces. The bad thing is that your son doesn’t understand that certain STD’s are transmitted by skin to skin contact, such as Herpes simplex virus, Human Papillomavirus, genital warts and Syphilis. These diseases are less effectively prevented by male condoms. (4)

Many teenagers (as well as adults) think that if they wear a condom that they are 100% protected. Unfortunately this is not the case. For skin to skin infections, such as Herpes, the transmission can still occur if a male is wearing a condom. Condoms do not cover the thighs, the scrotum, perineal area or the base of the penile shaft. These areas come into contact with the female’s labia majora or thighs and the herpes virus can be transmitted between those areas. (5) The interesting thing about Herpes in particular is that viral shedding, or spread of the disease can occur in the absence of any lesions. A recent study utilizing daily analysis of skin swabs revealed that a newly infected person can shed Herpes Simplex 2 Virus up to 40% of the time regardless of the presence of active lesions. (5)

A dilemma occurs when a teenager realizes that condoms do not protect them from all STD’s. Some may feel that they shouldn’t wear a condom at all since they don’t work. This is where education comes into play. Although condoms may not be 100% full proof, they will help prevent the transmission of some STDs. Since STDs typically occur together, there is a greater chance that a partner with Herpes for example also has HIV or Chlamydia. Therefore it would be important to protect yourself from the other STDs even if you don’t think the condom will protect you from Herpes.

Sexual activity is risky business. Besides the concern about STDs, teenagers involved with sexual activity put themselves at risk for an unwanted pregnancy as well as the responsibility and the strong emotional aspects of such a relationship. Therefore your initial advice supporting abstinence is a very wise decision.

(1) Fortenberry, J. Sexually Transmitted Infections. Pediatric Annals. 2005;34(10):803-810.
(2) Weinstock, H., Berman, S., Cates, W. Sexually Transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004;36: 6-10.
(3) Fleming D., McQuillan, G. , Johnson, R. Herpes Simplex Virus type 2 in the United States l976 to l994. N Engl J Med. L997;337:1105-1111.
(4) Davidson, M. Sexually Transmitted Infections. Clinician Reviews. 2004;14(6):56-60.
(5) Reitman, D. Update on Sexually Transmitted Diseases: Herpes Simplex Virus Type 2 Infections. Consultant for Pediatricians. 2006; April:238-243.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Advice For Teenagers

Wednesday, June 14, 2006

Gassy Baby

Dear Lisa,

Whenever I feed my 3 week old son the bottle he becomes fussy and he has a lot of gas. He cries a lot and eventually settles down after I burp him a few times, which seems like forever. I wish there was something I could do to help him because he is so uncomfortable. Is there anything I can give him for the gas that is safe for babies?

“Gassy baby in N.J.”

Dear “Gassy baby”,

An infant with "flatus" or gas usually cries and pulls his knees to his chest during and after feeding. The symptoms usually subside once the baby belches. Gas symptoms cause an infant to have much discomfort and crying which ultimately affects the lifestyle and sleep pattern of the whole family. All babies entrap air during sucking which results in gas bubbles in the baby’s stomach. A build up of these gas bubbles causes the infant to have abdominal discomfort until the gas dissipates. You can help a baby expel the gas by burping him after every one to two ounces of formula ingested. Effective burping includes patting the bottom of the infant's back or his diapered behind while maintaining the infant in an upright position. The idea is to pat under the level of the baby’s stomach so that the air bubbles will rise and escape out of the mouth.

Babies tend to entrap air while sucking on the bottle, especially those babies with a vigorous suck. In order to prevent the baby from sucking in too much air it is important to make sure the nipple is totally covered with formula during the entire feeding. To do this, the bottle needs to be tilted close to a 90 degree angle or positioned straight up. If the bottle is held at a 45 degree angle for example, only half of the nipple will be covered with formula and the other half of the nipple will be filled with air. If this angle is too hard to maintain, or if your baby still entraps a lot of air, you can purchase a Dr. Brown’s bottle which limits the amount of air that a baby takes in.

Parents who use dry powdered infant formula should mix the water and powder by gently rolling the bottle back and forth as opposed to vigorously shaking it. If you shake the bottle too much a layer of foam will appear on top of the formula, which essentially is a layer of air similar to the head on a beer. If the baby drinks this bubbly layer, he will suck in too much air which will very likely lead to problems with gas. Some parents switch to ready to feed preparations so as to prevent this from happening. Another option is to add an extra ounce of formula to the bottle so that the baby never drinks the foamy layer.

Most Doctors and Nurse Practitioners recommend Infants' Mylicon Drops for babies who suffer from gas symptoms. Infants' Mylicon Drops can be found over the counter at your local pharmacy. The recommended dosage is 0.3 ml given four times daily after meals and at bedtime. The dropper provided clearly marks the 0.3 ml dosage to be less than a full dropperful. You should not exceed 12 doses in a 24 hour period. The purpose of the Mylicon Drops is not to keep the baby from burping. Instead the medication works by changing the surface tension of the gas bubbles enabling them to stick together and escape more readily through belching.

If your baby has continued symptoms that seem to cause him pain, back arching, excessive hiccoughing, coughing or choking with feeding, blood in the stool or fever, it would be important to bring him to your health care provider for an evaluation. These symptoms may be a sign of a different problem, other than gas.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice for Healthy Babies

Tuesday, June 13, 2006


Dear Lisa,

I just found out that a boy in my son’s daycare has pinworms. Just the thought of it makes me sick. What are pinworms and how do you catch them? Can my son get pinworms too? What signs should I look for?

“I hate worms in N.J.”

Dear “I hate worms”,

Pinworm infection is caused by the roundworm Enterobius vermicularis. They are 3 to10 mm in length and found in the colon and perianal area of infected children. Also known as seatworm or threadworm; pinworm infection is the most common helminthic infection worldwide. (1) School age children are particularly at risk because of their tendency to put their hands in their mouth and share toys. Mother’s of infected children and institutionalized patients are also at risk.

Pinworm infection is spread through the oral fecal route. Adult female worms travel from the colon to the perianal area where they deposit their eggs. This migration occurs at night, and leads to intense rectal itching. When children scratch their rectal area, eggs become hidden under their nails and then are transmitted back to the child or to other children via shared toys. The eggs can also contaminate clothes and bed linens and remain viable and infectious for 2 to 3 weeks.

Signs of Pinworm infection include intense rectal itching at night or the presence of worms in the child’s stool. If you are suspicious that your child has pinworms, it is best to check your child 2-3 hours after he falls asleep. First, wrap the tip of a clean pop sickle stick with scotch tape. The sticky part should be on the outside so that when you touch the end of the pop sickle stick your fingers stick to it.

Next, examine your child’s rectal area while he is sleeping, but do not turn the lights on in his bedroom because this may cause the adult worm to migrate back into the colon. If you can’t see any worms, gently touch the rectal area with the tip of the pop sickle stick covered with scotch tape. Tiny white eggs will stick to the pop sickle stick or white worms will be visualized if your child has a pinworm infection.

Some people prefer to put scotch tape over a child’s anus before he goes to sleep and check it in the morning. If you find pinworms or eggs you can bring them to your Pediatrician or Nurse Practitioner and she can prescribe Mebendazole. It is common for most practitioners to treat the whole family at the same time with this medication in order to prevent family members from infecting each other.

It is interesting to note that this helminthic infestation has been reported in 0.2% to 2.4% of children seen with apparent Appendicitis. (2) When the appendix was examined after Appendectomy, pinworms were found more frequently in girls; 4.6% than in boys; 1.9%. (3)


(1)Liu L., Weller P. Intestinal nematodes. In: Fauci A., Braunwald E., Isselbacher K., Harrisons’s Principles of Internal Medicine. 14th ed. New York: McGraw Hill; 1994:1208-1227.
(2)Dalimi, A., Khoshzaban F, Comparative study of two methods for the diagnosis of Enterobius vermicularis in children. J. Helminthol. 1993;67:85-86.
(3)Dahlstrom, J. , Macarthur, E. Enterobuis vermicularis: a possible cause of symptoms resembling appendicitis. Aust N Z J Surg. 1994;64:692-694.

Lisa Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Sick Kids

Monday, June 12, 2006


Dear Lisa,

My son has Asthma and my pediatrician prescribed Albuterol to be used on as needed basis for when his Asthma acts up. The problem is whenever he gets a runny nose and cough, I can’t tell if it is from a cold, allergies or his Asthma. Since I’m not sure, I don’t use the Albuterol but then he usually ends up at the doctors and it turns out that he’s wheezing. Then I feel bad that I didn’t start the Albuterol, but at the same time, I don’t want to give him the medication if he doesn’t need it. Is there a way to tell if the cough is from Asthma or just a cold or allergies?

“Is the cough from Asthma in N.J.”

Dear “Is the cough from Asthma”,

Your question is a common question that I hear from parents of children with Asthma all of the time. The important thing to understand is that a runny nose or Rhinitis, regardless of the cause may contribute to the worsening of Asthma. Interestingly, Allergic Rhinitis is a contributing factor in the development and persistence of Asthma. (1, 2) Therefore it is important to treat the cough and runny nose, regardless of its cause, in order to help keep a child's Asthma under control.

If your child has been diagnosed with Asthma by a healthcare professional and has a history of repeated airway obstruction relieved by a bronchodilator ( such as Albuterol), then the administration of Albuterol is the proper treatment. In addition, effective treatment of the runny nose with the use of inhaled nasal steroids and /or antihistamine-decongestant preparations should be an integral part of your Asthma management plan. (2, 3)

When you treat your child with Albuterol you should see an improvement in his cough and work of breathing that lasts 4 to 6 hours. If you do not appreciate an improvement in his symptoms or if the improvement does not last for 4 to 6 hours your son should be evaluated by your Pediatrician. The important thing to remember is Albuterol is intended for intermittent use; or use on an as needed basis. It is not inteneded for everyday use.

Everyday use of Albuterol on a regular basis could be detrimental to your child, and a sign that your son’s Asthma is out of control. Albuterol does not address the underlying inflammation, which is the hallmark of Asthma, and may give you the false reassurance that your son is doing better than he really is.

Studies have shown that there is an association between the everyday use of Beta-agonists (Albuterol) and the increased risk of death or near death. (4) When the researchers talk about everyday use of Albuterol, they are not talking about using Albuterol everyday over the span of a week or two during an acute exacerbation. The concern is meant for long term, everyday use of Albuterol on a regular basis, especially when there is no daily maintenance medication being used (such as inhaled steroids or leukotriene inhibitors).

This information is not intended to alarm you, but to reinforce the importance of close follow-up with your health care provider and monitoring for over use of Albuterol. If you do find that your son needs Albuterol more than twice per week on a regular basis, this is a sign that his Asthma is persistent and not in good control. This situation warrants an evaluation by your Pediatrician and the addition of a daily maintenance medication.

Lastly if your son's nasal symptoms worsen or persist beyond 10 days it is a good idea to have him evaluated. If this is the case, he may need an adjustment in his allergy medication or need to be checked for Sinusitis. If left untreated, both Sinusitis and Allergic Rhinitis can cause your son’s Asthma to persisit and his condition to worsen.

(1)Linneberg, A., Henrik, N., Frolund, L., Madsen, F., Dirksen, A., Jorgensen, T. The link between allergic rhinitis and allergic asthma: a prospective population-based study. The Copengagen Allergy Study. Allergy. 2002;57:1048-1052.
(2) Hogan, M., Wilson, N. Asthma in the School-Aged Child. Pediatric Annals. 2003;32:23-24.
(3) Stelmach,R, Nunes, M., Rubeiro, M., Cukier, A. Effect of treating allergic rhinitis with corticosteroids in patients with mild-to-moderate persistent Asthma. Chest. 2005;128:3140-3147.
(4) Spitzer, W., Suissa, S., Ernst, P. The use of beta-agonists and the risk of death and near death from asthma. N England J Med. 1992;326:501-559

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Website

Friday, June 09, 2006

Excessive Crying

Dear Lisa,

My 4 year old daughter cries at everything. If you do anything from look at her funny to discipline her, she cries. It is getting so bad now that her younger brother is starting to act the same way. We can't go a day without her crying about something. What is your advice on how to handle her temperament?

"Crying in N.J."

Dear “Crying in N.J.”,

Some children are sensitive and seem to cry at a drop of a hat. Sometimes they cry because they are frustrated, insulted, tired, hungry or sick. If you eliminate all of the factors that you can control, such as making sure she has enough sleep, she is not hungry and she is not sick, and she still cries a lot then behavior modification can help. When children develop an undesirable behavior, we can help change that behavior by not rewarding the behavior. Children thrive on their parent’s attention, whether it is positive or negative. Therefore reprimanding undesirable behavior many times does not work. Rewarding good behavior teaches children to behave a different way.

The first thing you can do is explain to your daugher that mommy cannot understand her or help her when she is crying. Tell her that you will not talk to her until she is done crying. Remind her that when she stops crying you will listen and help her. It’s important to not give in, and ignore her when she is crying. You may need to help her at first because she will not be used to this approach. Tell her to take deep breaths, relax and have a drink of water. The second she attempts to stop crying and use her words, pay attention to her and attend to her needs. She will soon learn that it is more beneficial to control her crying.

This may be very difficult for your daughter at first and you can help her by using a star chart. Put a chart on the refrigerator and separate the day into morning, afternoon and night. Give her a star for each part of the day that she doesn’t cry. Set a low goal in the beginning (for example 6 stars) and work up to a higher number. Agree on a reward that she can receive once she reaches her goal. It doesn’t necessarily have to be a gift; it can be alone time with mommy at the library or staying up an extra fifteen minutes at night.

Some preschoolers are perceived to be more emotional because they do not have the ability to express themselves due to a speech or hearing delay. Therefore if her excessive crying persists despite your concentrated effort to help her, it would be a good idea to have her speech and hearing evaluated. I would be concerned about a child who has excessive emotional outbursts or tantrums on a regular basis that last more than 30 minutes. This may be an early sign of a psychological problem and would need to be addressed by a health care professional. Lastly, it is important to remember that children can become depressed too. If a child has a change in their normal temperament, difficulty making friends, a change in their eating or sleeping habits, or a major loss in their life (such as divorce or death of a pet or family member) it would be important to have an evaluation by a health care professional to rule out depression.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice about Raising Healthy Kids

Thursday, June 08, 2006

Tooth Avulsion

Dear Lisa,

My son got his front tooth knocked out playing soccer. Luckily my dentist was open and I brought him directly there. His tooth was saved, but now I realize, I wouldn’t know what to do if my dentist wasn’t open. I have three other children and I would like to be prepared if this happens again. What is the right way to handle a tooth that is knocked out?

“Knocked out tooth in N.J.”

Dear “Knocked out tooth”,

A tooth avulsion is the total displacement of a tooth from the dental socket. “In the United States, the prevalence of avulsions is 16% in permanent teeth and as high as 13% in primary teeth.” (1) It is very smart of you to ask about the proper handling of a knocked out tooth, because a tooth can be saved if handled correctly.

A tooth avulsion is considered a dental emergency and should be replanted within 30-60 minutes in order to decrease your chances of losing the tooth. Time is of the essence; therefore if your dentist’s office is closed you may want to contact him through the emergency line. Most dentists will come to the office for an emergency or offer a covering dentist who will. Your other option is to contact your pediatrician for a referral to a different dentist if yours is not available. In the case where a dentist cannot be reached a visit to your local emergency room may be necessary.

When handling the tooth, avoid contact with the root and only hold the tooth by the crown. Under no circumstances should you scrub the root because scouring is harmful to the fragile tooth root (1). You can place the tooth back in the socket and have the child bite down on gauze while transporting the child to your dentist or local emergency room. This is asuming that your child is mature enough to follow directions and sit still, otherwise the tooth may become dislodged and become a choking hazard. If the tooth is filled with debris, or it is not feasible to put the tooth back in the socket, then it is a good idea to transport the tooth in milk.

The important thing to remember is, only permanent teeth should be replanted. Primary teeth should not be replanted because the developing tooth bud in the gum may be injured in the process. (2) If for some reason the tooth is missing, shake out all of your child's clothing and check the area well. If you cannot locate the tooth, I would recommentd an evaluation by a healthcare practitioner to make sure your child did not aspirate the tooth and to check to see if the tooth became embedded in the cheek or inner lip.

(1)Triola, M. How to deal with dental emergencies. The Clinical Advisor. 2005;Dec 36-42.
(2)Halpern, J., Bernardo, L. Emergency treatment for dental injuries. Int J Trauma Nurs. 2002;8:15-17.

Lisa Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice-Updated Daily

Wednesday, June 07, 2006


Dear Lisa,

My four year old son has a problem going to the bathroom. Usually his bowel movements are very hard and he spends a lot of time in the bathroom trying to get them out. This causes him a lot of pain and I wish there was something that I can do for him. What can I do to make his stool softer and help them come out easier?

“Problems pooping in N.Y.”

Dear “Problems pooping”,

A child with hard stools and straining is constipated. Many times constipation in children is due to their dietary intake. I find, many children become constipated because they don’t drink enough liquid. This occurs a lot in the warmer weather when children spend a lot of time outside in the heat and seem less interested in drinking. Stool is mainly made of water, therefore when a child doesn’t drink enough, the body compensates by holding in the stool. The longer a person’s stool stays in the body, the more fluid is absorbed into the body, leaving a hard dry stool. The first thing that you can do to help your son is to increase his fluid intake.

Secondly, some children may be eating food which tends to be binding. These foods include soy, rice and bananas. If he eats a lot of these foods, try to reduce the amount that he takes or possibly eliminate them all together. Some children do not have enough fiber in their diet which is found in grains, fruits and vegetables. By increasing fiber in your child's diet, it increases the bulk of the stool, promotes stooling and returns the stool to a normal size. (1) I suggest trying Frosted Mini Wheat cereal; most children love the taste and the fiber adds bulk to the stool. Grapes, raisins, prunes, apple juice, peach nectar and oatmeal also may help loosen your son's stool.

If your child is having pain while he is trying to stool, you can put him in the bathtub filled with warm water up to a level covering his belly (always supervised of course). You should let him play in the bath tub for 30 minutes. The warm water will relieve discomfort and increase peristalsis (the movement of the large intestines). The warm water also acts as a natural enema. When he plays in the tub, water will go up into his rectum and add water to the stool which will help it come out easier. When your son gets out of the tub, gently put Vaseline in the crack of his but and tell him that it’s special medicine that will help him go to the bathroom. The Vaseline helps the stool slip out easier and prevents the child from pushing it back in. I find this trick works almost every time, because the child thinks the “medicine” will help him go.

If your child continues to have hard stools and straining despite dietary alterations, I would recommend an evaluation by your healthcare practitioner in order to rule out disease states that may be contributing to the problem.

(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA: Saunders Company. 1994: 1490-1491.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Healthy Kids

Tuesday, June 06, 2006

Trampoline Safety

Dear Lisa,

My daughter is a gymnast and trains on a trampoline at the gym. Now she wants one for home. My husband doesn’t like the idea because he feels trampolines are not safe. I am worried that the kids in the neighborhood are going to want to play on it. How dangerous are trampolines? If we do purchase one, what can we do to prevent injuries?

“On the fence about trampolines in N.J.”

Dear “On the fence about trampolines”,

Trampolines have gained popularity over the last 10 years and so have trampoline injuries. The Consumer Product Safety Commission report using the National Electronic Injury Surveillance System (NEISS) revealed hospital emergency department visits due to trampoline injuries almost tripled during the last decade, from an estimated 37,500 in l991 to almost 100,000 in 2000. (1) Injuries most commonly occur when jumpers collide into each other, when jumpers attempt stunts, fall or jump off of the trampoline or fall onto the trampoline frame and springs. Six deaths from spinal cord injuries occurred when children, ages 12 – 19 fell off of the equipment.(2) The American Academy of Pediatrics recommends that trampolines not be used at home, as part of routine physical education class in school or be part of outdoor playground equipment. The American Academy of Orthopaedic Surgeons (AAOS) recommends that there only be a single supervised child per trampoline with designated spotters at all times. The trampoline should be placed at ground level with adequate protective padding of the supporting bars strings and landing surfaces.

Having said that, thousands of households own trampolines and if you do not purchase one, chances are your daughter will be at a friend or relative’s home that has one. Therefore I recommend educating your daughter regarding trampoline safety. Stunts should only be performed during supervised lessons in gymnastic class on a trampoline with trained professionals, not at home. Always abide by the one person at a time on the trampoline rule, and always under supervision.

If you do decide to purchase a trampoline, make sure you install it on flat ground and pad the supporting bars and landing surfaces. Purchase a trampoline with protective netting which may help prevent children from falling off of the trampoline. In regards to your concern about neighborhood children, know that children under 6 years old are not recommended to go on trampolines. So don’t be afraid to be firm with your household rules from the beginning. This will save you a lot of battles in the future. Otherwise you will end up spending your entire day on trampoline monitoring duty. It’s a good idea to set up the trampoline in a non-accessible area, preferably behind a locked gate in order to prevent neighborhood kids from helping themselves to an unsupervised flip!

(1) Bautista, S., Flynn, J. Trauma Prevention in Children. Pediatric Annals.2006;35(20):88-89.
(2) US Consumer Product Safety Commission. National Electronic Injury Surveillance System Coding Manual, 2003. Washington, DC: US Consumer Product Safety Commission; 2003.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Kids Safe

Monday, June 05, 2006

Attention Deficit Disorder

Dear Lisa ,

My son has always been jittery. He can’t get his act together and get ready for school in the morning. Now that he’s in 4thth grade, he is struggling with his school work. He’s always forgetting his homework assignments or his books at school and doesn’t know how to study for tests. My friends tell me that he probably has ADD. I don’t want to see my Pediatrician about this because I know she’ll just want to put him on medication and I don’t believe in medicating children for ADD. How do I get him to listen?

"He doesn’t listen- N.J."

Dear “He doesn’t listen”,

I wouldn’t let your concern about medication prevent you from seeking out the reason behind your son’s behavior. It is true that he seems to have many characteristics of a child with Attention Deficit Disorder (ADD) but other diseases should be ruled out first. It is a good idea to contact your son’s Pediatrician and discuss your concerns. Your son’s Doctor may want him to be evaluated by a Neurodevelopmental specialist, or ask you to have his teachers fill out Connor’s rating scale forms.

Connor’s rating scale forms are questionnaires filled out by you, your son and his teachers in order to ascertain information about his behavior and compare that behavior to that of a child with ADD. The scores from the Connor’s forms will assist your doctor in his diagnosis.

In regards to your concern about medicating your child for ADD, I would cross that bridge when it comes. If your child is diagnosed with ADD, you can talk to your doctor about alternative measures for treating ADD symptoms, which include preferential seating in the classroom, behavior modification and dietary modification.

The most important thing to do is follow up with your doctor and keep an open dialogue about your concerns about medication. Be assured that you are not alone and many parents of children with ADD initially resist medicating their children. Most doctors share your view and do not want to medicate a child unless it is necessary.

With careful follow-up, trial of natural measures and time, you will be able to make an informed decision. It is better to know what your child’s problem is so that you can better understand his actions and know how to treat him. Otherwise, your son may find other ways to make himself feel better on his own, which in the end may be a lot worse than any treatment prescribed by your Doctor.

Lisa Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice- Keeping Kids Healthy

Friday, June 02, 2006


Dear Lisa,

I have a 10-month old. On Saturday, she was vomiting all day. I tried to give her just about everything and regardless of how much it was it all came out. At one point she was gagging with nothing left in her stomach to come out. On Sunday, she threw up once only, but had a fever of 100-101 degrees F. On Monday, she went back to vomiting. Throughout the three days she has been cranky and inconsolable. My doctor told me that she probably has a stomach virus. Could this be more then just a stomach virus?

“Helpless in N.J.”

Dear “Helpless in N.J.”,

Viral Gastroenteritis or a stomach virus is very common in childhood. The symptoms include vomiting, frequent watery diarrhea and a low grade fever. The complications of viral gastroenteritis include dehydration and electrolyte imbalance which if left untreated can be very serious. Therefore it is very important to keep a child with Viral Gastroenteritis hydrated well.

Although a child with Gastroenteritis may develop a fever, sometimes a fever in a child with Gastroenteritis may be a sign that the child is becoming dehydrated. An increasing or persistent fever may also be a sign that the child has another infection such as a throat or ear infection. If the fever persists it is a good idea to follow up with your doctor to rule out other infections.

It is common for children with Gastroenteritis to develop vomiting first, followed by diarrhea hours or days later. Rotavirus, a common type of Viral Gastroenteritis typically begins with 2 to 3 days of vomiting and fever followed by diarrhea. If a child has vomiting and fever and doesn’t develop diarrhea it is a good idea to have her re-evaluated. Infants and children with urinary tract infections many times do not present witht the classic symptoms of painful urination and changes in urinary pattern. Instead they may develop gastroenteritis like symptoms. Therefore if there is a family history of abnormalities in the urinary tract or if your child’s symptoms persist, it would be prudent to see your doctor for an evaluation.

It is very difficult as a parent to have a sick child and even more difficult to keep them hydrated when they are vomiting or having diarrhea. The good news is that most diarrheal illnesses in childhood are due to Viral Gastroenteritis. They usually are self-limiting and last only a few days. With careful monitoring for dehydration and good hydration most children are back to themselves in no time.

Lisa Kelly, R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice for Parents with Sick Children

Thursday, June 01, 2006


Dear Lisa,

My daughter is 11 years old. What vitamin should she be taking?

“Need Vitamins in N.J.”

Dear “Need Vitamins",

Most Doctors and Nurse Practitioners agree that a Multivitamin with Fluoride such as Poly-vi-Flor is the vitamin of choice for your daughter. As long as your daughter has no medical conditions that prevent her from taking vitamins she should take this chewable vitamin which can be prescribed by your Doctor or Nurse Practitioner. Poly-vi-Flor is recommended because most towns in New Jersey do not have Fluoride in the drinking water and Fluoride is needed in order to prevent dental carries. You can call your local water department to make sure there is no Fluoride in the drinking water of your town before taking the vitamin. If your child receives Fluoride from the dentist or drinks fluoridated water, you should discuss this with your health care provider because you don’t want your daughter to ingest too much Fluoride. Most health care providers stop prescribing Poly-vi-Flor between the ages of 12 and 14 years old. At that time a regular multivitamin such as one a day is recommended.

Lisa Kelly R.N., P.N.P., C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily