Withholding Stool

Lisa,

I have a four year old who is having problems going doodoo. What she will do is hold it for days, she will get down on her knees and almost struggle not to go. She usually ends up going in her pants, just a little bit then when I put her on the toilet she sits and holds it in again yelling about how she does not have to go. When she finally does go it takes her quite a bit of work. The worst of it is the size of it. It has got to be so painful for her, my daycare lady actually has to break it up before she can flush. Here at home it is the same way, so big in diameter that it will not go down the pipe. How can such a huge doodoo come from such a little girl?? I have tried everything from greens to grapes, even stool softeners. Is there anything you can suggest that may help her out?

“Desperate for Daughter to Doodoo”

Dear “Desperate for Daughter to Doodoo”,

Stool withholding or Encopresis is a condition that occurs in children who do not defecate when they need to. Instead they hold in the stool, the longer the stool is held in, the more water that is absorbed from the stool into the body. This results in a hard, large stool. The longer the child holds in the stool, the harder and larger the stool becomes. The colon and rectal vault accommodate the large stool by stretching and expanding, which allows the stool to become larger and thus a vicious cycle begins. The larger the stool, the more painful it is to defecate and because it is painful the child holds the stool in longer. Sometime the child holds the stool in so long or the stool becomes so hard that diarrhea or loose stool seeps around the blockage and children end up soiling themselves.

Usually children develop stool withholding or Encopresis because they had a past experience passing a hard stool due to constipation. They remember the bad experience and fear that stooling will hurt again, so they hold in the stool to avoid the pain. (1) The child does not realize that holding in the stool makes the situation worse because they are too young to understand cause and effect. When a parent sees a child holding in stool and in distress, it is quite upsetting and as a result psychological effects worsen the situation.

There is a thought that there may be a genetic predisposition to stool withholding. It is believed that children with Encopresis absorb more water from their stool in the large intestine leading to hard stools which are painful to pass. This is an explanation why many children with stool withholding have a history of constipation since infancy.

The first step in treating Encopresis is to evacuate or clean out the colon. (1) The large stool that distends the lower colon needs to be removed so that the colon can shrink down to its normal size. The best way to evacuate a colon is with a Pediatric Fleets enema, but this procedure is invasive and may be very stressful and only add to the psychological effects of stool withholding.(1) Therefore many Doctors and Nurse Practitioners will attempt evacuating the stool with alternative methods. I prefer to have a child sit in a warm bath, with the water high up over the belly a couple of times per day until the stool is expelled. The minute a child gets out of the bath, I suggest liberally applying Vaseline to the rectal area so that the stool can slip out easier and the child will not be able to hold it in. I recommend telling your daughter that the Vaseline is special medicine to help her go doodoo. Most children believe this and it helps them go. It is also a good idea to put Vaseline around the rectal area each time the child sits on the toilet to have a bowel movement.

The next step is to set up scheduled times for your child to sit on the toilet. Specific time sitting on the toilet should be incorporated into your daughter’s daily routine. Instead of asking your child to sit on the toilet when she feels the need to go, choose periods during the day where the child must sit for 3 to 5 minutes everyday regardless if they need to go or not. First of all, scheduled times to sit on the toilet eliminates the need to coax or battle over toileting. Secondly, if you wait for a child to tell you when she needs to go, she will tell you that she doesn't need to go when she really does because she is afraid that it will hurt. Also, a child may not sense the need to defecate because her rectum is so distended she may not feel the sensation the way that a child without a distended colon feels it. The best time to schedule time sitting on the toilet is after meals and in the morning because this is when the colonic motor activity is the highest. (1) Putting a stool under your daughter’s feet when she is sitting on the toilet may help. Proper foot positioning while defecating can help her push the bowel movement out. (2)

In addition to evacuation by using enemas or baths, colonic evacuation can be done with the use of laxatives. Although you said that you already used laxatives, laxatives alone usually do not work. A combination of all therapies together tends to be more successful. Sometimes the type of laxative used or amount given needs to be adjusted. This can be managed best with the assistance of your daughter’s Doctor or Nurse Practitioner.

Mineral oil works many times if given in the correct amount. One tablespoon of Mineral oil blended in the blender with your daughter’s favorite juice twice per day is a good start. Senna products have also been very successful for many children. If you have tried many over the counter products with no success, you can discuss with your Doctor or Nurse Practitioner the option of giving Miralax. Miralax is a prescription medication which is very successful in treating children with constipation and stool withholding.

The important thing to remember about giving laxatives is that they have to be used regularly. The laxative should be used on a daily basis until the stools are a soft consistency and no longer painful to pass. It’s important to continue the laxative until stooling is no longer feared by the child and they forget that going to the bathroom hurts. Some children need to stay on the medication for 3 to 6 months in combination with other therapies before they can be weaned from it. Some parents are under the impression that the medication doesn’t work because after giving the medication a few times they discontinue it and the stool returns back to the hard painful stools that they were before the introduction of the teatment. If the medication is given intermittently, the hard stools return, the child has a bad experience stooling and the cycle begins again.

In order to maintain soft stools once they are obtained, diet and exercise also needs to be addressed. Although you already tried grapes and grains, it is also important to increase your daughter’s fluid intake and avoid foods that tend to be binding. In some children, soy, rice and bananas cause hard stools and may need to be limited or removed from the diet to prevent constipation. Increasing the amount of foods that promote stooling such as peach nectar, prune juice, frosted mini wheats and oatmeal also helps. Exercise increases peristalsis, or the movement of the intestines and helps a child move her bowels. It is important to make sure that your daughter has exercise daily.

A child on a laxative should be monitored regularly by a health care professional in odor to watch for fluid and electrolyte imbalances and improper absorption of nutrients. In addition, a healthcare professional needs to monitor your child’s care to rule out other health conditions that may cause or contribute to hard stools. A child that has no response to therapy or persistent problems many times will have testing done to rule out other conditions that cause constipation. These conditions may include Hypothyroidism, Cystic Fibrosis, Celiac’s disease, electrolyte imbalances, Diabetes, lead toxicity, internal or external anal lesions or Hirschprung’s disease. Although in most cases, constipation is due to diet and inadequate stooling practices a further investigation may be warranted if symptoms persist. In some cases a child with persistent problems with constipation or stool withholding is referred to a Gastrointestinal Specialist for a further work up and treatment.

If your child has a distended abdomen, fever, vomiting, loss of appetite or increasing abdominal pain associated with constipation or stooling it would be important to have her evaluated right away to rule out an intestinal obstruction or other complications of constipation.

(1) Chronic Constipation in Children: Rational Management. Consultant for Pediatricians. 2003; April:152-155.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. W.B. 2nd ed. Philadelphia, PA:Saunders Company. 1994: 1044.

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

Advice About Pediatric Health Conditions

Refusing Vegetables

Dear Lisa,

My 2 ½ year old daughter used to be a great eater when she was a baby. She used to eat everything, fruits, vegetables and meats. Now she refuses vegetables all together. I have tried everything. I’m tired of throwing food away, but I am also worried that she’s not getting the nutrition that she needs. Any tips on how to get a child to eat vegetables?

“At the end of my rope”

Dear “At the end of my rope”,

It is very common for toddlers to be picky eaters. Refusing vegetables is a problem that most parents with toddlers encounter. According to the American Dietetic Association, a 2 to 3 year old child needs 1 cup of vegetables per day. It is recommended to vary the vegetable and give 1 cup of dark green vegetables, ½ cup of orange vegetables, ½ cup dry beans and peas, 1 ½ cups of starchy vegetables and 4 cups of other vegetables per week. (1)

This sometimes seems like an impossible task, and I myself have experienced feeding the garbage vegetables more than my child. Don’t lose hope there are some tricks I have learned from nutritionists, colleagues, other parents, experience and medical journals. If you put plain, unseasoned vegetables in front of any child most likely they will refuse it and the food will probably end up on the floor. You need to spice things up a bit to get a child to eat it. I remember watching a news special a few years back about a contest between day care centers. The competition rated which day care center got their children to eat more food from different food groups. When they interviewed the cook at the daycare center that won the contest, they asked her what she did differently. Her answer was that she put barbecue sauce on top of or in every meal!

I suggest finding the type of food that your child likes and use that as an additive in her vegetable dishes. If your child likes cheese, let your child dip the vegetable in cheese sauce. If your child likes bread, sprinkle bread crumbs on top of the vegetables with a little olive oil to make the breadcrumbs stick. If your child likes Chinese food, cook your vegetables in soy sauce and garlic, and if all else fails add a little barbecue sauce!

For parents who tried all of these measures and are still pulling out their hair, don’t lose heart. You just need to be a little more inventive. Just about every child likes pizza or spaghetti with sauce. Take some of the spaghetti sauce and cook it separately in a small pot and add a jar of pureed vegetables (a jar of baby vegetables). Try to use a different vegetable each time, so that your child receives a variety, some dark green vegetables, as well as some orange vegetables. Stir the vegetable into the sauce and pour it on top of her pasta or pizza. Your child will not be able to tell the difference, the sauce will taste and look the same. This is a great way to add vegetables to your daughter’s diet without her ever knowing it. Jarred baby food will end up your best friend, because you can add it to any recipe that needs moisture; add it to meatloaf, meatballs, stuffing, pastina, soups or stews. Another option is to grate vegetables into recipes. You can grate carrots or zucchini into meatloaf, muffins or breads. There will be no difference in the taste and once cooked your child will not see it.

Bring your child to a salad bar and let her pick out the food that she wants. You may be surprised with what she chooses. This way she has a variety of options and if she doesn’t like something, she doesn’t have to eat it. Children tend to like the control of picking what they can eat. It’s a good idea to bring a friend (preferably one with a good appetite) and make it a fun outing. Children are more likely try a new food if they see a friend trying it too.

No matter how frustrating it is to get your child to eat try not to let your emotions get the best of you. If your daughter sees and hears you complain about her not eating, she may capitalize on the situation and use meal time as a source of getting you to spend a lot of time coaxing her to eat. Soon she will learn to use eating or not eating as a tool to get your attention and meal time can end up a battle. Instead be a good example and eat vegetables in front of your child with a big smile on your face. (2) By keeping meals an enjoyable time there’s a better chance you’ll find success in getting your child to eat a healthy meal.

For more information about healthy eating and dietary requirements for children at different ages you can log on to The American Dietetic Association website at:

www.eatright.org
www.MyPyramid.gov

(1)United States Department of Agriculture. Mypyramid. The American Dietetic Association Website at: http://www.MyPyramid.gov. Accessed July 2006.
(2) Rosenthal M. Suggestions to help parents change their toddler’s behavior outlined. Infectious Diseases in Children. 2006. March:44-45.

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

Pediatric Advice About Keeping Kids Healthy

Bee Stings

Dear Lisa,

I was taking care of a friend’s child and he got stung by a bee. I didn’t know if he was allergic to bee stings or not. What are you supposed to do if a child gets stung by a bee? What would happen if a child was allergic to bee stings?

“What is the treatment for Bee Stings?”

Dear “What is the treatment for Bee Stings?”,

When a bee stings a child, venom is injected from the bee into the child’s skin which may cause an allergic reaction. If a child is allergic two types of reactions can occur. One type is a generalized reaction which is the more serious type of reaction that can lead to anaphylaxis. An anaphylactic reaction can be life threatening and requires immediate medical attention. The other type of reaction is called a localized reaction. This type of reaction is not life threatening and is limited to the area that was stung.

When a child gets stung by a bee, the first thing that you should do is look for signs of a generalized reaction. The signs of a generalized reaction include nausea, vomiting, wheezing, difficulty breathing, itching all over the body, body rash and swelling especially on the face or around the lips. If signs of a generalized reaction occurs contact your local Emergency Medical System immediately. A generalized reaction typically occurs within minutes to an hour after a bee sting, but can occur up to 6 hours later. (1)

The signs of a localized reaction include redness, itching and swelling at the site of the sting. You may see a black dot at the site of the bite which is the detached stinger. A localized reaction does not involve rashes or symptoms on other parts of the body. In some cases a localized reaction may spread. If you notice that the redness and swelling from a bee sting is spreading you should seek medical attention for an evaluation. Redness or swelling that extends beyond two joints of an extremity needs special attention and usually requires treatment with steroids. Increased reddness and swelling at the site may also be a sign of a skin infection. Other signs of a skin infection include fever, warmth at the site, increasing pain, discharge or red lines on the skin.

The first step in treating a bee sting is removing the stinger. If a stinger is present the child was stung by a honeybee. If there is no stinger present then the child was stung by a yellow jacket(which is more likely to cause anaphylaxis), a wasp or hornet. (2) In order to remove the stinger you can flick it off using a credit card by scraping the edge of the card against the skin. Once the stinger is removed, wash the area with warm soapy water and pat dry. It is important to wash the site in order to prevent a skin infection. Next, apply cold compresses or ice to relieve the pain and itching. If you have meat tenderizer in the home, you can make a paste by adding a few drops of water to the powder and apply the paste to the site. Meat tenderizer contains enzymes that destroy insect venom (3) and reduces inflammation and edema. (4) Continually monitor the child for signs of a generalized reaction and watch for increased redness or swelling at the site of a localized reaction.

You can be proactive in preventing bee stings by avoiding insect breeding grounds such as orchards and flower beds. Avoid dressing your children in brightly colored clothes which can attract bees and instead have them wear white or light colored clothing. Always make sure that children playing outdoors wear shoes. Many children get stung on the foot when they walk outdoors on the grass. Bees are attracted to scents therefore avoiding heavily scented soaps, lotions, perfumes or cosmetics may keep the bees away. If you have bee hives or nests on your property have them removed by a professional exterminator with experience in destroying hives.

If a child is allergic to bee stings, he should wear a medic alert bracelet so that adults and health care workers will be aware of the potential for a reaction. (5) It is important for children with a bee allergy to carry an Epipen or emergency epinephrine with him at all times. In addition, all adults caring for a child with a bee allergy should be trained to properly administer the medication in case a reaction occurs. (5) A good way to learn is with an Epipen Trainer. You can obtain an Epipen trainer from your pharmacist or doctor. An Epipen trainer is a device with no medication or needle so that it can be used over and over again for training. It is a good idea to practice with an Epipen trainer so that you can become more comfortable and familiar with the device in case of an emergency. If a generalized reaction does occur, you should administer the Epipen immediately and then call 911 or your local EMS.

For more information about a Medic Alert bracelet contact:
www.medicalert.org

(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. W.B. 2nd ed. Philadelphia, PA:Saunders Company. 1994:1633-1644.
(2) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:1016-1025.
(3)Von Witt R. “Topical Aspirin for Wasp Stings”. Lancet. 1980; 2:1369.
(4)Gaunder B. Insect Bites and Stings: Managing Allergic Reactions. Nurse Practitioner. 1986;11:16-28.
(5)Food Allergy and Anaphylaxis Network. Anaphylaxis. Available at: http://www.foodallergy.org/anaphylaxis/index.html .
Accessed July, 2006.

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

Ask Your Pediatric Health Advice Question

Bone Infections

Dear Lisa,

My son was diagnosed with a bone infection at 17 months old. What are the chances of reoccurrences and is it normal for his body temp has been slightly warmer since the infection?

“Concerned Mom”

Dear “Concerned Mom”,

A bone infection or Osteomyelitis occurs in 1 in 10,000 healthy children per year.(1) The femur and tibia (leg bones) are the most affected bones. (2) Osteomyelitis in children usually occurs as the result of an infection elsewhere in their body that deposits in the bone. The offending microorganism travels to the blood and then the blood carries the infection to the metaphysis or area of the bone that grows. Because children's bones are always growing this is a susceptible place for the infection to settle.(2)

Signs of Osteomyelitis include fever, pain, limp or refusing to walk. Younger children may present with poor feeding, irritability, or sepsis (overwhelming infection). The treatment for Osteomyelitis is intravenous antibiotics. The recommended duration of intravenous antibiotics is from 7 to 21 days. Following this period, oral antibiotics typically are administered for 3 to 6 weeks.(2) In some cases children develop chronic Osteomyelitis which requires much longer courses of antibiotic therapy.

Since different organisms (germs) can cause Osteomyelitis the type of antibiotic and course of treatment may vary. Also, children may respond to treatment differently, therefore, the time frame of recovery may vary from child to child. Signs that a child is improving include alleviation of pain, improvement in the ability to move the affected area and decrease in temperature. Usually a child is not discharged from the hospital until there is decreased pain, improved movement and at least 24 hours without fever. (3)

In regards to your question about your son’s temperature, there should have been a decrease in temperature after treatment. A sign of prolonged temperature is usually a sign of continuing infection. As mentioned above, it does take weeks of antibiotics to treat Osteomyelitis and therefore total resolution may take a while. Your doctor should tell you what temperature range he expects your son to have in relation to the point of therapy he is in. Most doctors agree that a rectal temperature greater than or equal to 100.4 degrees Fahrenheit is considered to be a fever in a child. If this is the case in your son, it would be important to report this to the doctor treating him for his bone infection so that he can monitor your son’s treatment.

There are a few factors that may cause a change in a child’s temperature. Therefore, what you perceive as a change in his temperature may be a normal variation. Depending on the amount of clothes a young child has on and the temperature of the environment the temperature may vary. Sometimes after exercising or eating the body temperature can elevate temporarily. The temperature may also vary depending upon the amount of time that a thermometer is in place and the type of thermometer used. In the course of a normal day a child’s temperature can vary 1 to 1.5 degrees. The lowest reading usually occurs early in the morning before rising and the highest temperature occurs between 5 to 7 pm in the early evening. (4)

The route that you use to take your son’s temperature also may affect the reading. A normal temperature is expected to be 98.6 degrees Fahrenheit if taken orally. If a temperature is taken rectally, it is expected to be one degree higher; therefore a normal rectal temperature is 99.6 degrees. If a temperature is taken axillary, it is expected to be one degree lower; therefore a normal axillary temperature is expected to be 97.6 degrees.

Taking an oral temperature on a 17 month old child is not an option because he is not able to hold the thermometer in his mouth properly. Performing an axillary temperature is also very difficult. You need direct skin to skin contact to get an accurate reading, which is very hard to do on 17 month old child who is moving. The only way to take an accurate temperature on a 17 month old child is rectally. Since the temperature may change due to the amount of time a thermometer is in place correctly, many times rectal temperatures are incorrect due to improper technique due to the child’s movement. I suggest purchasing an electronic rectal thermometer that takes only 30 to 60 seconds to take the reading. Having to hold a toddler still for any longer than this will most likely result in the incorrect reading.

Children at risk for developing Osteomyelitis include those with diabetes, chronic renal disease, rheumatoid arthritis, a compromised immune system or blood disorders ( such as sickle cell anemia). If your child has any of these disorders he would be at increased risk for developing Osteomyelitis. In general the long term complications of Osteomyelitis may include recurrent infection and gait abnormality.(3) Therefore in regards to your question about the probability of developing another bone infection, the chances are higher if he has any of these underlying problems.

Although it can be quite worrisome thinking about the possibility that your child may develop another bone infection, you are in a much better position now that you have experience with the problem. Your familiarity with Osteomyelitis will help you identify symptoms early which will result in proper diagnosis and early treatment. Addressing symptoms such as pain, limp, refusal to walk, fever and limited movement and bringing them to your Doctor’s attention will help your son get the care he needs to recover quickly.

(1) Wilson S, Leonard K, Luchs J, Sena V. Acute Osteomyelitis: Radiographs vs. MRI. Consultant for Pediatrics. 2006;May: 283-284.
(2)Green NE, Edwards K. Bone and joint infections in children. Orthop Clin North Am. 1987;18(4):555-576.
(3)Osteomyelitis. Pediatric Annals. 2006;35(2):113-122.
(4)Bellack J, Bamford P. Nursing Assessment, A Multidimensional Approach. 1984. Belmont California: Wadsforth Inc:283-285.

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

Answers to Questions about Childhood Illnesses

Skin Cancer

Dear Lisa,

My mother told me that children are now developing skin cancer at a young age. Is this true? Are children getting skin cancer? I thought that you got skin cancer when you were older, after years of being exposed to the sun. "What can I do to prevent my son from getting skin cancer?

“Skin cancer in children?”

Dear “Skin cancer in children?”,

You are right, the risk of developing skin cancer does increase with age. According to the 2005 Strouse article from the Journal of Clinical Oncology, the chance of developing Melanoma increases 2.9% per year of life. (1) Therefore, as a person gets older, they develop a greater chance of developing skin cancer. Even though, skin cancer is typically found in the older population, there has been recent documentation in the literature that pediatric skin cancer is on the rise. In the past two decades, pediatric Melanoma cases have increased by more than 100%, according to the Skin Cancer Foundation. (2) So, your mother is right too!

Since skin cancer has always been considered an adult disease, the index of suspicion of skin cancer in the pediatric population is very low. Because of this many Pediatricians do not diagnose skin cancer until it is in the later stages. (3) A retrospective study suggested that part of the reason for the late diagnosis of pediatric skin cancer is because the disease may present differently and the symptoms may appear differently in the young as compared to adults. Interestingly the researchers found that the typical signs of skin cancer that you see in adults are not necessarily the same signs to look for in children.

Most patients and clinicians follow the ABCD rule to determine if a lesion is suspicious for cancer. It turns out that the ABCD rule didn’t always prove helpful in the pediatric population. The ABCD rule outlines typical expectations of a cancerous lesion with each letter representing a typical finding. “A” stands for asymmetry which means cancerous lesions have an uneven shape. “ B” represents border irregularity. “C” stands for change in color of the lesion. “D” represents the diameter or size of the lesion. If the size of the lesion is large, or greater than 6mm it may be suspicious for cancer. This pneumonic guideline is helpful for the adult population, but may not necessarily be a good rule of thumb for children. (4) It was found that Melanomas can start as a speck and do not necessarily have to be the size of an eraser. (3)

In reviewing past cases of pediatric skin cancer, researchers found that of the 33 patients studied; only 14 lesions were asymmetrical. The majority of the lesions did not have an irregular border and actually 29 of the patients had cancerous lesions that had well defined borders. They also found that 14 of the lesions were not brown or black in color. They did find that pediatric lesions tended to be thicker and have nodular features. This study reported that the site of origin in 15 of the 33 children was on the extremities. Ten were found on the trunk, and eight on the face and head. (4) Another important thing to note is that only 20-40% of Melanomas originate from a pre-existing lesions. (5) Therefore the common notion that skin cancer only “develops” over time from an already known lesion is not always true. More than half of the skin cancer lesions diagnosed are not from a pre-existing lesion.

Children who are risk for developing Melanoma include those of white race, with fair skin, blond/red hair, light eyes, freckles, a history of sunburn, a family history of Melanoma, DNA disorders and those with compromised immune systems. (5) Other risk factors include use of indoor tanning booths, history of blistering sunburns and excessive sun exposure. (2,6,7).

The purpose of this information is not to scare you or encourage you to rush to the Pediatrician’s office to get your child checked for skin cancer. Its purpose is to increase your awareness about the possibility that children can get skin cancer too. This information can only help our children by encouraging their parents to be diligent about skin protection and in tuned to any new lesions on their child. Since Melanoma has a 90% cure rate if detected early, measures to prevent and diagnose skin cancer early is the key. (7)

My advice is to watch for the development any new or different looking lesions and bring them to your pediatrician’s attention. If your child has risk factors it is a good idea to have a total body skin evaluation on a regular basis. Your child’s Doctor or Nurse Practitioner can do this at her yearly physical examination. Some children with multiple moles and lesions may see a Dermatologist on a regular basis in order to have a total body skin evaluation. Research by Fisher in 2005 showed that the chances of finding a Melanoma are increased six times by conducting skin cancer screening through total body skin examinations. (8) This type of examination views the entire surface of the body and is critical for detecting melanoma since as much as 80% of melanomas are found on the body area covered by clothes. (7,9).

Lastly, the best prevention is using sun protection. Applying sunscreen every 2 hours while your child is out in the sun and remembering to reapply after swimming is a good idea. This is particularly important in the pediatric population because half of a person’s total sun exposure occurs before age 18. Despite the well known and documented statistics linking sun exposure to skin cancer, still less than 33% of adults, adolescents and children routinely use sun protection according to the Skin Cancer Foundation.(2) Since 90% of all skin cancers are due to sun exposure the simple task of applying sunscreen is your best line of defense.

(1)Strouse J, Fears T. Pediatric melanoma: risk factors and survival analysis of the surveillance, epidemiology and end results database. J Clin Oncol. 2005:23:4735-4741.
(2) Grassia T. The earlier, the better for skin cancer prevention. Infectious Diseases in Children. 2006;May:56.
(3)Johr R. Literature review on pigmented lesions. Presented at: Masters of Pediatrics 2006 Leadership Conference: Jan. 25-30, 2006: Bal Harbour,Fla.
(4)Ferrari A, Bono A. Does melanoma behave differently in younger children than in adults? A retrospective study of 33 cases of childhood melanoma from a single institution. Pediatrics. 2005; 115:649-654.
(5) Richards C. Pediatric melanoma rates increasing. Infectious Diseases in Children. 2006; May:54.
(6) Richards C. Risk of developing melanoma increases with age. Infectious Diseases in Children. 2006;May:55.
(7) Tuchman M, Weinberg J. Why everyone’s skin needs to be examined. The Clinical Advisor. 2006;Feb33-38.
(8) Fisher N, Schaffer J, Berwik M. Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma. J Am Acad Dermatol. 2005:53:393-406.
(9) Richards C. Total body skin exams help save pediatric lives. Infectious Disease in Children. May; 2006.55.

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

Your Pediatric Questions Answered

Vaccine Preservatives

Dear Lisa,

I have a question about vaccines. I am not against vaccinations, but I am very concerned what's in them. I informed my baby's doctor that I don't want any Vaccinations that contain mercury. She said that none of her vaccines except for Flu vaccines have mercury. A few days ago my daughter had her routine visit and 2 shots. One of them was polio. After the doctor left the room I looked at the bottles and read that Polio vaccine had some preservatives and formaldehyde was one of them. I was shocked and very upset. I trusted that doctor will tell me about anything like that. I blame myself for not looking at the bottles before she administered the shot.... Please, tell me about formaldehyde in vaccines. How bad it is. Also, are there any companies that make vaccines without the preservatives? Maybe the next time I will request those. Thank you very much.

“Concerned Mom”

Dear “Concerned Mom”,

You are correct; the Polio vaccine does have formaldehyde as a trace ingredient. The Physician’s Desk Reference (PDR) reports that there is less than or equal to 100mcg residual formaldehyde in the Polio portion of the Pediarix Vaccine(one of the combination vaccines that contains Polio). This formaldehyde is left over from the process that creates the vaccine. There are many steps in the process of making any vaccine. The process involves growing the germ that causes a particular disease and inactivating it, or killing it so that the person who gets the vaccine will not develop the disease.

When making the Polio vaccine, each of the three strains of the Poliovirus are individually grown. After clarification, each viral suspension is purified by ultrafiltration, diafiltration and successive chromatographic steps. After this, it is inactivated with formaldehyde. This inactivation kills the Poliovirus. It is the residual formaldehyde from this process that accounts for the portion of formaldehyde found in the vaccine. If the vaccine was not inactivated, it would be live.

Before the year 2000, live Polio virus was routinely used for vaccination. This live Polio virus was shed in the stool of infants, which put immunocompromised caregivers at risk for contracting Polio. A small percentage of babies who received the live Polio Vaccine developed the disease. To reduce the risk of vaccine associated Paralytic Poliomyelitis, since 2000, an inactivated Polio Vaccine schedule was recommended for routine childhood Polio vaccination in the United States. (1) The Polio virus was changed to the inactivated form in order to protect individuals from getting Polio.

All vaccines have small amounts of preservatives/additional ingredients due to the complicated process that creates them. If the vaccinations didn’t have preservatives they would spoil and be ineffective. Pharmaceutical companies and physicians tend to not report these additives to their patients because they are in such small amounts and are considered safe. The general thought is that the benefit of receiving the vaccine against a disease that can cause death and paralysis outweighs the risk of a trace amount of preservative.

If a child was to contract Polio, the symptoms and long term effects could include meningitis, rapid onset of flaccid paralysis and residual paralytic disease. Paralysis of the respiratory muscles may occur which would render a person unable to breathe. Adults who developed paralytic Poliomyelitis in childhood may develop post-polio syndrome 30 to 40 years later. Post-polio syndrome is characterized by muscle pain, exacerbation of weakness and or new paralysis or weakness.

I truly understand your concern about vaccine additives. Unfortunately, the diseases that childhood vaccines prevent can be devastating and the benefits of the vaccines in most cases outweigh the risk of administration. As a parent it is important to be an advocate for your child and ensure that you provide your child with the best opportunity to achieve health and wellness. It is very smart of you to be concerned about the vaccinations that your child receives, including their actions, benefits and potential side effects.

It is important to discuss your concerns with your daughter’s Pediatrician. Different parents have different levels of information that they wish to receive and different levels of responsibility regarding decision making. For some parents all of the clinical terminology and decisions are overwhelming, for others they feel much more comfortable knowing all of the pros and cons and wish to be more involved in decision making. You certainly have the right to know all of the components of a vaccine that your child receives. You also have the right to know about the possible side effects of each vaccine, and an explanation of the disease state that it prevents.

To find out more information about vaccinations you can read the printed package insert that comes with each vaccine. This is different from the VIS sheets that are handed out to patients that contain general information. The package insert describes the process that was used in making the vaccine and provides a list of all of the ingredients in the vaccine. This information can also be found in the Physician’s Desk Reference. Some parents with allergic children ask their doctor for a copy of this package insert before administering a vaccine to their child, so that they can make sure their child is not allergic to any of the components. If you are interested in the process of making each vaccine and the ingredients you can ask your Pediatrician for a copy of the package insert to review before your child receives the vaccine.

In regards to your question about companies that make vaccines without preservatives. Vaccines that are administered from a single dose vial have less preservatives as compared to vaccines dispensed from a multidose vial. When a doctor’s office uses a multidose vial they use a larger bottle with multiple doses of the vaccine in the bottle. Each time a child needs the vaccine a new needle is used to remove the dose and the bottle is put back in the refrigerator, awaiting the next dose to be given. It may take hours to days before the bottle is empty. The vaccine would spoil if it did not have a preservative. A single dose vial on the other hand, has only one vaccine dose in the bottle or pre-filled syringe. The bottle or syringe is opened and used immediately and then discarded. This type of vaccine has the least amount of preservative because there is no concern that it will spoil between dosages. Some vaccines come in single dose vials, and some don’t. Therefore you do have an option to choose a vaccine with less preservative in some cases. You can ask your Pediatrician if he offers a single dose vial version of the vaccine that your child needs.

It is very wise of you to be concerned about vaccines and their ingredients because pharmaceutical companies are in the process of creating more childhood vaccinations. With the introduction of these new vaccines it is important to educate yourself regarding the diseases that they prevent and the benefit of the vaccines. With each new vaccine, parents have a decision to make. Your Pediatrician can help and guide you regarding which vaccines are necessary for your child. During this dialogue with your Pediatrician there are many questions to be answered. Common questions that parents should ask include:What disease does this vaccine protect my child from? What is the probability of my child getting this disease? What populations are more at risk for getting this disease? Will the vaccine prevent life threatening complications or will it just lessen or shorten the effects of the disease? What are the risks of not getting the vaccine? Is the vaccine intended for 3rd world countries with ineffective sanitation or needed in industrialized countries too? If my child doesn’t get the vaccine and gets the disease naturally will he have better long term immunity?

For more information about childhood vaccines you can log on to the following websites:
www.vaccine.org
www.vaccine.chop.edu
http://www.cdc.gov/

For more information about the additives and components of vaccines you can log on to: www.cdc.gov/nip/vaccine/components/additives.htm

(1) Physician’s Desk Reference. 2004. Montville, N.J. Thomson PDR at Montville. 1594-1599.

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

Pediatric Advice About Keeping Kids Healthy

Night Terrors

Dear Lisa,

Hi - I have an eight year old son, who about an hour and half after going to bed wakes up crying. He will sometimes get out of his bed crying and searching out for me but most times he sits up in bed until I get there. I talk to him but he doesn't answer and after a couple of minutes of me sitting with him he stops crying and goes back to sleep. Although I sometimes feel he is actually not awake when he cries. I ask him in the morning if he remembers crying and coming to me but he remembers nothing. What could be causing this? Is he having bad dreams? He doesn't remember so he can't tell me. He is very active, diagnosed with ADHD and takes Concerta in the morning and Ritalin (10 mg) late afternoon though by the time he goes to bed the Ritalin has worn off. I feel bad that he wakes up crying and I can't seem to help him other than just holding him.

“Crying in his sleep”

Dear “Crying in his sleep”,

It sounds like your son is having Night Terrors. Night Terrors are sleep state disturbances that typically occur 1 ½ hours after a child goes to sleep. Children experience them during the transition out of slow wave sleep. When a child has a Night Terror he wakes at night intensely anxious and agitated. The child tends to sit up in bed and cry or scream and appears to be staring at something. A child having a Night Terror typically is disoriented and does not respond to his caregiver’s soothing. After a few minutes the child tends to fall asleep on his own and usually does not remember the episode in the morning.

In order to prevent Night Terrors from occurring you need to break the sleep cycle, since Night Terrors are a sleep cycle disturbance. You can break the sleep cycle, by waking your child ½ hour before the time the episode typically begins. Once you wake your son, have him walk around the house for a few minutes and then let him go back to bed. If you do this a few nights in a row, it should break the sleep disturbance pattern and he should stop having Night Terrors. Since children tend to have Night Terrors when they are overtired or when they don't get enough sleep it is important to make sure your son is well rested in order to prevent the Night Terrors from occurring.

Sometimes what appears to be Night Terrors may really be seizure activity. Seizure activity, unlike Night Terrors commonly occurs early in the morning before arising. (1) Therefore if the symptoms occur early in the morning instead of shortly after going to sleep at night , it would be important to have an evaluation to rule out seizures. If you are not sure if your son’s symptoms are consistent with Night Terrors, you can video record the event and bring in the tape to your Pediatrician for review.

Interestingly, Obstructive Sleep Apnea, another type of sleep disorder, is associated with Attention Deficit Disorder. It is thought that Obstructive Sleep Apnea results in ADD symptoms. (2) The signs of Obstructive sleep apnea include, pauses in breathing during sleep, excessive sleepiness during the day, hyperactivity during the day, nocturnal enuresis (bedwetting), night time awakenings, restless sleep, poor school performance, mouth breathing, behavioral problems, loud snoring or stridor. Since your son has ADD it is important to look for signs of Obstructive Sleep Apnea. If your son is experiencing symptoms consistent with Obstructive Sleep Apnea, you should bring this to your doctor’s attention. There are pediatric doctors that specialize in sleep disorders and if indicated your son’s Pediatrician may refer you to one.

Children with ADD tend to have difficulty sleeping. The disorder itself is associated with sleep disruption. (2,3) Additionally, many times the medications for ADD contribute to difficulty sleeping. If your son’s symptoms started when he began or increased his ADD medication, you should tell the prescribing doctor. Sometimes medications dosages, times of medication administration or type of medication need to be adjusted in order to alleviate side effects. Other times, a child just needs to get used to a new medication or different dosage.

It can be very stressful for a parent to watch their child have a Night Terror. Especially when your child does not respond to you. The good thing is that children do not remember the event in the morning. Also it is reassuring to know that most children outgrow Night Terrors in time. If your son continues to have night time symptoms, contact his Pediatrician for further guidance.

(1)Rosen, G. General Overview of Neuroanatomy and Neurophysiology of Sleep. Presented at Pediatric Sleep Disorders Conference. JFK Medical Center, NJ; May 31, 2002.
(2)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.
(3)Kaplan BJ, McNicol J, Conte RA, Moghadam HK. Sleep disturbance in preschool-aged hyperactive and nonhyperactive children. Pediatrics. 1987; 80:839-844.


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

Pediatric Medical Questions Answered

Heat Exhaustion

Dear Lisa,

My friend’s child was sent home from camp today sick. His mother told me that he had heat exhaustion. How does a child get heat exhaustion? Is there anything that I can do to prevent my child from getting it? Is there something they did at camp that could have caused it?

“What is heat exhaustion?”

Dear “What is heat exhaustion?”,

Heat exhaustion is one of the heat related illnesses caused by an accumulation of body heat. It can develop when children are exposed to extreme heat or strenuous exercise. The incidence of heat related illness in the United States is 17.6 to 26.5 cases per 100,000 people.(1) Risk factors for heat exhaustion include children with a fever or illness, dehydration, hot environment, young age, use of certain medications (neuroleptics or sedatives), ingestion of alcohol, use of over the counter supplements with creatine or ephedrine, excessive activity, prolonged heat exposure, and not being acclimated to a hot environment. (2) Activities that put children at risk for developing heat exhaustion include; accidentally leaving a child in a hot car, excessive exercise in the heat, exercising when a child has a temperature and prolonged sauna exposure.

When the body overheats it compensates by shunting the circulation to the extremities so that the excess heat can be removed through sweating. When the body loses a large amount of fluid, it no longer can produce sweat. Because the body cannot produce sweat, it is not able to lower its core temperature. (3) As a result the body becomes too hot and symptoms of heat exhaustion ensue.

The symptoms of heat exhaustion include elevated temperature, dry hot skin, mental status changes such as dizziness or lethargy, nausea and vomiting. If the symptoms go untreated a child may develop heat stroke which is a life threatening condition. Signs of Heat Stroke include; a temperature over 104 degrees Fahrenheit, a fast heart rate, quick breathing, vomiting, diarrhea, headaches, abdominal pain, dizziness, seizures and coma. Heat stroke is a medical emergency. Any child showing signs of heat stroke should seek medical attention immediately.

If your child shows signs of being overheated you should first take him out of the heat and remove excess clothing. Cool him down by giving him something cold to drink. Sponge his body with cool water, making sure that he does not shiver, because this would cause the body temperature to elevate. (4) Children with signs of heat related illness should be evaluated by their health care provider.

The best treatment is knowing the cause of heat related illnesses and taking measures to prevent them. Make sure children don’t exercise when they have a fever or gastroenteritis. Teach teenagers the dangers of drinking alcohol, and using creatine or ephedrine. Do not let children go into saunas and never leave children unattended in a car, especially with the windows rolled up. Children should avoid excessive exercise in extreme heat. Children who exercise in the heat should always be monitored by an adult. Make children take fluid breaks when exercising in the heat. A 40 kg child should drink 150 ml of cold liquid every 30 minutes while exercising in the heat. (4) Children should avoid wearing heavy clothing when exercising and instead wear light weight clothing.

(1)Jones, TS, Liang AP, Kilbourne EM. Morbidity and mortality associated with the July 1980 heat wave in St. Louis and Kansas City, Mo. JAMA. 1982;247:3327-3331.
(2)Dawson G. Unusual case of heat stroke in a young boy. The Clinical Advisor. 2006;March:50-5.
(3)Bouchama A, Knochel JP. Heat Stroke. N Engl J Med. 2002;346:1978-1988.
(4)Betz C, Hunsberger M, Wright S. Family Centered Nursing Care of Children,2nd ed. 1994; Philadelphia: W.B. Saunders Company:315.

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

Pediatric Health Advice- Updated Daily

Introducing Milk

Dear Lisa,

I have a 1 year old daughter and I was wondering about the best way to introduce her to milk. She is currently on Nutramigen formula because as a newborn she was constantly spitting up and vomiting the other formulas and she was a bit colicky. Is it OK to start with whole milk?

“Introducing Milk”

Dear “Introducing Milk”,

It is a good idea to introduce milk slowly to babies who had previous symptoms of a sensitivity or allergy to milk based formula. Symptoms such as vomiting and colic in infancy could be a sign of either a milk allergy or Gastroesophageal Reflux. Most babies outgrow both of these problems by the time they are 9 to 12 months old. Children with a history of severe milk allergy in infancy should not start milk at one year old until they are evaluated by an Allergist. Symptoms of a severe allergy to milk include difficulty breathing, hives and facial swelling.

Although most babies “outgrow" food sensitivities by one year old, there are some babies that tend to manifest symptoms longer. There has been some recent literature reporting milk allergy lasting longer than what was originally thought. In particular children with Asthma, Eczema or those with a history of a severe reaction to milk tend to keep their allergy longer. (1)

I found in my practice that by one year old, many babies have ingested small amounts of milk mixed in foods that they have eaten. For examples, parents commonly reported that their babies ate yogurt, a piece of cake made with milk or a pancake made from milk. Babies that ingested small amounts of milk in other forms and didn’t develop a reaction, tended not to have a problem with milk when it is introduced at a year old. On the other hand, those babies that developed symptoms when they ate items that contained milk, tended to have problems when they introduced whole milk at one year old.

If your daughter ingested small amounts of milk in other forms in the last couple of months and developed symptoms, it is a good idea to have her evaluated by your health care provider before adding whole milk to her diet. When introducing whole milk to your child, it should be introduced slowly so that she can become accustomed to the new taste and temperature. If you hand a bottle of cold milk to a child who is used to Nutramigen, there's a good chance that she'll throw it at you!

Start by taking an 8 ounce bottle and fill it with 6 ounces of Nutramigen (at the temperature that you normally give it to her) and 2 ounces of cold whole milk. Coninue to give these same proportions for three days and watch for a reaction. The most common signs of a food allergy include, hives, eczema, other rashes, vomiting, abdominal pain, diarrhea, congestion, cough, difficulty breathing, and wheezing. (2) I found children who are allergic to milk may also develop a rash on the skin where the milk dripped or red blood streaks in the stool.

If there is no reaction then progress to 4 ounces of Nurtramigen mixed with 4 ounces of cold whole milk. Give this for three days and watch for a reaction. Next, give her 2 ounces of Nutramigen and 6 ounces of cold whole milk for three days. Once again watch for a reaction and if everything is unchanged give her full strength cold whole milk. Over this period of time your daughter will get used to the taste and temperature of cold milk and you shouldn’t have problems with her refusing the bottle.

If at any point your daughter develops symptoms consistent with an allergy or sensitivity, go back to full strength Nutramigen and contact your health care provider. I found that many children who continued to have symptoms at 12 months tended to outgrow their allergy later; closer to 15 months. If this is the case, try reintroducing milk at 15 months, following the same procedure.

If severe symptoms such as hives, facial swelling or problems breathing occur when you introduce milk you should contact your healthcare provider right away. Children with severe milk allergy should be seen by an Allergist.

References:
(1)Fiocchi A, Terracciano , Sarratud T. On tolerance to cow’s milk in various clinical presentations. Abstract 11. Presented at: 63rd Annual Meeting of the American College of Allergy, Asthma and Immunology; Nov. 4-9, 2005; Anaheim , Calif.
(2) Wood RA. Food allergy: comprehensive diagnosis. Workshop 37. Presented at :63rd Annual Meeting of the American College of Allergy, Asthma an Immunology; Nov. 4-9, 2005; Anaheim, Calif.

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

Pediatric Questions Answered

Chronic Cough

Dear Lisa,

My 5 year old daughter has been coughing for three weeks. I brought her to the Pediatrician’s office and I was told to give her an antibiotic for a sinus infection. She never got better and now her cough is worse. She’s waking up at night coughing and during the day her cough sounds terrible. Six months ago she had the same symptoms and was diagnosed with pneumonia. I am worried that the cough may be from Asthma since I have Asthma and I remembering coughing like that when I was young. I went back to the Pediatrician’s and she said that we’ll have to watch her and wait and see if she is developing Asthma. If it is Asthma, why can’t she tell now? Can the cough be from something else? Why can’t she just give her cough medicine to make her stop coughing?

“Coughing a lot”

Dear “Coughing a lot”,

It is important to find out the cause of a chronic cough in a child before administering medication. (1) In the pediatric population, a cough is considered chronic when it lasts more than 3 weeks. Since your daughter has a cough for three weeks it is necessary for her to have a complete evaluation in order to find out the source of the cough. A complete evaluation includes a physical examination, a detailed past medical history, family history, environmental history, social history and laboratory testing.

Repeated evaluations over a period of time may be necessary to ascertain the cause of a cough. It is common for healthcare practitioners to see patients for frequent follow-up visits in order to see if new symptoms develop, if the cough goes away on its own, if it worsens with exposure to triggers or if there is a response to medication.

Cough medications are not recommended because there is no clinical evidence from controlled studies that they work in the pediatric population. (2) Preparations containing Dextromethorphan or Codeine may cause nausea and vomiting which will make a child more uncomfortable. More serious side effects of respiratory suppression may also occur with these preparations. (2,3)

It is important to remember that a cough itself is a symptom and the body’s way of protecting the airway. Coughing prevents mucus from dripping into the airways. The force of a cough expels the mucus in the lungs out of the body. A cough may be a sign of inflammation of the bronchial tubes, an infection, an irritation or in some cases a habit.

A child may develop a chronic cough due to a variety of health conditions including; Asthma, respiratory infections, Pertussis, foreign body aspiration, Tuburculosis, Gastroesophageal reflux, environmental pollutants, allergies, post nasal drip, airway lesions, vascular malformations, Cystic Fibrosis or a habit. (1, 4), This is a long list and the important thing to know is that majority of cases of children with a chronic cough have Asthma, Gastroesophageal reflux or Sinusitis. (5) Sometimes the place where a child lives and travels may be a greater indicator of the cause of a cough. A study done in India found that the most common causes of chronic cough in children between ages 1 and 12 years were Asthma, Tuberculosis, Sinusitis, Pertussis, Gastroesophageal reflux and respiratory infections. (6)

Unfortunately there is no one test that determines if a child has Asthma. The diagnosis of Asthma is based on a child’s history, physical examination, clinical presentation, response to medication, family history and laboratory tests. The diagnosis is usually made after all of these factors are evaluated and only after other causes of chronic cough are ruled out. This process takes time and in most cases repeated evaluations.

Asthma is defined as a chronic inflammatory disease of the airway that results in airway obstruction in response to a trigger. Asthma is recurrent in nature and reversible. Since Asthma is expected to be recurrent, many practitioners will wait to see if symptoms reoccur and will make the diagnosis only after the child's third episode.

In response to your question about medication for the cough; cough suppressants are not recommended. A reasonable option is to give your daughter a trial of Asthma medications for 2 to 3 weeks to see if her symptoms are reversible. If a child is treated for an Asthma related cough, the cough should respond to inhaled steroids and go away within 2 to 3 weeks. (3) Other indicators that a child with a chronic cough may have Asthma include nocturnal coughing, a cough in response to a trigger (such as exercise or environmental exposure) and a history of Eczema or Allergies.

There is a strong correlation between Asthma, Allergies and Eczema. (7,8) It also has been shown that allergies are one of the most important predictors for Asthma. (8) Asthma is up to three times more likely to develop in individuals with allergic rhinitis than those without allergic rhinitis. (9) Therefore if your child has Allergies and or Eczema, this may also tilt the scales in favor of a diagnosis of Asthma.

A child has a genetic predisposition to develop Asthma if her parents or family members have Asthma, Allergies or Eczema. If one parent has Asthma, a child has a 25 % chance of developing Asthma. If both parents have Asthma there is a 50 % chance that a child will develop Asthma. Therefore, there is a probability that your daughter will develop Asthma since you have Asthma.

It must be very frustrating and worrisome watching your daughter cough. It is important to follow up with your Pediatrician and see the evaluation through to get to the bottom of the reason for her cough.

References:
(1) Nield, L, Kamat D. How to Handle Chronic Cough in Kids: A Practical Approach to the Workup. Consultant for Pediatricians. 2003; Sept:315-321.
(2) Bell, Edward. Is codeine a useful medication in pediatrics? Infectious Diseases in Children. 2006;July:12.
(3)Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics. ACCP evidence-based clinical practice guidelines. Chest. 2006;129:260S-283S.
(4) Chronic Cough in Children: New Guidelines Offer New Direction. Consultant for Pediatricians. 2006; April:251-256.
(5) Hollinger LD, Sanderd A. Chronic cough in infants and children: an update. Laryngoscop. 1991;101(6, pt 1):596-605.
(6)Mogre VS, Mogre SS, Saoji R. Evaluation of chronic cough in children: clinical and diagnostic spectrum and outcome of specific therapy. Indian Pediatr. 2002;39:63-69.
(7)Hogan B, Wilson Nevin. Asthma in the School-Aged Child. Pediatric Annals. 2003. 32(1): 20-25.
(8) Kumar R The Wheezing Infant: Diagnosis and Treatment. Pediatric Annals. 2003. 32(1):30-36.
(9) Grossman J. One airway, one disease. Chest. 198;111(2suppl):11S-16S.

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

Advice for Parents with Sick Kids

Molluscum

Dear Lisa,

My daughter’s friend has Molluscum. She visits our house regularly and we have a swimming pool. I do not want to make her feel bad and exclude her, but I am worried that my daughter will catch the rash if she goes in the pool. She is a good friend and I don’t want to break up their friendship by not letting them play together. How is Molluscum spread? Can my daughter catch this?

“Friend with Molluscum”

Dear “Friend with Molluscum”,

Molluscum contagiosum is a viral skin infection that is caused by a pox virus. Molluscum is common in childhood and presents as flesh colored, waxy bumps with umbilicated tops. In children the rash is typically found on the trunk and extremities. The size of the bumps range from 2-6 cm and may be larger in people that are immunosuppressed, such as in people with HIV. (1)

Transmission occurs from person to person by direct skin to skin contact or from contact with shared objects such as towels, gymnasium equipment and locker room benches. There have been some recent reports of swimming pool use and Molluscum contagiosum. (1) The incubation period is 7 to 60 days, so if your daughter does catch this from her friend, it might not show up for a couple of months.

Generally, Molluscum contagiosum is a benign disorder which usually is asymptomatic and rarely has complications. Complications include an eczema like reaction which occurs in about 10% of cases. In people with dark skin the healed lesions leave behind an alteration in the color of the pigment, resulting in a white or brown flat spot. Very rarely the lesions leave a chickenpox-like scar. (1)

In regards to your daughter’s friend, this is a very touchy situation. If you eliminate her from playing at your home or playing in your pool you may cause her to be insulted and embarrassed. On the ohter hand, if she has close contact with your daughter, shares clothes or towels, or swims in the pool, she may spread the disease. Although the obvious thing to do is to avoid this friend in order to stay free of Molluscum this may not be necessary if you take the proper precautions. Besides, separating the children may put a strain on their relationship.

Perhaps, engaging in activities together that do not involve intimate contact would be a better choice. You can still maintain their friendship by having them play together in activities that do not involve skin to skin contact such as going to the movies, going bowling or doing arts and crafts together. If the lesions are covered and not exposed there is no reason to be concerned about catching the disease. On the other hand, if the lesions are exposed (located on the arms or face) and the children engage in close contact such as hugging other measures need to be taken. You can gently ask her mom to cover the lesions with a band-aide or tight fitting shirt. Most parents are sensitive to the spreading germs to other children and should not be insulted by this.

The important thing to remember is that even though the incubation period for catching this skin condition usually is 2 to 7 weeks, it may take up to 6 months to manifest itself. So in reality, your daughter may already have been exposed and any attempts to separate the children at this point might not make a difference. Additionally, Molluscum contagiosum typically lasts 9 months; which is a very long time to avoid a good friend. Since Molluscum is a very common childhood rash, if your daughter doesn’t catch it from her friend, she may catch it from another child.

Once you examine all of the scenarios, you can make an informed decision knowing how Molluscum contagiosum is spread. If you decide to continue to have your daughter’s friend in the pool, it would be a good idea to teach your daughter not to share towels. So as not to single out your daughter’s friend, a general rule to not share towels with all guests is a good practice to follow. This will protect all children because many skin infections can be spread this way. Also, discourage the children from borrowing or sharing clothes, and avoid dress up games where the children try on different play outfits and play out a story.

(1) Dermatologic Look –Alikes. Molluscum contagiosum. The Clinical Advisor. 2006(April):98.

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

Pediatric Health Questions Answered

Travel

Dear Lisa,

Hello. I have an emergency situation with a family member who lives in Europe. I have to fly there to visit for about a week. Would it be OK to leave my 17 months old daughter with her father and my mother or should I take her with me to Europe? I am the one who takes care of her all day and I don't know how the separation would affect her. However on the other hand I don't like the idea of her flying across the ocean.Thank you.

“Need to Leave the Country”

Dear “Need to Leave the Country”,

It sounds like you are needed by a family member in Europe. If you bring your daughter with you, you will not be able to give 100% of your attention to the situation. Although you are used to taking care of your daughter all day, the disruption in her routine traveling over seas may be a stress on you and her. In addition, trying to take care of her and the emergent situation at the same time may also be very draining. It is a long plane trip, and many children at that age do not do well confined to a small area. Being that your mother and baby’s father are willing and able to take care of your child, it seems like a viable option to leave her home in an environment that is familiar to her.

Developmentally, children experience the greatest stress from separation from their mother at 9 months old. (1) The developmental stage of a 17 month old is quite different. At this stage children are very interested in exploring and learning about their environment. She probably will be quite content doing this with the company and attention from her dad and grandma. It will also be a great bonding experience for her dad who will get to spend so much time with her, not to mention the benefits of the wisdom and love she will receive from grandma. Children grow and learn from interactions with different caregivers. Therefore, giving your daughter the opportunity to be with other adults will teach her social skills and encourage her to be more versatile.

Ultimately, it is your decision if you are going to bring her or not, because you are the mom and know what is best for your baby. Be assured that many parents leave their child for a multitude of reasons and the children do just fine. I’m sure your daughter will miss you because you are her mom, but at her age she can be distracted with activities and will not remember that you were gone when she is older. It is reassuring to know that a person’s long term memory does not have the ability to recall events under three years old.

On the other hand, I am more worried about you. You may have a more difficult time with the separation than she will. One of the most difficult things to be, is a mother. Chances are, no matter where you go, your child will always be a part of you and you will always feel the need to take care of her. Planning special mommy and daughter time when you get back can help you get through it. If you do decide to go, be prepared that she may snub you for a little while when you get back. Just be patient because if this does occur it will be short lived. Before you know it, you’ll be back to your regular routine again.

Have a safe trip.

(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 329-330.

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

Pediatric Advice Updated Daily

Career as a Nurse Practitioner

Dear Lisa,

Hi, I was writing a paper on Pediatric Nurse Practitioners and I was wondering besides the joy of working with children what are other reasons why you became a PNP?

“Future PNP”

Dear “Future PNP”,

I have to say that my career has always been a work in progress. I did not know that I was going to be a Pediatric Nurse Practitioner (PNP) when I was in High School deciding upon a career path. A matter of fact, I didn’t even know I wanted to become a PNP when I entered college. The one thing that I did know was that I wanted to work in the health field because it always amazed me how the human body worked. I was always interested in Anatomy and Physiology and medicine. I excelled in Math and Sciences and my school counselors and parents encouraged me to become a pharmacist. Initially this was the path that I took. I decided to learn more about being a pharmacist, so I got a job as a pharmacy technician when I was a senior in High School. By the time I finished my freshman year in college I figured out that pharmacy was not for me.

I realized that I wanted to be more involved with patient care and at that point in my life enjoyed the excitement and challenge of working in a hospital. I changed my major to nursing after talking to a few nurses who inspired me and explained what nurses really do. During undergraduate nursing school I worked in a doctor’s office and as an EKG technician in a major medical center where I was exposed to all types of nursing. That’s when I knew that I would become a pediatric nurse.

Pediatric nursing always interested me because of the wide variety of health conditions and all of the different developmental stages of childhood. What amazed me the most was how resilient children are. A child could go through a major operation and have multiple dressings, tubes and IV lines and all you have to do is mention the playroom and they would hobble there if they had to, with a big smile on their face. I also enjoyed the teaching aspect of nursing and found in pediatrics, parents are always willing to learn how to better take care of their children.

After working in the hospital for years I found myself at a point in my life where I needed to learn more and have more responsibility. I decided to go back to school for my masters degree with the intentions of going into teaching. When I met with one of my previous professors, she told me that I wanted to become a Pediatric Nurse Practitioner. I wasn’t even sure what a Pediatric Nurse Practitioner was at the time. I remember telling her, "no I want to teach" and she said, "no, you want to become a Nurse Practitioner". She was right!

The problem was, in 1989 the role of the Nurse Practitioner was not well recognized in New Jersey and I didn’t have many role models to look to. The more I learned about the role of the Nurse Practitioner, the more I realized that my professor was right. Even by the time I graduated with my masters degree four years later, the role of the Nurse Practitioner was still not fully understood or accepted. I remember Pediatricians telling me that I would never get a job and others questioning if what I was doing was against the law! They were wrong.

Luckily, the role of the Nurse Practitioner is much more recognized and understood today. Now, I meet young high school girls who tell me that when they grow up they want to become a Nurse Practitioner. That just puts a smile on my face because I know that it is a wonderful career and an honor to be able to take care of patients in the capacity of a Nurse Practitioner.

I wish you much success in your career. You have made a good choice.

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

Pediatric Advice Website Updated Daily

Vomiting

Dear Lisa,

My 2 ½ year old daughter was up all night vomiting. She doesn’t have any other symptoms. I tried giving her water, but she threw that up too. My doctor told me that she probably has a stomach virus. Is there any medication I can give her to make her stop vomiting? What should I give her to drink?

“Vomiting all night”

Dear “Vomiting all night”,

Unfortunately the anti-emetic medications that are prescribed for adults to stop vomiting are not recommended for children because of their side effects. Occasionally, these medications may be given to an older child, but there is a risk that the side effects can cloud the clinical picture. If a child becomes tired and listless on this medication you will not be able to decipher if it is due to worsening of her condition or if it is a side effect of the medication.

The best thing to give a 2 1/2 year old is ice in the form of Pedialyte pops, ice pops or homemade ice pops. The coldness of the ice will help take away the sensation of nausea. I do not recommend giving ice cubes to this age group because of the risk of choking. You can make your own ice pops from an ice cube tray using Pedialyte, Gatorade, sugar sweetened iced tea, sugar sweetened lemonade, or white grape juice. First pour the liquid into an empty ice cube tray. Next place aluminum foil over the ice cube tray. Take 7 straws and cut them in half with a scissor so that you end up with 14 short straws. Pierce the aluminum foil covering each small rectangular cube with the straw and leave the straw in the hole that you make. The straw should stand upwards because of the stiffness of the aluminum foil. Finish putting the rest of the straw pieces in each of the remaining cube spaces, each time piercing through the aluminum foil. When you are finished, put the ice cube tray in the freezer and wait 1 hour and 15 minutes. The homemade cubes will be frozen and ready to eat. Remove the aluminum foil and take out one cube at a time. The straw becomes a handle which perfectly fits a little child’s hand.

The child can lick the ice cubes slowly until the vomiting and nausea goes away. Licking ice cubes is a good way of intaking small amounts of fluid. If you give a child who is vomiting large amounts of fluids or if the child drinks the fluid too quickly she will probably just throw it up. Once your child stops vomiting you can advance to Pediatlye in a cup. Start out giving only 2 ounces at a time every 15 minutes, and if she doesn’t vomit you can continue to increase the amount slowly. Rehydration with oral electrolyte solutions such as Pedialyte is successful in 90% of children with dehydration from gastroenteritis. (1) Pedialyte is the preferred liquid to give to a child with vomiting or diarrhea because it contains the proper balance of fluid and electrolytes that are needed in order to rehydrate a child.

The problem I found is that many children do not like the taste of Pedialyte, regardless of the flavor purchased. If this is the case you can experiment with different brands of electrolye solutions. I have had some success with grape flavored Gerber electrolyte drink which is very similar to Pedialyte. Children who like grape juice or the taste of Dimetapp elixir tend to like this. For those children that won’t take these electrolyte drinks, the second choice would be Gatorade, sugar sweetened iced tea, sugar sweetened lemonade, white grape juice or pear juice.

I prefer not to use apple juice because it tends to cause diarrhea. Usually diarrhea follows the vomiting phase in children with gastroenteritis therefore the addition of apple juice may just worsen the situation. If your daughter refuses to take any liquids at all you can use a medicine dropper or syringe and squirt the liquid into her mouth. Instill one dropperful into the side of your daughter’s mouth between her cheek and gum every 5 to 10 minutes. This can prevent your child from becoming dehydrated and developing an electrolyte imbalance.

Water is not a good choice of liquids to give a child with vomiting or diarrhea. Water does not contain any of the essential electrolytes that are needed for body functions. When a child develops a fluid and electrolyte imbalance from vomiting, diarrhea or sweating; sodium, chloride, potassium and glucose need to be replaced. These electrolytes can be found in the correct proportions in Pedialyte, but are not found at all in water. Children who drink water alone as a means of replacing fluids during a stomach virus will remain dehydrated and may suffer the consequences of an electrolyte imbalance.

The vomiting phase of a stomach virus typically lasts 4 to 8 hours. If your child continues to vomit beyond this point and you can’t get her to drink any fluids she should be seen by a health care professional. Additionally, if the vomiting is associated with severe abdominal pain, headache, cough, rash or fever this may represent a problem other than a stomach virus. If this is the case your daughter should be evaluated by your Doctor or Nurse Practitioner. Other concerning signs include bilious vomiting (thick foamy greenish yellow vomit), vomiting with excessive coughing, a child with Asthma who vomits mucus, blood in the vomit, high fever, inconsolability, listlessness and signs of dehydration. If your daughter has any of these symptoms, she should be evaluated without delay.

Unfortunately there is always that small percent of children with a stomach virus whose symptoms are so severe that rehydration cannot be accomplished at home. Less than 5 % of children with gastroenteritis will need intravenous fluids and emergency treatment for fluid and electrolyte imbalance.(2) Signs that your child is dehydrated and rehydration attempts are not successful include; lack of voiding or urination, sunken eyeballs, sunken fontanel(soft spot), dry mucus membranes, non-elastic skin, decrease in tear production, listlessness, irritability, increased heart rate and inability to keep down liquids. If you notice these signs you should seek medical attention.

(1)The American Academy of Pediatrics. Practice parameter: The management of acute gastroenteritis in young children. Pediatrics. 1996; 97:424-435.
(2)Fonesca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis. A meta-analysis of randomized controlled trials. Arch Pediatr Adolec Med. 2004;158:483-490.

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

Pediatric Health Questions

Swimmer's Ear

Dear Lisa,

My daughter has right ear pain. She has been swimming a lot. How can I tell if the ear pain is from swimmer’s ear or from an ear infection? If she’s having a lot of pain does that mean it must be an inner ear infection?

“Ear Pain”

Dear “Ear Pain”,

“Swimmer’s Ear” or acute otitis externa is an infection of the external auditory canal. Swimmer’s ear affects one in every 100 to 250 Americans each year. It frequently occurs in children who have been swimming since the water trapped in the ear canal can lead to inflammation and infection. Trauma to the ear canal, such as a scratch from a cotton swab, fingernail or foreign body may also lead to otitis externa or swimmer’s ear. The symptoms of swimmer’s ear includes pain with chewing , pain with touching or manipulation of the tragus (the triangle shaped piece of cartilage that is located in front of the ear canal opening, at the level where the cheek bone and jaw bone meet), white cheesy discharge from the ear, and ear pain.

An “ear infection” or acute otitis media is an infection behind the eardrum in the space of the middle ear. It is a common complication of an upper respiratory infection. The symptoms include deep ear pain, ear pain which increases at night or when lying down, pulling or holding the ears, pain with sucking, cough, runny nose, fever, irritability, and difficulty hearing. If a child has otitis media, the ear drum may spontaneously rupture due to the pressure of the accumulated exudate behind the eardrum. If this occurs there will be an immediate relief of pain and a discharge will come out of the ear canal. This discharge typically has a bad odor and usually is very sticky. This discharge should be gently cleaned from the exterior of the ear (not with a cotton swab) because it may cause an infection of the ear canal (swimmer’s ear) or the skin around the ear (cellulitis).

The level of pain that a child has cannot differentiate one type of infection from another. Even though most people feel that an inner ear infection is the most painful, “Swimmer’s ear” is also many times very severe and can interfere with a child’s normal activity level. (1) In addition, a child can have both swimmer's ear and a middle ear infection at the same time. The only way to be sure which type of infection your child has is to have an examination by a Doctor or Nurse Practitioner.

Children with swimmer’s ear should not participate in swimming until the infection clears. Most cases resolve in 7 to 14 days with proper treatment. The treatment for swimmer's ear includes pain medication as well as ear drops with an antibiotic/antiseptic and cortisone as ingredients. The ear drops typically provide prompt relief if administered correctly. (1) Proper adminstration involves cleaning the debris out of the canal before the drops are instilled. If the ear canal is very swollen your Doctor or Nurse Practitioner may put an ear wick in the canal to ensure the drops get into the ear. Once the drops are administered, the child should lie flat on her side for 20 to 30 minutes. Within twenty-four hours of starting the ear drops there should be a marked improvement in your child's condition. Therefore, if a child diagnosed with swimmer’s ear does not have any improvement in pain, she should be re-evaluated in order to rule out other health problems such as an inner ear infection or cellulitis of the surrounding area.

(1) Rosenfeld RM, Brown L, Cannon CR. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2006;134:S4-S23.

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

Pediatric Advice for Sick Kids

Introducing Juice

Dear Lisa,

I have a six month daughter who is on formula and I'm wondering when is it safe to allow her to start drinking water alone and juices?

“Is it time for Juice?”

Dear "Is it time for juice?”,

At 6 months old it is okay to introduce juice to babies. Whenever you introduce a new food or drink to a child for the first time, you should wait three to five days from the introduction of the last new food and wait another 3 to 5 days before adding the next new item. During this time you should observe your infant for signs of a sensitivity or allergic reaction. If you introduce items too quickly or more than one item at a time, and your child has a reaction, you will not know what food or drink caused the reaction.

It is a good idea to start with ½ strength juice. You can add 1 ounce of water per 1 ounce of juice to make ½ strength juice. For a 4 ounce bottle, add 2 ounces of water to 2 ounces of juice. Some babies develop diarrhea or a diaper rash when they are given full strength juice, therefore, diluting the juice may prevent this from happening. If your baby does not have a reaction then you can gradually increase to full strength juice as your baby tolerates it.

Giving a baby juice is not meant to replace formula. By the time a baby is 6 months old, she should be taking 28 to 32 ounces of formula per day. If your baby is taking this amount of formula and has been gaining weight appropriately it is okay to give 4 ounces of half strength juice per day. You can start giving your baby juice when you introduce the cup. The sweet flavor of the juice will be an incentive for a baby to try drinking from a cup.

Developmentally a baby is ready to start using a cup at 6 months of age. A cup with a spout and handles will be easier for your baby to hold. The process of using a cup teaches coordination and strengthens the muscles in the mouth which are necessary for future speech development. This is achieved when a baby brings a cup to her mouth, pours the free flowing fluid, controls the flow of liquid with her mouth and swallows it. It is not recommended to use a spill proof cup or “sippy” cup when teaching a baby how to drink from a cup. A “sippy” cup requires that the baby sucks on the cup the same way that she sucks on a bottle. This does not exercise the muscles in the mouth that promote speech development.

When choosing a juice, stay away from juices with more than one ingredient, because you will not know which ingredient she is sensitive to if she has a reaction. Also juices with strawberries should not be introduced until 12 months of age, because strawberries tend to be an allergic item. White grape juice, apple juice and pear juice are good choices. The added benefit of choosing these light colored juices is that they won’t stain when your child makes a mess. Don’t be surprised if your baby cannot drink from the cup right away. It usually takes most babies weeks of practice to learn how to drink from a cup and in the beginning many babies just play with the cup.

I prefer that babies do not drink juice from a bottle because this may encourage the development of dental carries. Dental carries and “bottle mouth” occurs if a baby sucks on the bottle for a length of time, goes to sleep with a bottle or keeps the bottle in the mouth for comfort. Each of these scenarios causes the teeth to be exposed to the juice for a long period of time which can lead to cavities. (1) In addition the ingestion of excessive amounts of juice and sweetened drinks have been linked to obesity. Therefore 4 ounces of juice per day is sufficient.

Usually it is not recommended to give a baby water. Nutritionally, an infant needs the calories from formula or breast milk for proper growth and development. Water does not provide any calories or nutrition. If you feed a baby water she may take less formula and not receive the nutrition that she needs.

There are some instances when water is indicated. An infant needs water if she is exposed to extreme heat as in the case of a baby who is outside in the sun or at the beach. In this case 1 to 2 ounces of water should be given in between feedings in order to prevent infants from becoming overheated or dehydrated. Water is also indicated for infants who are constipated. For infants with hard stools it is a common recommendation to give 1 to 2 ounces of water or sugar water per day to help alleviate the constipation. Once a baby is 6 months old it is okay to give her a small amount of water in a cup in order to teach her how to swallow. It is important to remember that water should never be given in order to replace formula or a feeding.

(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Delmar Publishers, New York.2nd ed 1984; 683.

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

Pediatric Advice For Healthy Babies

Celiac Disease

Dear Lisa,

I brought my daughter to the doctor’s because she was having a lot of stomach aches. She has been having diarrhea and has lost weight. The doctor ordered some tests and told me that she needed to be tested for Celiac Disease. What is Celiac Disease and how do you get it?

“Need to know more about Celiac Disease”,

Dear “Need to know more about Celiac Disease”,

Celiac Disease or gluten-sensitive enteropathy is an autoimmune disease that is brought on by the ingestion of gluten. Gluten is the major protein found in wheat, rye and barley. Celiac Disease is also considered a malabsorption disorder because gluten ingestion causes intestinal inflammation which leads to inadequate absorption of nutrients. Therefore, children with Celiac Disease develop problems when they eat foods with gluten.

The symptoms of Celiac Disease vary from person to person. Celiac Disease can appear any time in life in genetically susceptible individuals. It can be triggered by surgery, a viral infection, severe emotional distress, and childbirth. In children, the symptoms tend to start between 6 months and 2 years old and include diarrhea or constipation, abdominal distention, signs of malnutrition, failure to thrive, lack of appetite, short stature, irritability, lack of energy and developmental delay (1).

The development of symptoms can develop weeks to months after consuming products that contain gluten. Earlier symptoms usually include poor weight gain which eventually leads to weight loss. Older children may present with less typical symptoms which include recurrent abdominal pain, nausea, vomiting, bloating, constipation, short stature, delay in puberty, iron deficiency, dental enamel defects and abnormalities in liver function tests. (2) The long term effects of untreated Celiac Disease include recurrent miscarriages, infertility, osteoporosis, seizures, hair loss, dental abnormalities, anemia and malignancy.(3)

Celiac Disease is thought to be an inherited disorder since 5-15% of first degree relatives- parents, siblings or children of a person who has biopsy-proven Celiac Disease also test positive for the disease (4) People with other autoimmune disorders such as Type 1 diabetes mellitus, thyroid disease, systemic lupus erythematosus, liver disease, collagen vascular diseases and rheumatoid arthritis have an increased risk of developing Celiac Disease. Between 5-10% people with Down’s syndrome will be diagnosed with Celiac Disease. (3)

The treatment for Celiac Disease is a gluten free diet. Eliminating gluten from the diet stops intestinal inflammation, stops tissue damage and allows the lining of the intestines to heal. Once the proper diet is adhered to, the small intestine typically heals within 6 months. (3) Removing gluten from a child’s diet seems like a very simple solution to what can be a very serious health condition, but this diet is sometimes hard to maintain.

Gluten can often be a hidden ingredient of many products such as herbal supplements, vitamins, minerals and as an inactive ingredient in common medications. (5) Besides this, most of the popular children’s food such as cereal, bread, bagels, pasta, cookies, waffles, pizza, hotdog and hamburger rolls and snack bars all contain gluten. Children with Celiac Disease are also not supposed to eat oat even though it does not contain gluten. The problem is cross-contamination, or accidental mixing of oat with wheat, rye and barley in the plants that commercially prepare oats in the United States. (5)

Children with Celiac Disease should maintain a diet including plain meat, fish, rice, potatoes, fruits and vegetables. Potato, rice or soy flour can be substituted for wheat flour in recipes. If your daughter is diagnosed with Celiac Disease, be assured that it is treatable with the proper dietary modifications. A consult with a nutritionist can assist you with meal planning, choosing the appropriate foods and giving you information about the types of foods that tend to have gluten as hidden ingredients.

For more information about Celiac Disease contact The National Institute of Diabetes and Digestive and Kidney Diseases:

http://www.digestive.niddk.nih.gov.

References:
(1)Leffler D, Saha S, Farrell RJ. Celiac Disease. Am J Managed Care. 2003;9:825-831.
(2) Gelfond D, Fasano A. Celiac Disease in the Pediatric Population. Pediatric Annals 35(4):275-279.
(3)Rewers M. Epidemiology of Celica Disease: What are the prevalence, incidence and progression of Celiac Disease? Gastroenterology. 2005;128(suppl):47-55.
(4)National Digestive Disease Information Clearinghouse. Celiac Disease. Available @ www.digestive.niddk.nih.gov/ddiseases/pubs/celiac. Accessed July 2006.
(5)Kupper C. Dietary guidelines and implementation for celiac disease. Gastroenterology. 2005;128(suppl):121-127.

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

Pediatric Advice Website