Thursday, August 31, 2006

Sweaty Teenager

Dear Lisa,

My 15 year old daughter sweats a lot and it embarrasses her terribly. Now that school’s around the corner it just makes matters worse. She sweats so much that it stains the underarm area of her shirts which makes her very self conscious. She has to change her shirt a couple of times a day because she sweats so much. I wanted to ask her Doctor about it, but she is too embarrassed about it to tell anyone. I have tried many over the counter antiperspirants, but nothing seems to help. Is there anything that I can do to help her?

“Sweating too much”

Dear “Sweating too much”,

Excess sweating or “Hyperhidrosis” affects 2.8 % of the U.S. population or 7.8 million people. (1) So you can reassure your daughter that she is not alone. Hyperhidrosis is a medical condition where the sufferer produces four to five times the amount of sweat than a person without the condition. People with the condition can experience excess sweating on their face, hands, feet or underarms. Usually the amount of sweat is too difficult to conceal which can cause a lot of distress, especially for a teenager. Teenagers typically are self conscious about their bodies and tend to want to fit in with the group. It is at this time of life that Hyperhidrosis typically begins, with the average onset between 14 and 15 years old. (1)

It is common for teenagers to refuse to talk about the problem because of their fear of being ridiculed. (1) So, it is not surprising that your daughter did not want you to bring it up with the Doctor. It can be a very sensitive issue and the emotional and social aspects of having Hyperhidrosis can affect a teenager’s life in many ways. The sweating can be very embarrassing many times to the point where some teenagers won’t participate in sports, dances, clubs, social gatherings or other activities. (1) Some students won’t participate in class because they are afraid to raise their hand and expose the sweat stains on their shirt. Teenagers with Hyperhidrosis commonly experience social anxiety, negative self-esteem, paranoia and depression. (1) Therefore it is important for parents like yourself to take the condition seriously and seek out professional help.

There are some measures that you can take that will help your daughter. Drysol is a highly potent topical antiperspirant that is very successful in treating teenagers with excess sweating. (2) It can be obtained by prescription from your daughter’s Doctor. Perhaps if you told your daughter that there is a treatment that will help her, she would be more willing to see the Doctor about it. I found that the teenagers that I treated were very happy with the results and reported that it was better than any over the counter product that they used.

A teenager can use antiperspirants on their underarms and also spray it on the soles of their feet and between their toes. Antiperspirants are the first line treatment for excess sweating and work by plugging the sweat ducts, which reduces the amount of sweat that reaches the skin. A side effect of antiperspirants can include skin irritation, if this occurs contact your daughter’s Doctor for further treatment.

The choice of clothes that your daughter wears is also important. Pick fabrics that breathe, such as cotton, preferably in layers. (1) A lot of teenagers prefer layers of cotton shirts, wearing a sleeveless shirt under another shirt with sleeves. This way they can remove the top shirt when it gets stained. Your daughter can use absorbent insoles in her shoes and leave the shoes out to dry for a day rather than wearing the same shoes everyday. This way the shoes get a chance to dry out before wearing them again. (1) It is a good idea to avoid shoes or sandals made from plastic, rubber or fake leather because they tend to cause more sweating. (2) Also, certain foods people eat cause them to sweat. Your daughter can keep a record of those foods that cause her to sweat more and avoid eating them in public.

Adolescents with excess sweating of the feet are at risk for developing “Athlete’s Foot”. “Athlete’s Foot” is a fungal skin infection found between the toes. The symptoms include redness, itching and scaling in the toe web spaces. (3) A secondary bacterial infection may occur because of the warm moist area of shoes. (3) If your daughter develops any of these symptoms it would be important to have her evaluated by her Doctor.

If your daughter’s excess sweating causes her psychological stress or can not be controlled with the above measures, it is important to discuss this with her Doctor. She may need to be screened for physiological complications such as depression. Or a Dermatologist may be consulted in order to help select a treatment plan that can help treat her problem. (1) Some patients may be candidates for one of the latest treatments for excess sweating; Botox.

Botox injections have been used for various medical conditions including cerebral palsy, stroke and for cosmetic purposes to treat facial lines. In 2004, the FDA approved Botox or botulinum toxin type A to treat Hyperhidrosis. This treatment has been found to block the nerves that stimulate the sweat glands. A patient is injected with the botulinum toxin at the site where there is excess sweating and the medication works by freezing the nerve that normally stimulates the sweat gland. The treatments can be administered in the doctor’s office and typically last for 6 to 9 months. I have never had a patient that needed this treatment because most of them responded well to Drysol. Although, the Dermatologists that I dealt with did recommend and use this treatment successfully.

More information can be found about Hyperhidrosis on the Hyperhidrosis Society’s Web site at There’s a section on the site for teens called “Teen Sweat 101”. Your daughter may find comfort in knowing that there are other teens that are experiencing the same symptoms.

(1) Grassia T. Hyperhidrosis is not a “no sweat” issue when it comes to teenagers. Infectious Diseases in Children. 2006. May: 50.
(2)Hyperhidrosis Society’s Web site. Available at: Accessed August 2006.
(3)Treadwell P. Spot the Rash. Infectious Diseases in Children. 2006. June:66.

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

Pediatric Advice for your Teenager

Wednesday, August 30, 2006

Caring for Infant's Teeth

Dear Lisa,

My son is 16 months old and has 4 teeth. When are you supposed to start brushing a child’s teeth? At what age should a child see a dentist?

“Is it time to Brush Teeth?”

Dear “Is it time to Brush Teeth?”,

Dental problems in childhood many times start early, for some children as early as infancy. An infant who sleeps with a bottle or breastfeeds throughout the night after the first tooth eruption is at risk for tooth decay and other dental problems. (1) In order to prevent dental carries it is commonly recommended to wipe an infant’s gums with a clean wet washcloth at bedtime. (1) Once teeth erupt, they should be wiped with a clean wet washcloth at bedtime or brushed with a soft bristle toothbrush and water. (1)

Infant toothpastes such as Baby Oragel toothpaste can be used to make brushing more tasteful and enjoyable to the child. (1) It is not recommended to use Fluoride toothpaste until a child is over 2 years old. Children ingest toothpaste during brushing and if the toothpaste contains Fluoride the child can develop Fluorosis. Fluorosis occurs when a child ingests more than the recommended daily amount of Fluoride. Signs of Fluorosis include mottling of the teeth (the appearance of white spots on the surface of the teeth), brown stains on the teeth, and pitting and erosion of the enamel. (2)

Dental carries or cavities are one of the most common pediatric health problems. They are five times more common than Asthma and seven times more common than Hay Fever. (3) Food with a high carbohydrate content can lead to the development of dental carries. If teeth are exposed to foods high in carbohydrates for a long period of time, dental carries can occur. The practice of having a child drink milk before bedtime, without brushing puts him at risk for developing cavities. (1)

Other foods that may also contribute to the development of cavities include cookies, candy, ice cream, peanut butter and jelly sandwiches, dried fruit and raisins. (2) Sweet sticky snacks in particular pose a threat because they remain on the teeth for extended periods of time. Food stuck to the teeth overnight while a child is sleeping can not be washed away with drinking water. In addition a person’s saliva is dryer at night which only contributes to the stickiness of the food left on the teeth. (1)

The bacterium that causes cavities is called Streptococcus mutans. This organism is many times passed from a mother to her child. (1) Therefore sharing of items such as toothbrushes should be avoided. In addition, a parent should not clean off a baby’s pacifier or nipple by putting it in their mouth because this can potentially spread the organism from the parent’s mouth to the baby’s. (1)

There are different policies on when children should have their first visit to the dentist. The American Dental Association recommends that children see a dentist no later than their first birthday. (4) Each Pediatrician may have their own recommendation regarding when an infant should first see a dentist. You should ask you son’s Doctor or Nurse Practitioner what his or her recommendations are.

In general the first dental visit should occur between 1 and 3 years old, when a child has 6 to 8 teeth in place. (1) Children with craniofacial abnormalities such as cleft lip or cleft palate, delayed tooth eruption or tooth decay should see a dentist earlier rather than later. Cavities run in families, therefore it would be prudent for children with a family history of multiple cavities in childhood to also see a dentist earlier rather than later.

The purpose of the first dental visit is to identify any potential problems and to counsel parents on proper oral health. From my experience, most parents of one year olds complain that their child did not cooperate with the first dental exam. If this is the case, the Pediatrician or Nurse Practitioner can evaluate the child’s teeth and gums during the well child visits and educate parents on proper oral health until the child is ready for a visit with the Dentist.

(1)Grassia T. Talking teething: Start good oral hygiene early. Infectious Diseases in Children. 2006. August:44.
(2) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 677-679.
(3)American Academy of Pediatrics. Children’s Health Topics. Oral Health. Available at: Http:// Accessed August 2006.
(4)American Dental Association. Oral Health Topics A-Z. Teething. Available at:
Http:// Accessed August 2006.

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

Pediatric Advice For Infants

Tuesday, August 29, 2006

Burning with Urination

Dear Lisa,

Today my 8 year old daughter was at the pool all day in her bathing suit swimming and playing in the hot sun. Now it’s 8:30 at night and she tells me that when she went to the bathroom to urinate that it burned and only a little urine came out. Otherwise she is acting normal and doesn’t have a temperature. The doctor’s office is closed and I won’t be able to bring her in for a visit until the morning. Is there anything I can do in the mean time to help the burning go away? How can I tell if her symptoms are from a urinary tract infection?

“Worried about a urinary tract infection”

Dear “Worried about a urinary tract infection”,

A young girl can develop discomfort with urinating after being outdoors in the sun and in the pool all day for a couple of reasons. Wearing a wet bathing suit for a long period of time may cause a vaginal irritation or a vaginal yeast infection. (1) Also exercising in the heat for extended periods may cause a child to become overheated and dehydrated. This is a concern if your daughter did not drink extra fluid today while outside in the heat.

Ours bodies compensate for overheating and dehydration by concentrating and withholding urine. When the urine becomes concentrated it can burn when it comes out. Therefore the pain your daughter felt with urination may have been due to external irritation from concentrated urine. Also, she may have noticed only a small amount of urine output because of mild dehydration.

The first thing you can do is give your daughter extra fluids to drink. She should have two large cups of liquids, such as sugar sweetened iced tea, lemonade, cranberry juice or Gatorade. If she urinates a couple of times and no longer complains of burning it means that she drank enough.

If your daughter still complains of burning with urination or continues to have only a small amount of urine come out at a time, you can give her a baking soda bath. This will soothe the exterior vagina in case it is irritated. You can sprinkle a couple of Tablespoons of baking soda in a warm bath and let her sit in it for 20 minutes. This will soothe the area and take away any irritation.

When your daughter gets out of the bathtub, gently pat her dry instead of rubbing the area. You can externally wipe (do not insert into the vaginal opening) an over-the-counter anti-fungal crème such as Monistat or Lotrimin to her outer vagina. (2) These anti-fungal cremes treat vaginal yeast infections. When she goes to bed, she should wear a light cotton nightgown with no underwear so that the area stays dry.

If your daughter still has symptoms despite these interventions, she should be evaluated by a healthcare professional in order to rule out a urinary tract infection. Signs of a Urinary Tract Infection include pain with urinating, change in urinary pattern or flow, urinary incontinence, change in urinary stream, urinary frequency, urinating in the middle of the night, visible blood in the urine, diarrhea, foul smelling urine, abdominal pain, back pain, irritability or fever. (1)

To test for a Urinary Tract Infection, your doctor will need a clean catch urine sample collected in a sterile container in order to do a urine culture. (1) Therefore it is a good idea to have your daughter drink fluids before going to the doctor’s office so that a sample can be obtained.

If your daughter is exhibiting signs of a Urinary Tract Infection, having a lot of discomfort with urination, experiencing abdominal pain, develops a fever or if she has a history of Urinary Tract Infections, it would be important to contact her doctor this evening for further guidance. Some after hour clinics are open late into the evening, which may be an option for you if your daughter’s symptoms persist, interrupt her sleep or cannot be tolerated until the doctor’s office opens in the morning.

I hope she is feeling better soon.

(1) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1524-1526.

(2)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 492.

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

Pediatric Advice For Parents with Sick Kids

Monday, August 28, 2006

Toddler with Yellow Skin

Dear Lisa,

I was looking at my 1 ½ year old son today and he looks a little yellow. His fingertips, feet, ears and the tip of his nose are yellowish-orange. He otherwise is a healthy little guy, he hasn’t been sick and has no problems eating or going to the bathroom. He’s not on any medication that could be causing any side effects. What could this be from?

“Son is yellow around the ears”,

Dear “Son is yellow around the ears”,

Many times the yellowish discoloration of a toddler’s skin is due to the type of food that he eats. Toddlers that eat a lot of orange vegetables may develop Carotonemia. Carotenemia is a benign condition that develops in children who ingest large amounts of Carotenoids over a long period of time. (1) Carotenoids are found in orange vegetables such as carrots, sweet potatoes and squash. Carotenemia is harmless and can be reversed by reducing the amount of orange vegetables in a child’s diet. (1) I found that if the amount of servings of orange vegetables is reduced to 2 to 3 times per week the yellowish-orange color of the child’s skin should disappear.

Jaundice is a different condition that involves the discoloration of the skin and sclera due to the build up of bilirubin. Children with jaundice develop yellow skin as well as yellow eyes. Therefore if the whites of a child’s eyes are yellow this would represent a more serious condition. Childhood conditions that cause jaundice include infections such as Hepatitis, Liver Disease, Hemolytic Anemia, medication side effects, prematurity, or bilirubin glucuronyl transferase enzyme deficiency. (2) If the whites of a child’s eyes are yellow this would require immediate medical attention.

Hepatitis is an inflammation of the liver caused by a virus;Hepatitis A Virus, Hepatitis B Virus, Hepatitis C virus or Hepatitis D virus. (3) Hepatitis A is spread through the fecal-oral route and is the least serious of the four types. (3) Hepatitis B is a blood borne pathogen which is transmitted through contact with bodily fluids, such as during unprotected sex, sharing of needles, contact with infected blood or from mother to child at birth.

The symptoms of Hepatitis include jaundice, fever, chills, fatigue, malaise, nausea, vomiting, anorexia, fever, abdominal pain, dark urine, pruritis (itchiness), acholic stools(light grey colored stools) and hepatomegaly(liver enlargement). (3) Many people with Hepatitis do not display any symptoms at all. (3) Interestingly, 70% of cases of Hepatitis A in children younger than 7 years old are subclinical or do not display symptoms. (4) Hepatitis is of a great concern because chronic Hepatitis B infection usually leads to liver inflammation and can progress to cirrhosis and liver cancer. (3,5)

If a child demonstrates orange discoloration localized to only his hands, you may want to review the amount and type of hand soap used. An interesting case documented in the literature describes a young adult female with an orange discoloration only on her hands. It turns out that she had an obsessive compulsive disorder which resulted in repetitive hand washing with an orange colored anti-bacterial hand soap. As a result her hands became stained orange. (6)

If you baby’s yellow discoloration is limited to his skin and his eyes remain white, you can try to limit the amount of orange vegetables that he consumes. After a few weeks you should notice that the yellowish color has dissipated. If it is too difficult to discern if your child’s eyes are yellow, it would be a good idea to have him checked by a health care professional. From the description that you gave, it sounds like your son is healthy and not exhibiting signs of Hepatitis or other conditions that present with jaundice. If your son develops changes in his feeding pattern, irritability, vomiting, abdominal pain, fever, flu like symptoms, light colored stools, dark urine, yellow eyes or has been exposed to someone with Hepatitis he should be examined by his doctor.

(1)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990:22-23.

(2)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:748-749.
(3)Holloway M, D’Acunto K. An update on the ABC’s of viral hepatitis. 2006. The Clinical Advisor. June:29-39.
(4)Brunell P. New hepatitis recommendations issued. Infectious Diseases in Children. 2006. June:4-5.
(5)Infectious Diseases in children. High Hepatitis B infection rate found among NYC’s Asian American Community. 2006. June.20.
(6)Adams D. Orange pigmentation and other skin clues. The Clinical Advisor. 2006. August:111-112.

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

Pediatric Advice About Keeping Kids Healthy

Friday, August 25, 2006

Problem Waking in the Morning

Dear Lisa,

It is a nightmare getting my 10 year old son out of bed in the morning. Every school year it’s a problem. He hates getting up in the morning and he’s so grumpy when he does get up. I have tried everything but nothing seems to work. I tried to make him go to sleep earlier, but he just stays awake in his room. I threaten him that he will get detention at school for being late but he doesn’t seem to care. Now that September is around the corner I am dreading the return to school. He’s been staying up late at night all summer and waking up late in the morning. I know he’ll never get out of bed in the morning for school. Any suggestions to change my son’s behavior and get him to go to sleep earlier?

“Son won’t wake up for school”

Dear “Son won’t wake up for school”,

Each person has his own circadian rhythm or sleep wake cycle. Some people are “morning types” and like to wake up early and go to sleep early. Some people are “evening types”, they like to go to bed late and wake up late. This is a genetically determined propensity. (1) The problem is many times a child’s circadian rhythm is not always congruent with the rest of the family’s schedule or his school schedule. Unfortunately, there is little that you can do to change someone’s circadian rhythm. There are some measures that you can take to adjust the time a child wakes up and falls asleep.

It is common for families with school age children to encounter problems when their child stays up late at night and wakes up late in the morning during the summer break. (2) Typically this behavior cannot be changed in a couple of days and the process needs to be adjusted weeks before a child returns to school. (2) In general it takes about 2 to 3 weeks to make a change in any childhood behavior and sometimes months to change sleep behaviors. (2)

In order to get a child adjusted to going to sleep earlier and waking up earlier you will have more success if you start with an adjustment of the morning routine, instead of the nighttime routine. If you attempt to put your child asleep earlier, chances are this will not work because your son will not be tired enough to fall asleep. Instead start by waking your child up earlier in the morning. Wake your child up 15 minutes earlier than his usual wake time. Continue this for a week so that he will gradually get used to the change.

If your child has been waking up at 9:00 a.m. and he needs to wake at 7:30 a.m. for school, start by waking him at 8:45 a.m. After one week, start waking him up at 8:30 a.m. for the next week. Continue waking him earlier each week until you reach his goal.

During this time do not make any change in his nighttime routine and let him go to sleep the time he is used to. After a few days he will become sleep deprived from waking up early and he will naturally fall asleep earlier. By keeping the evening routine the same, it prevents a confrontation and stress in the household before your child retires.

Increase activity and emotional stress before bedtime many times interferes with normal settling down and a child’s ability to go to sleep. It is important for your child to engage in quieter activities before retiring so that he will have have an easier time going to sleep. (2)

This is the point where every parent asks, "How am I supposed to wake him up in the morning if he is so tired?" The answer is to use light. Light is the most powerful circadian time cue and the greatest driving force that affects a person’s circadian rhythm. (1) People are uniquely sensitive to light during the beginning and at the end of the circadian cycle. (3) Therefore adjusting the amount of light can help children naturally wake up.

The reason why we wake up is because our body senses the light which is a natural alarm clock that makes a person wake. In order to help your child wake in the morning, open all of the shades and put all of the lights on in your child’s bedroom 30 minutes before the time that you expect him to wake up. If you want him to wake at 9:00 a.m., then open the shades and put the lights on at 8:30 a.m. The bright light shining in his eyes when he is sleeping should naturally wake him up. Following this same idea, make the house dark by turning off the lights 30 minutes prior to the time that you would like your child to go to sleep.

Patience is the key, since children generally take a few weeks to adjust to any change in their routine. Your child will still probably be grumpy in the morning and sometimes may become discouraged. Praise your son’s accomplishments because this will encourage him to make this change in his routine and give him the confidence that he needs to succeed.

There are certain health conditions that may alter a child’s sleep pattern. Some children with respiratory conditions such as Asthma may spend a lot of time waking at night due to coughing, which will make them more tired in the morning. (3) Also children with Obstructive Sleep Apnea are many times excessively tired in the morning due to the excessive awakening at night. (3) Medications may also interfere with a child’s sleep pattern. (1)

Certain medications for Attention Deficit Disorder may keep a child awake at night, while long-acting anti-histamines for allergies may make a child more sleepy and difficult to arouse in the morning. If your child has a health condition that may interfere with his sleep pattern or if he is on medication it would be important to discuss this with your Doctor. Sometimes adjustments in a child’s medication needs to me made in order to provide a child with restorative sleep.

I hope you have a happy and successful school year!

(1)Rosen G. General Overview of Neuroanatomy and Neurophysiology of Sleep. Presented at: Pediatric Sleep Disorders Conference: May 31, 2002:Edison.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:310.
(3) Rosen G. Circadian Rhythm Disorders in Children. Presented at: Pediatric Sleep Disorders Conference: May 31, 2002:Edison.

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

Your Pediatric Questions Answered

Thursday, August 24, 2006

Belly Button Discharge

Dear Lisa,

My baby is 7 weeks old, he has a yellow-green discharge from his belly button, he does not have a fever, and there is no red color around it either. If it was urine or bowels draining from his belly button wouldn't he have an odor coming out of it?

“Very concerned mom”

Dear “Very Concerned Mom”,

Typically a newborn’s umbilical cord falls off between 2 to 3 weeks of life. Once the cord falls off the area should heal and dry within a couple of days. A baby's belly button should not have discharge coming out of it after this time. Since your baby is 7 weeks old, the cord should be completely healed and dry. If you notice that your baby’s belly button has a yellow green discharge, it is most likely soiled from your baby’s bowel movement or dirty diaper. It is very common for babies to have a large bowel movement that fills the diaper and dirties the belly button area. The stool that comes out of the baby’s bottom many times seeps around to the front of the diaper and sticks to belly button. The color and consistency of a newborn’s bowel movement is typically yellow-green and sticky. If a baby is breastfed this stool should not have an odor.

The first thing you should do is give your baby a bath with warm soapy water. The bath should wash away any stool that may be stuck in the belly button. Sometimes you may need to use a Q-tip and gently wipe the belly button area to clean away the stool. After the baby is clean and dry, recheck the site to see if the discharge returns.

Signs of “Omphalitis” or a belly button infection include redness and warmth of the skin around the belly button area, fever, irritability and a discharge from the belly button that has a foul odor. (1,2) If your baby develops any of these signs it would be important to have him checked by his Pediatrician. It would also be important to have your baby checked by his Pediatrician if after cleaning your baby there is still discharge oozing out of the belly button. Your Pediatrician can take a sample of the discharge if necessary in order to determine if the discharge is due to an infection.

In regards to your question about urine or bowel contents draining from your baby’s belly button, this is not very likely. If your baby had a condition where there was a communication between the belly button and the bowel or bladder, it would have been identified at birth or shortly after during one of his routine well child physical examinations. In addition, conditions such as these are very rare. In some cases there may be a cyst in the area that can drain. Chronic discharge from the umbilical area may be a sign of a draining omphalomesenteric cyst or urachal cyst; but then again these conditions are also very rare.(1,2) If your baby has had chronic discharge it would be important to tell your Pediatrician about it. Other concerning signs include a baby with a fever, abdominal distention, difficulty feeding, vomiting or irritability. If any of these signs occur you should bring your baby into the Pediatrician’s office for an evaluation.

Having a newborn baby is a very exciting and a very scary experience. Because the baby’s body looks so different from ours and it is constantly growing and changing, it is very common to become alarmed when we see something different. Sometimes a look “from a second pair of eyes”; from a person with experience with babies is all that we need to reassure ourselves that everything is okay. Other times, a parent knows their child and instinctively feels that something is wrong. My recommendation is to never be afraid to have your baby checked if you are uncomfortable with something or if you feel that there is something wrong. I can’t tell you how many times a parent came in to the office with questions about their newborn and were embarrassed when there was nothing wrong. No new parent is expected to know everything and there is never a reason to be embarrassed when it comes to the health of your child.

I hope everything goes well and you enjoy your new baby.

(1) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:497.
(2) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:173.

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

Pediatric Advice About Caring for your Newborn

Wednesday, August 23, 2006

Oral Thrush

Dear Lisa,

My 3 week old daughter has a white coating on her tongue. My sister said it is thrush. I am breastfeeding her and she seems to be eating without any problem. She doesn’t have any rashes, she has a bowel movement everyday and there is no fever. What are the signs of thrush? Why do babies get thrush and how do I treat it?

“White coating on baby’s tongue"

Dear “White coating on baby’s tongue”,

Oral Thrush or Oral Candidiasis is a fungal infection caused by Candida albicans. Oral Candidiasis is commonly found in a baby’s mouth during the first 6 months of life. It presents as a white coating on the tongue or as white patches with an irregular border inside the mouth, in the back of the throat and on the inner lips. The white patches may look like curdled milk. (1)

Many times a coating of milk on a baby’s tongue may be mistaken for Oral Thrush. In order to decipher if the white coating on the baby’s tongue is due to milk or Thrush you can give your baby a few sips of water to drink. If the coating washes away, then the tongue coating was milk. If the coating remains your baby’s Doctor or Nurse Practitioner can evaluate your child to determine if the condition is Oral Thrush.

If a baby’s tongue is scraped with a tongue depressor and the white film comes off easily, then the coating was due to milk. If the coating is difficult to remove and the tongue starts to bleed or if a red raw area is exposed after the scraping, then the coating is due to Candida. (2)

Candida albicans is found on the skin, in the mouth, intestinal tract and vagina of healthy individuals. Five percent of all newborn infants contract Thrush when they are born, through the decent of an infected birth canal. Typically a Candida albican infection results 7 to 10 days later. (1,2)

Infants are susceptible to contracting oral thrush because they lack the circulating anticandidal factor present in the blood which keeps individuals free from Candida infections. This factor is absent or deficient in newborns during the first 6 months of life. (2) Other factors which make individuals more susceptible to Candida infections include use of antibiotics, administration of steroids, immunodeficiency, HIV, Diabetes and low birth weight infants. (1) Children with Asthma who take inhaled steroids are also at risk for developing Oral Thrush. Using holding chambers or spacer devices when taking inhaled steroids cuts down on the risk in this population. (3)

Treatment for Oral Thrush includes the application of a fungicide to the inside of the mouth four times per day. (2) The medication Nystatin is commonly used and can be prescribed by your Doctor or Nurse Practitioner. This liquid medication is given via a syringe or dropper which should be squirted on each side of the baby’s mouth. It is important to continue treatment for the duration that your Doctor prescribes even if the lesions seem to have cleared. (2) Many times the infection will reoccur if stopped too soon.

In addition to fungicide therapy, the baby’s bottles, nipples and pacifiers need to be cleaned. Simply washing these items in a dishwasher is not good enough. The dishwasher leaves plastic items wet and if the bottles, nipple and pacifiers are left wet and stored in a dark place, the organism may grow. Bottles, nipples and pacifiers should be dried well and left on a countertop exposed to the sunlight until the moisture is gone.

In addition, breastfeeding mothers may need to visit their Doctor or Obstetrician in order to see if they have a Candida infection too. They may need to treat their breasts with a topical antifungal creme because many times the Candida infection is also present on breastfeeding Mother’s breasts. If left untreated the infant can become re-infected when they breastfeed. I found that many Mothers experienced a lot of breast pain especially during breastfeeding when they had a Candida infection.

If your baby has recurrent Candida infections, difficulty feeding, fever or a concurrent diaper rash she should see her Doctor or Nurse Practitioner for an evaluation.

(1)American Academy of Pediatrics. Candidiasis. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:162-164.
(2) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1702-1703.
(3)Hogan B, Wilson N. Asthma in the School-Aged Child. Pediatric Annals. 2003;32(1):20-25.

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

Pediatric Advice Website Updated Daily

Tuesday, August 22, 2006

Iron Deficiency Anemia

Dear Lisa,

My 2 year old son went to the Pediatrician’s for a check up yesterday and the doctor told me that his hemoglobin level was lower than normal and he has mild anemia. The doctor said that my son was not getting enough iron in his diet and told me that I have to start giving him more food with iron. I admit, he is a very picky eater, but I thought that I was giving him nutritious food. Are there any other reasons besides improper diet that cause inadequate amounts of iron? What foods are a good source of iron? Any foods that kids like?

“Need more Iron in Son’s Diet”

Dear “Need more Iron in Son’s Diet”,

Iron Deficiency Anemia is the most common cause of childhood anemia. The major factors that cause Iron Deficiency Anemia in children include the rapid increase in body size (blood volume) of a child and the insufficient amount of iron in the child’s diet. Young Children, two years old and younger and teenagers are at the greatest risk for developing Iron Deficiency Anemia. Children 2 years old and younger are particularly at risk for developing Iron Deficiency Anemia because of their high rate of body growth during this period of their life combined with poor dietary iron intake. (1)

Children who drink a lot of cow’s milk (more than 1 quart per day) also tend to develop Iron Deficiency Anemia. (3) It is thought that microscopic amounts of blood are lost in the stool in children who drink a lot of milk. (2,3) In addition the phosphate found in cow’s milk binds with iron removing it from the body. This prevents the body from absorbing the amount of iron that is needed. (3) If you son drinks more than 24 ounces of milk per day and is a picky eater, he may be filling up on milk and need more iron fortified solids in his diet.(3)

Some children develop Iron Deficiency Anemia because they have “Pica”. (1) Pica is a condition where children purposefully ingest objects with no nutritional value. Children with Pica tend to put everything in their mouth and eat it. These children can commonly be found eating things such as paper, clay, plaster, dirt, hair or paint chips. (3)

Foods that are high in iron include liver, iron fortified cereals, iron fortified pastas, iron fortified breads, dried fruit, beans, meat, and eggs. (3,4) Liver contains the most iron, but it may be impossible to get a child to eat it. However, many children will eat a slice of liverwurst. I recommend a low fat brand of liverwurst because it is less sticky and easier for a child to pick up. Regular liverwurst is very sticky and many children do not like the texture and consistency on their fingers.

Luckily, most children do like Cheerios which is a good source of iron. One half cup of cheerios with skim milk fulfills 50% or half of all the iron requirements needed for a child under 4 years old. One whole egg contains approximately 1.2 mg of iron. Therefore mixing an egg into soups, pasta, rice or as an additive to recipes will increase the amount of iron that your child ingests per day. A small hamburger patty contains approximately 1.5 mg of iron, and many children like to eat hamburgers on a roll.

Four halves of dried apricots contains 1.7 mg of iron, which is also a great source of iron. Spinach, another good source of iron contains 1 mg of iron per 1/4 cup. Unfortunately, most children do not like spinach but they are likely to eat it if you mix it in their food. You can add pureed spinach or spinach from a jar of baby food to soups, pastina or red sauce in order to get your child to eat it. Adding Molasses to recipes also adds iron to a child's diet. Molasses contains 1.2 mg of iron per Tablespoon. You can add one tablespoon of Molasses to muffin mix, bread mix or cake mix when baking. This will not only increase your child’s iron intake but add moisture to the recipe. Children who refuse to eat beans may eat nachos with a bean dip.

Not all of the iron available in a food source is absorbed by the body. (3) The bioavailability of iron from food sources ranges from only 1 to 20 percent. In other words, if your child consumes a food source containing 10mg of iron only 1 mg or ten percent of the iron is actually absorbed from the intestine. Foods enriched with Vitamin C improve the absorption of iron; therefore it is a good idea to give children fruits and juices containing vitamin C with meals. (3)

The symptoms of Iron Deficiency Anemia are often vague and non-specific. Children may have pallor (be pale in color), irritability, anorexia (lack of appetite) and growth retardation. (3) Sometimes children do not have any symptoms at all. Iron deficiency anemia can become severe with long term consequences affecting a child’s heart, kidney and neurological system if not addressed. Therefore it is very important to follow up with your child’s Pediatrician so that he can monitor your son’s progress. Since there may be no signs that a parent can identify that indicate worsening of the condition, repeat blood tests for hemoglobin levels are necessary. If a child’s hemoglobin level does not improve after dietary changes your Doctor may prescribe an iron supplement or vitamins with iron and order additional testing.

(1) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990:440-442.

(2)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:617-620.
(3) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1406-1409.
(4) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 124 -132.

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

Pediatric Advice About Keeping Kids Healthy

Monday, August 21, 2006


Dear Lisa,

My son just got back from camp and told me that one of the kids at camp had scabies. What does a scabies rash look like and how do I know if my son caught it?

“Scabies at Camp”

Dear “Scabies at Camp”,

Scabies is a skin infestation caused by a parasite, a female itch mite called Sarcoptes scabiei. The disease is spread through close personal contact and is usually found in more than one person in the family. Younger Children tend to develop Scabies after a sleep over at a friend’s house or after attending sleep away camp. In teenagers and adults, scabies can be transmitted during sexual contact and is considered a sexually transmitted disease. (1)

Many times scabies is not suspected because there is a long span of time from the time of exposure to the initiation of symptoms. The incubation period is usually 4 to 6 weeks in a child that has not previously been exposed. (2) By the time a child gets a rash, the parents many times forget that there was a sleep over or that the child was in contact with a person with a rash.

The rash that develops as a result of Scabies is caused by a hypersensitivity reaction to the proteins of the mite. (2) The symptoms are very similar to a wide spread case of contact dermatitis and many times is mistaken for eczema. The difference is that a patient with scabies has burrows in the skin which appear as gray or white threadlike lines.

A burrow is formed when the adult female mite burrows through the skin leaving behind this characteristic rash. Many times the burrows cannot be appreciated because of damage to the skin inflicted by repetitive scratching. In an attempt to identify the burrows Doctors or Nurse Practitioners may use a black permanent marker. Writing on the patient’s skin with the marker makes the burrows easier to see.

The symptoms of Scabies include intense itching which occurs especially at night. (2) In older children the rash is typically distributed on the skin between the fingers, around the belly button area, the wrists, the buttocks, the belt line, thighs and the penis. Occasionally, 2-5 mm red-brown nodules can be found that persist for weeks or even months after a person is treated. These nodules are formed in response to the dead mites that remain on the skin after treatment. Infants younger than two years old typically do not present with the classic “Scabies” rash. The rash on younger children appears more like vesicles and is likely to occur on the head, neck, palms of the hands and soles of the feet.

The important thing to remember about Scabies is that the rash is wide spread throughout the body and intensely itchy. The rash due to Scabies is not limited to one part of the body. Because it is highly contagious, many times it is found in family members at the same time. Therefore if a child has a new rash that looks like a wide spread case of contact dermatitis, plus other members in the family members have a similar rash, Scabies should be suspected.

In order to determine if your son has Scabies, you should inspect his skin 4 to 6 weeks from his initial exposure. Look for the characteristic rash that is widespread and found between the fingers, at the beltline, on the thighs and around the belly button area.(1) If your son develops such a rash it would be a good idea to you bring him to his Pediatrician to confirm the diagnosis.

The treatment for Scabies includes the application of a scabicide cream or lotion over the entire body. A 5% Permethrin crème such as Elimite is commonly used in children over 2 months old. (2,3) The crème should be washed off of the body 8 to 14 hours after the application. It is common for a child’s symptoms of itching to persist for a couple of weeks after treatment since Scabies is due to a hypersensitivity reaction to the mite. After the mite dies the protein that causes the reaction remains on the skin and continues to cause symptoms for a couple of weeks. (2,3) Antihistamines may be used during this time to alleviate symptoms. (4)

Whenever there is open lesions on a child’s skin, especially when there is scratching involved, there is a chance of developing a bacterial skin infection. If your child has Scabies and develops a fever, increased redness, warmth or induration at the site of a lesion, oozing discharge or pain, an evaluation by a health care professional is necessary. In order to prevent your child from developing a bacterial skin infection it is important to keep your child’s nails clean and cut short.

To prevent scabies from spreading to other members in the household you should wash all clothing and bedding that came into contact with an infected child for the four days previous to the initiation of therapy. The clothes should be laundered on the hot cycle of the washing machine since the heat kills the mites. The mites cannot live for more than 3 to 4 days off of the body, therefore you can put stuffed animals or non-washable items in a plastic bag for 4 days in order to kill the mites too. (2)

(1) Monroe J. DermaDiagnosis. Clinician Reviews. 2006;16(2):54.
(2) American Academy of Pediatrics. Scabies. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:387-390:468-470.
(3)Physician’s Desk Reference. 2004. Montville, NJ. Thomson PDR at Montville:552-553.
(4) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 620-621.

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

Advice about Pediatric Infectious Diseases

Saturday, August 19, 2006

Infant Exposed to Strep

Dear Lisa,

I have a 7 day old infant. My mother came down shortly after she was born and stayed with us for 5 days. The day she left she found out she had strep throat (her throat had been bothering her during her stay). Should I be concerned that my baby was exposed to strep throat and should I bring her to a physician. She has been fine with eating, voiding and bowel movements. She is also breast fed.

“Concerned Parent”

Dear “Concerned Parent”,

Strep throat is an infectious disease caused by group A beta hemolytic streptococcus. It is commonly found in school age children and can be found in toddlers 1 to 3 years old. (1) It may occur in infants if there has been close contact with a person with strep pharyngitis, but this is rare. In my practice, I occasionally had an infant who developed Strep Pharyngitis, but they tended to be older infants (between 9 and 12 months old) who crawled on the floor, played with toys and put their hands in their mouth. I have never seen or read any journal articles about a 7 day old infant with Strep Pharyngitis (Strep Throat).

Strep is transmitted from one person to the next through exposure of respiratory secretions. Therefore there is little opportunity for an infant to become infected because of the unlikelihood that they would come into contact with respiratory secretions. Older children who engage in play resulting in close physical contact through wrestling or hugging are at risk for catching Strep throat. Older children tend to share foods and drinks, kiss on the mouth, drool, suck on toys, share toys that are soaked with respiratory secretions and sneeze and cough in each other faces. In addition children generally do not practice good hygiene skills such as covering their mouth with coughing and sneezing or washing their hands after touching their mouth or nose. These are the practices that put children at risk for catching Strep Pharyngitis.

A seven day old infant in a crib does not engage in any of these risky behaviors and therefore should not be a candidate for acquiring Strep Pharyngitis. I can understand that you are concerned because your mom did stay at your house and was diagnosed with Strep Pharyngitis shortly afterwards. It is true that infants are susceptible to infections because of their immature immune systems. In particular, infants for the first 12 weeks of life are at risk for developing serious bacterial infections such as Meningitis and Bacteremia (blood infection). (2)

Since your baby was exposed you should watch for signs of an infection in a newborn which include fever (rectal temperature of 100.4 Fahrenheit or higher), irritability, lethargy, vomiting, rash, change in her feeding pattern, redness and swelling around the umbilical cord, or odorous discharge coming out of the umbilical cord. If any of these symptoms occur you should have your baby checked by your Pediatrician. The good thing is that your baby is breastfeeding well and from your description seems to behaving normal.

One of the best ways to prevent infants from catching infections is to practice good hand washing techniques. (3) Anyone handling a baby for the first 12 weeks of life should wash their hands first. Caregivers should wash their hands before handing the baby’s formula, bottles and pacifiers. Infants can develop a Strep infection in their umbilical cord (Neonatal Omphalitis) therefore adults caring for infants should also wash their hands before cleaning or touching the umbilical cord. (2) Adults and children with an illness, especially with “the Flu” or a virus should not visit a baby under 3 months old until they are well. It is also a good idea to keep a baby away from large crowds of people for the first 4 to 6 weeks of life.

(1)Herd Immunity produced by PCV7 protects infants to young to immunize. Infectious Diseases in Children. 2006. June:22.

(2) American Academy of Pediatrics. Group A Streptococcal Infections. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:483-485.
(3) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:139.

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

Pediatric Advice About Keeping Babies Helathy

Friday, August 18, 2006

Blocked Tear Duct

Dear Lisa,

I brought my infant to the doctor’s office because his eye was tearing a lot. The Doctor said that my son has a blocked tear duct. How did he get a blocked tear duct and why does this make him tear so much? I was told to massage the corner of his eye, but every time I try to do this my baby fusses. Any suggestions?

“Baby has a Blocked Tear Duct”

Dear “Baby has a Blocked Tear Duct”,

Each of your baby’s eyes has a lacrimal gland. The purpose of the lacrimal gland is to make tears. The tears serve to clean the eyes; washing away any accumulated dead skin cells, dust or oil from the skin that accumulates. Besides cleaning the eyes, the tears keep the eyeball moist and lubricated. Tears are formed and released onto the surface of the eyes and after cleaning the area the tears pass through the tear ducts and drain into the nose. (1) The process of producing tears and draining the fluid into the nose occurs continuously throughout the day. The tears should be removed as quickly as they are produced.

Many times, an infant’s lacrimal apparatus is immature and not able to clear the tears as quickly as they are produced. It is common for an infant to be born with “Dacrostenosis” or a narrow tear duct. (2) Because the tear duct is narrow it is not able to drain the tears efficiently and it frequently becomes blocked. As a result, an excessive amount of tears can be found rolling down the infant’s cheeks. This condition is commonly referred to as a blocked tear duct.
A baby with a “blocked tear duct” should not have a fever, there should be no swelling around the eye and the white part of the eyeball should not be red. If your baby has any of these signs your doctor should be contacted because it may represent another condition.

The treatment for a blocked tear duct includes gentle massaging of the area with a finger or thumb covered with a soft baby washcloth. The motion should be a slow, steady downward rolling of the finger. (2) The pressure of this motion should cause the tear duct to open. (3) It is important to make sure your fingernails are cut short and smooth so that you won’t scratch the baby’s eye by accident. (3) It is recommended that you massage the area between the bridge of the nose and the corner of the eye where the upper and lower lid meets four times per day. If your baby is fussy, try massaging the area when he is eating because babies tend to be calmer at this time. (3) Another alternative would be to massage the area when your child is sleeping. If the baby continues to fuss when you massage the tear duct I would be concerned that he may have a cyst or an infection of the lacrimal gland. If your baby seems uncomfortable, the area is red or swollen, he has a fever or if the baby continues to be fussy he should be evaluated by his Doctor.

Blocked tear ducts should resolve by the time a baby is between 6 to 9 months old. If the symptoms continue beyond this point you can consult a Pediatric Ophthalmologist who can probe the duct and repair it if necessary. (4) In the meantime, simply wash away the tears and mucus that is produced by cleaning from the inner canthus to the outer canthus of the eye with a soft clean cloth. Many parents become concerned about the amount of mucus and worry that their child may have conjunctivitis. When the tears wash across the eye, they pick up dead skin cells and dirt. Because the tear duct is blocked the fluid is not drained away and instead it continues to accumulate debris, therefore it is not surprising that a lot of discharge results. As long as the eyes are white and not pink the child does not have conjunctivitis and should not need an antibiotic. (3) The administration of antibiotic eye drops will not open an obstructed tear duct. If you cannot tell if the white part of the eye is red or if you are concerned about your baby, you should bring him to the Pediatrician’s office in order to confirm the diagnosis.

(1) Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:377-379.
(2) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:126.
(3)Brunell P. Bacterial Conjunctivitis in Children: Containing the Infection. Infectious Disease in Children. 2006:January(S6-7).
(4)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 650.

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

Pediatric Advice For Parents with Infants

Thursday, August 17, 2006

Food Allergies

Dear Lisa,

Now that my daughter is one year old, my Pediatrician told me that it is time to start introducing table food. The thing that worries me is that I have two nephews with food allergies and I have seen how much it affects their lives. I ’m afraid that my daughter is going to develop food allergies too, so I prefer to be very cautious when giving her new food. Please tell me what types of food are most likely to cause food allergies. What are the signs of food allergy that I should look for? Is there anything that I can do to prevent her from developing a food allergy?

“Worried About Food Allergies”

Dear “Worried About Food Allergies’,

At one year old a child is developmentally ready to eat table food. Different tastes, textures and temperatures of food will help her learn and strengthen the muscles in her mouth which will eventually help her speak. Although this is a necessary step, it is also difficult for many parents because of the fear of food allergies. When choosing table food it is much harder for parents to decipher which foods are appropriate and safe for their children.

If you follow a few simple steps, it can help the transition from jarred food to table food go more smoothly. When introducing new food, make sure that you introduce one new item at a time. This way if there is an allergic reaction you will know which food is the culprit. Secondly, when introducing highly allergic foods, start by giving only small amounts at a time. The severity of an allergic reaction can vary due to quantity of the food ingested. (1) Therefore if you start with a smaller amount, it is more likely if a reaction occurs that it would be mild and easier to handle. Know the signs of a food allergy and observe for them when introducing highly allergic food to your child.

The foods that tend to cause allergies in children include cow’s milk, eggs, peanuts, tree nuts (such as walnuts, hazelnuts, Brazil nuts and Pecans), fish, shellfish, soybean and wheat. (1,2) The important thing to remember when introducing table food is that these allergic items may be hidden ingredients in foods when you may not suspect it. (1) For example milk may be hidden in deli meats when the slicer is used for both meat and cheese. Some meats may have casein (one of the proteins found in milk) as a binder. Powdered milk may be added to products such as pancake mix, spices or tuna fish to prevent the item from clumping.

Peanut oil may be a hidden ingredient in red sauce used to make pasta dishes or Pizza. In certain restaurants, peanut oil may be used to coat the pan when cooking ethnic dishes such as Mexican food, Asian food, Vietnamese foods or Thai food. (1) Therefore, if you give your daughter a dish and she develops a reaction you can not assume that the reaction is due to the obvious item, because it may be due to a hidden ingredient.

Signs of an allergic reaction include; hives, flushing, facial swelling, nasal congestion, itchiness of the ears, itchy mouth, itchy throat, swelling of the tongue, cough, trouble breathing, itchiness of the skin and vomiting. (1,2) It is important to remember that young children may not be able to tell you how they feel. If their mouth and throat is itchy they may react by putting their hands in their mouth or spitting out the food. Sometimes the first sign that a child is allergic is they spit out the food. The interesting thing I found when leading a support group for parents with food allergic children is that many of the parents reported remembering their child repeatedly spitting out the foods that they eventually ended up being allergic too.

If your child develops allergic symptoms when introducing a new food the first thing to do is to remove the offending item. Thoroughly rinse the child’s face, neck, hands and whatever part of the body that the food came into contact with. Contact your child’s doctor and inform him of the allergic reaction and follow the instructions given regarding treatment and follow up. For severe allergic reactions where facial swelling occurs and the child’s breathing is affected, contact the Emergency Medical Services without delay.

Once it has been determined that a child had an allergic reaction it is important to keep a log recording the incident. The log should include the type of food ingested, the time the food was eaten and the time and type of reaction. Keeping a log is important because sometimes it is difficult to identify the offending food. Keeping a log can help you determine the offending item over time.

In other cases, there may be more than one offending food. Some reactions only occur in combination with other foods or activities, such as in the case of Exercise-Induced Allergic Urticaria/ Anaphylaxis. (1) Exercise Induced Anaphylaxis occurs when a child ingests an offending food, such as celery, and then engages in exercise like jogging for example. The allergic reaction only occurs when the two situations occur together. If the child ate celery and did not exercise, there would be no allergic reaction. In the same instance if a child exercised and did not eat celery before engaging in the sport, there also would be no reaction.

Children with food allergies should have an evaluation by a board certified Allergist. (1, 2) Blood or skin testing should be performed in order to verify the food allergy and an emergency treatment plan should be reviewed in case there is an accidental ingestion. Regular follow up visits are recommended because in time, many children do outgrow some food allergies. (3) Allergies to peanuts, tree nuts and seafood are likely to continue throughout a person's life. Although, it is expected that about 20% of children with peanut allergies will loose their sensitivity. (3)

If an Allergist confirms that your child has a food allergy there are measures that you should take to keep your child safe. The best prevention is avoidance of the allergic food. Many times you may not only have to avoid the allergic food, but you may need to avoid all foods in the same class. With some food families, especially tree nuts and seafood, an allergic sensitivity to one food in a group may confer an allergic sensitivity to other foods in the same group.(1) For example if a person is allergic to Almonds there is a greater chance that they are also allergic to Pecans because they are in the same family.

Parents should read the food labels of everything that their child eats to make sure the allergic item is not a hidden ingredient. (3) You will also need to teach your child’s caregivers about the allergy and the need to read all food labels. Since anyone with a food allergy could have a severe reaction or life threatening reaction from such minimal exposure, an Epipen should be carried at all times and all caregivers should be trained how to use it. (2) The new guidelines recommend carrying two Epipens because an anaphylactic reaction may be prolonged and two doses may need to be given. (3) It is also important to make sure your child wears a Medic Alert bracelet listing his food allergy. (1)

In regards to your question about what you can do to prevent food allergies; it is a good idea to wait until your child is between 2 and 3 years old before introducing peanuts and tree nuts. It is believed that the avoidance of nuts early in a child’s life may prevent a child from developing a food allergy. (1) Since 80% of children with Peanut allergy will not outgrow their allergy, this extra effort early in life may prevent a lot of grief in the future.

For more information about Food Allergies contact:

The Food Allergy and Anaphylaxis Network (FAAN)

(1)Bassett CW. What to do when foods become allergens. The Clinical Advisor. 2005. Dec:43-48.
(2)Grassia T. The diagnosis of food allergy is ‘an inaccurate science’. 2006 Jan:52-53.
(3)Lieberman PL. Diagnosis and treatment of anaphylaxis: How can we do better? Presidential plenary session. Presented at: 2006 Annual Meeting of the American Academy of Allergy, Asthma and Immunology; March 3-7, 2006: Miami Beach, Fla.

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

Pediatric Advice Updated Daily

Wednesday, August 16, 2006

Strep Throat

Dear Lisa,

What are the signs of Strep throat? My 9 year old daughter frequently tells me that her throat hurts, but I know that she is just doing this to get my attention. I used to bring her to the Pediatrician’s office every time she complained, and it turned out that she never had an infection. After the Doctor’s visit she would run around and play like there was nothing wrong. Now I prefer to wait a little while before I bring her to the Doctor’s to make sure she really has a sore throat. Are there other signs of Strep besides a sore throat that I should be looking for? I don’t want to ignore her symptoms if there is really something wrong, but on the other hand, it doesn’t make sense to run to the Doctor’s office for every little complaint.

“Daughter is Faking Strep”

Dear “Daughter Faking Strep”,

The symptoms of Strep Throat or Strep Pharyngitis include throat pain, decrease in appetite, fever, runny nose, halitosis (bad breath), swollen lymph nodes in the neck, headache, nausea, vomiting, and abdominal pain. (1,2) Although Strep Pharyngitis is usually associated with fever, some children with Strep have little or no fever at all. (1)

Many of the symptoms of Strep Pharyngitis are also found in children with throat infections caused by a virus. Sometimes it is difficult to determine if a child’s symptoms are due to a virus or Strep from the physical examination alone. The only way to be sure if a throat infection is due to Strep is to perform a throat culture in the doctor’s office. (1)

Symptoms that are specific for Strep Pharyngitis include pettechiae on the soft palate (red marks on top of the mouth toward the back of the mouth) or a sandpapery like rash on the torso. (1,2) A Strep infection in another part of the body is sometimes the first sign that a child has Strep throat. It is possible to develop a Strep infection on the skin (Impetigo), on the rectum or in the vagina. (2)

An open wound or bug bite can become infected with Group A beta hemolytic Streptococcus when a child with Strep Pharyngitis scratches her skin after having her hand in her mouth. Spreading of germs to the rectal area can occur the same way. When a child with Strep Pharyngitis puts her hand in her mouth and then touches her bottom she can end up with Rectal Strep or Perianal Streptococcal Dermatitis. ( 3) Signs of Rectal Strep include rectal pain with defecation, rectal itching, redness, and rectal bleeding. (3). Signs of Vaginal Strep include itching, redness, or discomfort with urination. If necessary, your Doctor can perform a culture of these sites in order to determine if the symptoms are due to Strep.

Other signs of Strep that I frequently encountered in my practice include pimples around the mouth, impetigo around the nose and mouth, younger children who cry when drinking from their bottle, a coating on the tongue, peeling of the hands and paleness around the mouth.

Deciphering which childhood complaints are true and which ones are not is quite difficult. As a child matures she becomes more in tuned with her body and more interested in how the body works. It's common for a school aged child to be interested in every little bump and movement, and many times exaggerate the slightest symptom. During this period of growth it is important to reassure your daughter what is normal and what is not.

For children who frequently complain of a sore throat, it is important to determine if the complaints are a method of getting their mother's attention. I can’t tell you how many times a school aged child came into the office with the complaint of a sore throat and it turned out absolutely nothing was wrong with the child. I found many children telling their parents that there was nothing wrong and admitting that they just didn’t want to go to school that day or they didn’t want their mom to go to work.

It is a good idea to seriously consider a complaint of a sore throat if it is accompanied by a fever or if the child appears ill. In this situation having your daughter checked by your Doctor would be time well spent. If there is a history of close contact with a friend infected with Strep or a family member with Strep, then a complaint of a sore throat should be evaluated.

It would also be concerning if a child with a sore throat opted not to participate in activities that she previously enjoyed or if she was sleeping longer than usual. On the other hand, if your daughter complains of a sore throat and then proceeds with her normal activities; playing, eating and attending social functions, it would make more sense to wait to see if her symptoms worsen or if other symptoms develop.

It is important to remember that Streptococcal Pharyngitis has a 2 to 5 day incubation period. Therefore, it may take a few days for a child to exhibit symptoms of Strep Pharyngitis after being exposed. (2)

If you find that your daughter is continually using somatic or health complaints as a means to get your attention, it would be a good idea to sit down and talk with her about it. Ask open ended questions about her friends, teachers, school experiences or struggles that she may be having. Her somatic complaints may be a sign that something else is bothering her. She may not know how to express herself or how to get your attention. Addressing these issues can save you a lot of time guessing what is wrong and help your daughter relieve the stress that is in her life.

(1) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990: 496-498.
(2) American Academy of Pediatrics. Group A Streptococcal Infections. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:483-485.
(3)Perianal Streptococcal Pharyngitis. Consultant for Pediatricians. 2005. Oct:441.

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

Pediatric Advice About Childhood Illnesses

Monday, August 14, 2006

Pink Eye

Dear Lisa,

How can I tell if my son has pink eye? His eyes are red but he has been swimming in the pool a lot. How can I tell if my son’s eyes are red from the pool or from pink eye?

“Red eyes”

Dear “Red eyes”,

The term “Pink Eye” is a general term that describes the condition of the sclera (white part of the eye). When a person has "Pink Eye" their sclera turns pink due to the dilation of the blood vessels in the eye. This redness is a symptom that can represent many different diseases. Conjunctivitis or the inflammation of the conjunctiva is one of the most common causes of “pink eye”. (2) Conjunctivitis may be due to a virus, bacteria, allergy or irritation.

Therefore a child’s eye may appear red or pink for a variety of reasons. A child with itchy, red eyes may have Allergic Conjunctivitis due to allergies. Watery, red eyes may be caused by a virus. If a child with eye pain keeps his eye closed shut or covers his eye with his hand it is likely that he has an injury or corneal abrasion. (1) Red eyes and blurred vision may represent a drug reaction or Blepharitis. (1)

"Pink Eye" due to Bacterial Conjunctivitis is the type of "Pink Eye" that concerns most parents because it is contagious. Bacterial Conjunctivitis is due to a bacterial infection which causes crusting on the eyelashes, thick eye discharge that sticks to the eyelashes and matting of the eyelids. It is common for a child with Bacterial Conjunctivitis to wake in the morning with his eyes sealed shut. Other symptoms of Bacterial Conjunctivitis include burning, discomfort, blurred vision due to the purulent discharge and injected sclera (the white part of the eye turns red). (3,4) Young children may not be able to tell you that their eye hurts or that they have blurred vision. Instead, many times they present with irritability and fussiness.

If your child has signs of Bacterial Conjunctivitis he should be seen by a health care professional so that treatment with antibiotic eye drops or ointment can be started. Implementing treatment quickly may prevent spreading of the infection and allow the child to return to his regular activities. (3). Conjunctivitis can be spread by direct contact with the infected eye or through contamination of the hands. Once the organism gets on the hand it is spread to the eyes by accidental touching or rubbing of the eyes. (5) A child with Pink Eye can continue to spread the germs for 24 to 48 hours after therapy begins. (2)

Since Conjunctivitis can easily be spread from one eye to the next and from one person to the next meticulous hand washing is necessary in order to contain the disease. (2) I recommend that a parent use a wet paper towel to wash the face and hands of a child with Conjunctivitis. This way the towel can be discarded immediately after use which cuts down on the chance of accidentally spreading the infection to other members of the household. It is also a good idea to wash the child’s pillowcase and the toys that a child plays with.

Once a child with conjunctivitis is treated you should see some resolution in symptoms within 48 to 72 hours. (4, 5) If the symptoms persist beyond this period your child should be checked by a healthcare professional. (4) Persistence of symptoms may represent a different problem such as Herpes infection, Blepharitis, Lice infestation on the eyelashes, Molluscum Contagiosum on the eyelids or Conjunctivitis-Otitis Syndrome.

It is common for young children to develop Otitis Media (middle ear infection) along with Conjunctivitis. (2) This tends to occur in younger children and many times is associated with a fever. Fever occurs in 40 to 50% of children with Conjunctivitis-Otitis Syndrome. (2) If a child has a fever along with “Pink Eye”, it is important to have him evaluated by his Physician or Nurse Practitioner to determine the cause. A persistent fever accompanying “Pink Eye” may also represent a more serious condition such as Kawasaki syndrome. (7)

It is common for children to develop red eyes after swimming in a chlorinated pool because the chlorine is an irritant to the eyes. If your child complains of pain and excess tearing along with red eyes after swimming in a pool or playing outdoors in the sun, it is important to have him evaluated. Exposure to excessive chlorine in swimming pools, excessive sunlight, aerosol sprays and other noxious gases can cause diffuse superficial punctuate corneal abrasions that are painful. This condition needs to be treated by a Physician.

(1) Morrow GL, Abbott RL. Conjunctivitis. Am Fam Physician. 1998:57735-746.
(2)Pichichero ME. Co-Infections of Conjunctivitis. Infectious Disease in Children. 2003. March;(S6-7).
(3)Brunnel P. Bacterial Conjunctivitis in Children: Containing the Infection. Infectious Diseases in Children. 2006; Jan:(S3-4).
(4) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990: 323.
(5) American Academy of Pediatrics. Infections Spread by Direct Contact. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:96-97.
(6)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:331-336.(2)Pichichero ME. Co-Infections of Conjunctivitis. Infectious Disease in Children. 2003. March; (S6-7).
(7)American Academy of Pediatrics. Kawasaki Syndrome. In: Pickering L.K. ed. Red Book: 2003. Report of the Committee on Infectious Disease. 26th ed. Elk Grove Village. IL: American Academy of Pediatrics; 2003: 392.

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

Pediatric Advice About Childhood Infections


Dear Lisa,

My friend’s son had a rash that they thought was Eczema. His mother brought him to the Doctor’s office and it turned out that he has Ringworm. My 7 year old son was playing with him the other day. Does this mean that my son is going to get Ringworm too? What is Ringworm? Does it mean that there is a worm under the skin?

“What is Ringworm?’

Dear “What is Ringworm?”,

Ringworm or Tinea Corporis is a common fungal skin infection found in children. It is called Ringworm because the lesion on the skin is in the shape of a circle or ring, not because there is a worm under the skin. (1) The rash typically appears as flat, round, pink lesions with a distinct scaly border but may also appear as inflammed nodules. (2) If you feel a Ringworm lesion it has a rough texture and in some people it may appear the same color as their skin. If left untreated the lesion enlarges and tends to have central healing or an area in the middle that appears less scaly. (3)

The skin lesions are typicaly found on the non-hairy parts of the body such as the face, body and extremities. (1) Tinea rashes found on hairy parts of the body have different names and courses of treatment. Ringworm on the scalp is called Tinea Capitis and is much harder to treat than Tinea Corporis(Ringworm on the body).

The microorganisms Trichophyton tonsurans and Microsporum canis are the most common causes of Ringworm. (2) Microsporum canis is responsible for the majority of the cases of ringworm in the United States and Europe. (4) Cats and dogs are natural reservoirs of Microsporum canis and they typically do not show signs of the infection. (2) Other animal hosts include cattle, sheep, pigs, rodents and monkeys.

The organism is transmitted when an exposed area of the child’s skin comes into direct contact with an infected animal or its dander. (2) The condition can also be spread due to direct contact with an infected child’s lesions, clothing or towels.

Usually Ringworm is diagnosed by a Doctor or Nurse Practitioner through a physical examination of the child. Sometimes the symptoms mimic the appearance of Eczema or in other instances the characteristics of the lesion may be altered due to the application of steroid crème.

When this occurs, a Wood’s lamp examination could be performed in the Doctor’s office in order to aide in the diagnosis. A Wood’s lamp is an Ultraviolet lamp which is used in a darkened room to identify fungal infections. When the skin is exposed to this light it will fluoresce if a fungal infection is present. A greenish glow should appear at the site of the lesion if the rash is due to Ringworm. (2, 3)

Some Doctor’s may take a scraping of the lesion and look at the cells under a microscope in order to make a diagnosis. A culture of the site may also be obtained, but the results typically are not available for weeks. (2) Therefore this approach is usually reserved for children with persistent conditions or for children with lesions on the scalp.

In regards to the question about your son catching Ringworm from his friend, if he had direct skin contact with his friend’s lesions there is a chance that he will catch it. If he shared towels or clothes with his friend he also is at risk. The exact incubation period for Ringworm is not known; therefore it would be a good idea to inspect your son's skin over the next few weeks. If your child develops a new skin lesion he should be evaluated by his Pediatrician in order to confirm the diagnosis.

If your son develops Ringworm, it can be easily remedied with the use of topical antifungal crèmes such as clotrimazole, miconazole or ketoconazole applied twice per day. (2) Ringworm is not the type of skin infection that dissapears after a couple of applications of medicated crème. Unfortunately, it takes a much longer time to go away. Typically the treatment needs to be continued for 4 to 6 weeks before resolution occurs. (1)

I found that many times a child’s Ringworm reoccurs because the treatment is discontinued too soon. When the lesion is initially treated it tends to lighten in color and this may be interpreted as the resolution of the problem. The fungal infection remains on the skin and may be difficult to see at this point, but can still be felt. I recommend that parents continue treatment until they can no longer feel the lesion.

It is a good idea to cover the lesions with a band-aide when the child is outdoors or around other children in order to limit the spread of the infection. A band-aide also prevents the child from scratching the area. Whenever there is a break in the skin integrity or a rash present that causes a child to scratch, superinfection with a bacteria may occur. Signs of a bacterial skin infection include fever, pain, warmth or redness of the skin, induration (hardening) of the skin, streaking, discharge or odor. (5)

If signs of a bacterial infection occur contact your child’s pediatrician for an evaluation. In addition, if the Ringworm lesion persists, become recurrent, enlarges or travels to the scalp it is important to have your child evaluated by a healthcare professional.

(1)American Academy of Pediatrics. Tinea Corporis. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:525-526.
(2)Ringworm. Consultant for Pediatricians. 2006. January:44.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:604-622.
(4)Chan YC, Friedlander SF. New Treatments for tinea capitis. Curr Opin Infect Dis. 2004:17:97-103.
Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:231-233.

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

Pediatric Advice About Preventing Childhood Infections

Friday, August 11, 2006

Hand Foot Mouth Disease

Dear Lisa,

When my daughter was 1 year old she developed Hand Foot Mouth disease. She had sores in her mouth and wouldn’t drink. I was told by my daughter’s Pediatrician that it was caused by Coxsackievirus. She went to the Doctor’s office the other day because she had a sore throat and I was told that she had Coxsackievirus again. Is it possible to get Coxsackie twice? I thought once a child got a virus that they are not supposed to get it again?

“Coxsackievirus Again?”

Dear “Coxsackievirus Again?”,

Coxsackievirus is a virus and yes children can catch it more than once. The reason for this is that there are a few strains of Coxsackievirus. The different strains are labeled Group A Coxsackieviruses or Group B Coxsackiviruses. (1) A child can catch Coxsackievirus more than once because each time they are exposed to a different strain. The symptoms for each strain may vary a little bit. For example, Coxsackievirus A16 usually results in Hand Foot Mouth Disease which is a virus where children develop lesions in their mouth, on their feet and on their hands, hence the name; Hand Foot Mouth Disease. A child who is infected with Coxsackievirus A24 tends to get conjunctivitis. (1)

The signs and symptoms of Coxsackievirus include painful vesicles and ulcers in the mouth, fever, diarrhea and vesicular lesions on the palms of the hands and soles of the feet. (2) Sometimes these lesions may appear on the extremities and in the diaper area. (3). Infections with the Group B Coxsackievirus tend to be more serious and may result in sepsis in infants, myocarditis, pericarditis (inflammation of the lining of the heart) and Central Nervous System infections.

The Coxsackievirus is spread via the fecal-oral route and via the respiratory route. (1) Therefore diligent hand washing and appropriate disposal of diapers is necessary to prevent spread of the disease. Coxsackievirus actually can be shed from the stool for several weeks after the onset of the infection. Once the stool gets on a person's hand they can spread the germ by putting their hand in their mouth.

It is important that children with Cocksackievirus do not share food because the germ can be spread this way too. Coxsackievirus tends to spread quickly in children because they tend to put toys in their mouth, share toys and because they stool in their in diapers. (1) The incidence of Coxsackievirus tends to be higher in the summer and early fall.

The treatment for Coxsackievirus includes supportive care. (4) Many children with Coxsackievirus refuse to eat or drink because the mouth lesions are so painful. Giving children ice pops and sherbet helps because the coldness temporarily relieves pain. It is a good idea to avoid orange juice or acidic food which may irritate the lesions. Soft foods such as pudding and Jello are a good choice. Crackers or pretzels may scratch the mouth and throat area and irritate the lesions.

Children that refuse to eat and drink because of the pain are at risk for developing dehydration. Therefore it is very important to control the pain in order to prevent dehydration. You can give your child pain relieving medication such as Tylenol thirty minutes before a feeding. Tylenol should not be given more frequently than every four hours.

For children over 1 year old, there’s a mixture you can prepare that can help take away the sting of the mouth lesions. Measure equal parts Benadryl and Maalox and mix together well. For example, add one teaspoon of Benadryl with one teaspoon of Maalox. Coat the lesions on the child’s lips, tongue and inside of the mouth with this mixture. Using a Q-tip may help. This will temporarily take away the pain. Even though this is a topical application, the medication is absorbed therefore it is important not to use too much. To make sure that your child doesn’t get too much Benadryl, you should not give a 33 pound child more than 2 teaspoons of the mixture (which contains 1 tsp of Benadryl) in a 6 hour period.

If your child has Coxsackievirus and you cannot get him to eat or drink it is important to look for signs of dehydration. The signs of dehydration include decreased urine output(children should urinate at least 6 times in a twenty four hour period), dry oral mucosa (inside of the mouth), sunken eyeballs, lack of tears, sunken anterior fontanelle (soft spot), poor skin turgor (dry non-elastic skin), weight loss, increased heart rate, lethargy, irritability and change in temperature (5). If your child demonstrates signs of dehydration it is important to have her evaluated by a health care professional.

(1)American Academy of Pediatrics. Enterovirus Infections. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:198-99.
(2) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990: 478-479.
(3)Nield L, Kamat D. Diaper Dermatitis: From “A” to “Pee”. Consultant For Pediatricians. 2006. June:373-380.
(4)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:379-382.
(5) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990:406-410.

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

Pediatric Advice For Sick Children

Thursday, August 10, 2006

Umbilical Granuloma

Dear Lisa,

My three week old son’s belly button fell off a few days ago. It looks different than the way my daughter’s did when her belly button fell off. It looks like there is something shiny sticking out of it. He doesn’t have a fever and he’s been eating good. There’s no discharge or redness, so I don’t think that it’s infected but I don’t know what it is?

“Weird looking Belly Button”

Dear “Weird looking Belly Button”,

It sounds like your child may have an Umbilical Granuloma. In some cases, when a baby’s umbilicus (belly button) heals there’s an overgrowth of the umbilical stump. This umbilical tissue that persists after the belly button falls off usually appears white, smooth and shiny. Sometimes it looks pinkish or red in color. (1) An Umbilical Granuloma can be seen sticking out of the middle of the belly button. Many parents don’t notice it unless they push down gently on both sides of the belly button. It frequently has a “wet” appearance, but should not have an odor or discharge.

A discharge from the umbilicus, especially one with an odor is a sign of a belly button infection and should be seen by your child’s Pediatrician. Other signs of infection of the belly button include redness and warmth of the skin that surrounds the belly button, irritability, fever or difficulties feeding. If necessary your Doctor can do a culture of the belly button to determine if there is an infection.

You should bring your child in for an examination so that your Pediatrician or Nurse Practitioner can verify if your child has an Umbilical Granuloma. The treatment for an Umbilical Granuloma includes the application of Silver Nitrate which is a simple procedure that can be done right in the doctor’s office. (1) Silver Nitrate is a drying agent that serves to stop the overgrowth of the umbilical stump. This drying agent continues to work after the application therefore it is important not to clean the area after the visit. You should just leave it alone for approximately 24 hours.

This application is not painful, but many sometimes a baby cries during the procedure because they are cold from their clothes being removed. I myself have gotten Silver Nitrate on my skin during the application and it does not feel like anything at all. If Silver Nitrate touches the skin, a couple of hours later a brown stain will appear that will eventually go away on its own. It is common for the skin around the umbilicus to turn brown a couple of hours after the application of the Silver Nitrate. In addition, a small amount of grey colored liquid may ooze out of the belly button for the first twenty-four hours. This may stain the clothes grey and may be patted gently with a piece of gauze.

An Umbilical Hernia is another condition that causes the belly button to protrude. This has nothing to do with the healing of the belly button itself. Instead, it is due to the incomplete closure of the umbilical ring inside the baby's abdomen during fetal development. (2) During fetal development, the intestines return to the abdominal cavity around the 11th week of fetal life. An Umbilical Hernia occurs when the umbilical ring fails to close completely. As a result the intestines slide in and out of the defect which causes bulging around the belly button. (2) A parent may notice this bulging when there is increased abdominal pressure such as when the baby cries a lot, coughs or has a bowel movement. (3) If you put gentle pressure on the belly button the protrusion seems to “deflate” and appears flat again. The difference between the appearance of an Umbilical Granuloma and an Umbilical Hernia is the Umbilical Granuloma is an overgrowth that sticks out of the inside of the belly button and the area around it appears normal. When there is an Umbilical Hernia, the area around the belly button sticks out and many times pops out of the top of the diaper.

In 90% of the cases an Umbilical Hernia resolves on its own. (2) In most cases the Umbilical Hernia resolves by 2 years old, but in African American children it tends to not resolve until they are older. (3) If a child’s Umbilical Hernia is still present by 5 years old it is a good idea to see a Pediatric Surgeon for an evaluation. (2) In the past it was a common practice for parents to bind the abdomen or tape a quarter over the belly button in the attempt to cause the Umbiical Hernia to heal. This is not recommended because it has never been documented that these remedies aid in the closure of the defect. (2) In addition, the application of tape and binders cause irritation and may lead to infection. (2)

(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 275-276.

(2) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1458-1459.
(3) Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:423-426.

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

Pediatric Advice About Keeping Babies Healthy