Tuesday, October 31, 2006


Dear Lisa,

My one year old daughter's skin tone is yellow in color. I didn't think much of it because I know it could be due to her eating the orange vegetables (sweet potatoes), but more people are remarking on it and I have shied away from the orange vegetables but her skin tone is still yellow (has been for awhile) and I also noticed lately that her gait is unsteady (not all the time but it is noticeable) almost like she is walking like she is intoxicated. How concerned should I be with these symptoms?

“Sweet Potato Mom”

Dear “Sweet Potato Mom”,

Carotenemia is the condition that commonly occurs in children when they eat too many yellow-orange vegetables. When a child eats too many foods containing carotenoids over a period of time their skin turns an yellow-orange color, but the whites of the eyes stay white.(1) If your daughter eats a lot of orange vegetables such as carrots, sweet potatoes and squash this could be the reason for her yellow-orange discoloration. A child’s orange vegetable intake would have to be cut down to less than three times per week in order to alleviate the symptoms. The orange color should go away gradually and should take a few weeks.

Another condition that can cause the skin to be yellow is Vitamin B 12 deficiency. One of the signs of Vitamin B 12 deficiency is a lemon yellow tinge to the skin.(2) Vitamin B 12 is found in meat, liver, milk, eggs, cheese, fish and soybeans. (3) Although rare in childhood, this condition may occur in children who are strict vegetarians and in those who lack the proper stomach enzymes needed to absorb Vitamin B 12.

Both intrinsic factor and proper Hydrochloric Acid production by the gastric mucosa are necessary for the absorption of Vitamin B 12. Therefore a deficiency in either of these can result in Vitamin B 12 Deficiency. (4) Vitamin B 12 Deficiency is more common in the elderly population because as people age they naturally develop decreased amounts of gastric secretions. (2) There also may be a concern in patients who take medications that block Hydrochloric Acid production in the stomach.

The fish tapeworm, Diphyllobothrium latum is another cause of Vitamin B 12 deficiency, although this is a rare condition. (5) Other consequences of Vitamin B12 deficiency include anemia, gastrointestinal problems, neurologic deterioration and spinal cord degeneration. (3, 4)

If a baby’s eyes are yellow as well as their skin, this represents a more serious condition called Jaundice. Jaundice is caused by Hepatitis (liver infection), Liver Disease, Hemolytic Anemia (the breakdown of red blood cells in the body), 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.

In regards to your daughter’s skin color, as long as the whites of her eyes are not yellow there is no need for alarm. You may need to cut down on the sweet potatoes more and wait a little longer before you see a change. If your daughter was breastfed while you maintained a strict vegetarian diet or if she presently is a strict vegetarian then Vitamin B 12 deficiency may need to be considered. If her discoloration does not seem to improve or if it worsens she should be evaluated by her Pediatrician. Other concerning symptoms would include fever, weight loss, diarrhea and fatigue. If these symptoms occurr your daughter should be checked by her Doctor.

Without actually seeing your daughter’s gait it is difficult to tell if it is normal walking behavior or a sign of a problem. Unsteady gait in a one year old can be due to something as simple as ill fitting shoes or as complicated as Congenital Hip Dysplasia, an injury, leg length discrepancy or an infection. Interestingly, painful feet and limps in children are most commonly caused by ill-fitting shoes. (3)

All children who begin to walk generaly have an abnormal appearing gait. When first learning to walk, their feet typically turn outward. Sometimes new walkers will push off with one foot and slightly drag the other. (3) So what looks like abnormal gait to an onlooker, may be normal for a new walker. Since your daughter is only one year old, her gait may be normal for her age. The best way to have her gait evaluated is to bring her to the Pediatrician’s office and have her walk in front of the Doctor. Your daughter’s doctor will be able to tell you if her gait is normal for her age.

There is a concern when a child has pain or limping with walking. If this is the case a more serious disorder may need to be ruled out. Developmental Dysplasia of the Hip also known as Congenital Hip Dysplasia (CHD) is one of the childhood conditions that may present as abnormal gait. Althought this condition is typically discovered in infancy, it may first be noticed when a child begins to walk. It occurs in 1.5 to 20 out of every 1000 live births. (6) Congenital Hip Dysplasia is defined as the abnormal growth or development of the hip.(6)

The exact cause of CHD is unknown, but there are common risk factors noted in babies with this condition. Babies that are large for their age, those who had low amounts of amniotic fluid, those with a family member with CHD, breech presentation, fast delivery and traumatic delivery can all contribute to Congenital Hip Dysplasia. The symptoms of CHD include asymmetric skin folds in the thigh and buttock region, decreased rotation of the hip, laxity of the hip joint, shortening of the leg and abnormal gait. (5, 6) An evaluation by your Pediatrician will be able to rule out this condition, as well as other conditions that cause a baby to limp.

If your child’s abnormal gait is accompanied by other signs such as fever, irritability, a recent illness, weight loss, a recent injury, pain, crying or developmental delays an evaluation by your Doctor is necessary. Otherwise, check your daughter's walking while she is barefoot and with different pairs of shoes and see if the symptoms are consistent. If the abnormal gait is only present with a certain pair of shoes, then the problem is no more than the poor fitting shoes.

If you are interested in reading other Pediatric Advice Stories covering these topics:

First Pair of Shoes

Vitamin B 12 Deficiency


(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)Waley L, Wong D. Nursing Care of Infants and Children. 2nd ed. St. Louis, Missouri:The C.V. Mosby Company.1983:468-469,1342.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:748-749,100,848,839.
(4)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:649, 449-450.
(5)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:82-83,682-685.(6) Horn P. A painless limp and leg-length descrepancy in an 18-month-old girl. The Clinical Advisor. 2006.July:121-124.

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

Pediatric Advice About Keeping Kids Healthy

Monday, October 30, 2006

Gastroesophageal Reflux

Hi Lisa,

My 3 month old has been 'snuffly' since birth, her nose has never been never runny but just seems blocked. She has been into hospital as in the early weeks she found it hard to breathe and had a ct scan on her sinuses which showed nothing. I changed her formula to a thickened formula as she used to bring up a lot of her milk after feeds. This has helped and she only spills a little now but her nose even though better seems to always be blocked with thick clear mucus which dries out. Could it still be reflux that’s causing her 'snuffles' and should I investigate it further and get a second opinion from a pediatrician or will she grow out of it?

Thank you,

“snuffles mum”

Dear “Snuffles mum”,

I’m sorry to hear that your little one has had such a difficult time with her nose. The good news is that her CAT scan was normal which rules out any anatomical problems, masses or infections. You did mention that your daughter has Gastroesophageal Reflux (GER), and that the symptoms seem to be improving. Gastroesophageal Reflux certainly can cause infants to have a stuffy, congested nose.

Infants typically have a lot of problems when their nose is stuffy and congested even if they do not suffer from GER. A stuffy nose affects their feeding and breathing dramatically since infants are obligate nose breathers. (1) The best thing that you can do at this point to help her nose is to make sure the house is not too hot, keep your daughter's head elevated, use a cool mist vaporizer and use saline nose drops to keep the nasal secretions loose.

GER is very common in infancy. It affects approximately 50% of infants younger than 2 months old and up to 70% of infants by 4 months old.(2) GER is defined as the retrograde passage of gastric material into the food tube. (3) Infants can develop esophageal symptoms from GER which are caused by inflammation and hypersensitivity to the gastric contents. Infants can also develop symptoms outside of the esophagus which are caused by direct acid-induced injury and stimulation of airway reflexes. (4)

The typical symptoms experienced in infancy include irritability, recurrent and persistent vomiting and regurgitation (reflux into the mouth and swallowed again).(5) Symptoms outside of the esophagus can include; sore throat, hoarseness, wheezing, chronic cough, recurrent pneumonias, Asthma, dental erosions, laryngitis(inflammation of the voice box), Sinusitis, Pharyngitis (throat infection), Otitis media (middle ear infection), failure to thrive, Sandifer’s syndrome and vomit with blood in it. (5,6) When these problems occur, an infant is considered to have Gastroesophageal Reflux Disease (GERD). (5)

The good news is that symptoms of reflux usually resolve spontaneously by age one. (5) In the mean time the measures that can be taken to help your daughter’s reflux include; thickening her formula, elevating the head of her mattress 30 degrees, avoiding position changes for 30 minutes after a feeding, avoid moving your daughter after feedings, plan diapering and play time so that it does not occur after a feeding, avoiding exposure to second-hand cigarette smoke, avoiding allergic foods and feeding her hypoallergenic formula. (4,5) When elevating an infant's head it is importatnt not to use pillows. Instead put a folded blanket under the mattress. Acid blocking medications may be recommended, especially when symptoms outside of the esophagus occur. (5)

By controlling your daughter’s GER symptoms, you may be able to control her nose symptoms. Since GER may cause other problems such as ear infections and respiratory infections it is important that you follow up with your daughter's Doctor if new symptoms develop. As long as she presently doesn’t have other symptoms such as fever, problems moving her bowels, difficulty gaining weight, coughing, change in the quality of her cry, stridor (high pitched inspiratory sound), wheezing or problems breathing, it sounds reasonable to wait it out at this point.

Your daughter’s GER symptoms and nasal symptoms are expected to improve with age. If at any point her condition seems to worsen you should bring her in to see her Pediatrician and a specialist if your Pediatrician feels that it is necessary.

If you are interested in other Pediatric Advice stories covering this topic:

Newborn Congestion

Infant Vomiting

Vomiting and Weight Loss

Baby with Cold Symptoms

I hope your daughter's "snuffles" go away real soon.

(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1168-1171.

(2) Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of Gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 1997. 151(6):569-572.

(3)Gold BD. Gastroesophageal reflux disease: could intervention in childhood reduce the risk of later complications? Am J Med. 2004. 117(Suppl 5A):23S-29S.

(4 )Rudolph CD, Mazur LJ, Liptak, GS. North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of Gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001. 32(Suppl 2);S1-31.

(5 )Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006. 35(4):259-266.

(6)Christensen M. Gold B. Clinical Management of Infants and Children with Gastroesophageal Reflux Disease: Disease Recognition and Therapeutic Options. Presented at: The 2002 ASHP Midyear Clinical Meeting; Dec 9, 2002: Atlanta.

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

Pediatric Advice For Infants

Sunday, October 29, 2006


Dear Lisa,

I have a five year old boy. I started night training him when he was not quite four and I was five months pregnant with his little brother. The whole process went perfectly. I would get up two or three times a night and take him to the potty, gradually the number of times I had to get up reduced until about a month later when he began getting himself up to go potty without my assistance. I assumed that when his little brother was born he would regress somewhat. Just because of the emotional stress of having a new baby in the house. I was overjoyed when he didn't regress!!! He went seven whole months without one accident! Then we went to visit some family members out of town and he came down with the flu. He was seriously ill for the better part of a week. He started bedwetting. I thought it was just because he was so sick, and he would be back to getting himself up to go when he felt better.

That has been five months ago. I have tried everything I know to try. I am so frustrated. I have asked so many people and nobody can help me. I am very careful about being gentle and kind with him, I don't want to embarrass him or make him feel like he's done something wrong. But, if I don't get him up to go in the middle of the night, he WILL wet the bed, and sometimes he still wakes up with wet sheets. I asked him once why he started having accidents again and he said "Because I'm just too tired to get up." I'm trying really hard to do things right, but when I'm up changing sheets at two o'clock in the morning because my five year old didn't WANT to get up and go potty, it's almost more than I can take. I just don't understand what could have caused him to regress so completely. Please, please help me!!! This is putting a strain on the whole family.

Thank You,

“Tired and Frustrated”

Dear “Tired and Frustrated”,

It’s interesting how your son did not regress when your new baby was born, but started his bedwetting again after her was ill. Since your son had control of his urine for such a long time and the symptoms returned it would be important to figure out the cause of the return of his bedwetting.

Children with urinary incontinence only at night have Nocturnal Enuresis. Nocturnal Enuresis is a very common childhood condition that affects approximately 13% of all 6 year olds. (1) Children who never gain control of their urine at night have Primary Nocturnal Enuresis. This is the most common type of Nocturnal Enuresis. Children who gain control of their urine at night for at least 3 months and then resume bedwetting are considered to have Secondary Enuresis. (2) Your son’s symptoms fit into the category of Secondary Nocturnal Enuresis. This type of enuresis is usually not caused by a small bladder capacity or immature sleep arousal pattern. (2)

In order to treat your son’s wetting at night, it would be important to first find out the cause. It was very smart of you to ask him why he started wetting at night again. Whenever a child develops a change in behavior it is important to ask him directly about the problem. Since your son replied that he was too tired to get up , this is a good place to start.

It may be a good idea to investigate why your son feels that he is too tired. Has he been sluggish during the day? Is he more tired with exercise as compared to other children his age? Has he not been getting the appropriate amount of sleep? These are some questions that you need to ask yourself. Before we can assume his symptoms are behavioral, it would be a good idea to make sure the symptoms aren’t due to something out of his control.

Since the symptoms began after his prolonged illness, reasons for being tired after an illness should be investigated. Some childhood viruses or infections can cause a child to become temporarily Anemic. (3) A child can have Anemia without their parent knowing it because the signs are typically quite vague and non-specific. Signs of Anemia may include excessive sleepiness, irritability, disinterest in eating, pale skin color, pale mucus membranes, exercise intolerance, short attention span, poor school performance and difficulty eating in infancy. (2,4,5)

Two examples of such infections are the EBV virus and Mycoplasma. (5) Your doctor can evaluate your son for signs of Anemia, or other conditions such as Hypothyroidism that can cause a child to be fatigued. (2) Urinary screening may also be performed in order to look for signs of infection, the kidney’s ability to concentrate the urine, the presence of blood and sugar. (6)

Another very important question to ask is, does your son has any problems with urinary incontinence during the day? This is very important information to know, because children who experience Nocturnal Enuresis along with daytime incontinence may have an organic problem that needs to be ruled out. (2) A child who gains control of their urine during the day for a period of time and then develops incontinence has Secondary Enuresis.

Secondary Enuresis is a type a dysfunctional voiding that develops as a result of constipation or pelvic floor dysfunction. Secondary Enuresis may also occur following a urinary tract infection.(3) Some children who develop a urinary tract infection learn to suppress the need to urinate by controlling the pelvic floor muscles. When this occurs, the muscles of the bladder and the bowel become distended. The urine accumulates and pools in the distended bladder and as a result the child loses the sensation of needing to void. (3)

When this happens it takes months for the bladder to regain its tone. If your son is experiencing day time and night time incontinence, it would be important to bring him to the Doctor for an evaluation so that these factors can be ruled out. In some cases, the expertise of an Uurologist and diagnostic testing such as a bladder ultrasound may be needed.

Once you know that there is no organic cause for your son’s bedwetting, then you can work on the behavior. To start, there is no reason why you should get up in the middle of the night. All that is necessary is that you wake your son and bring him to the bathroom before you go to bed at night and bring him to the bathroom the first thing in the morning. The feeling of being wet and uncomfortable is necessary in order to provide an incentive for your son to change his behavior.

It would be a good idea to purchase a few washable waterproof pads and put one under his body, on top of the sheets before he goes to bed. When he wets himself this waterproof pad will absorb the moisture and prevent the sheets from getting soiled. This way the sheets will not need to be laundered everyday. It is much easier to wash a pad, then to change the whole bed.

Your son should be taught to remove the pad from his bed in the morning and put it in the wash. It is important that this is not viewed as a punishment, but a way of helping him become responsible for himself. It is a good idea to take a matter of fact approach, helping him realize that a mess needs to be cleaned. Understanding that an important step in overcoming bedwetting is having the child have an active role in dealing with their bedwetting should help you relinquish this responsibility. (2) Not only will this approach teach your son responsibility, it will keep you from being overburdened.

You can purchase one of these 34 inch by 26 inch washable pads at a baby supply store such as Babies R Us or Toys R Us. It is also a good idea to limit the amount of fluids that your son drinks in the evening by not letting him drink after 7:30 p.m. (6) Remind him gently before he goes to sleep that he has underwear on and that you expect him to stay dry.

The other thing to consider is a dietary change that may be causing your son’s bedwetting. Has there been a change in his diet since he was ill? Does he now drink soft drinks, caffeine or drinks with sugar-substitutes and he didn’t before? Recent literature has shown that food sensitivities can play a part in enuresis. (6) It has been reported that milk, milk products, caffeine, vitamin C, citrus juices, corn, heavily sugared foods and carbonated beverages may contribute to enuresis. (2,7)

If there has been a change in his diet since he was ill you may want to consider a food sensitivity as a possible cause of his bedwetting. You can eliminate the new products from his present diet for a period of two weeks in order to determine if they are causing a problem. Gradually add the products back, one at a time and take notice which nights your son wets his bed. (6) If the Nocturnal Enuresis consistently occurs when your child ingests a certain food then chances are that item can be contributing to the problem.

Since Constipation contributes to Nocturnal Enuresis it would be important to consider this as factor. It is common for school age children to have firm, infrequent stools. A full rectum can restrict the bladder’s expansion and cause a bladder contraction which leads to urinary incontinence. In addition, constant rubbing of the bladder by the full rectum decreases the sensitivity of the bladder and causes the brain to begin to ignore messages from the area. (3,6) If your son has hard, infrequent stools it would be important to bring this to your Doctor's attention so that this can be addressed before attempting to train your son to stay dry at night.

Bedwetting can be very frustrating, because it is a problem that usually takes some time to resolve. It puts a strain on the family emotionally and physically. It is a very messy problem and the effort that it takes to keep the child’s body and bed clean is not only time consuming, but exhausting. It is also very normal to become frustrated. Children frequently become very embarrassed by the situation and the emotional trauma can many times interfere with a child’s socialization. (8) You have done the correct thing by being gentle and kind with your son. Keeping a non-accusatory tone and having your son involved with his care will help everyone involved.

I wish you dry and restful nights in your near future.

(1)Fergusson DM, Hons BA, Horwood LJ. Factors related to the age of attainment of nocturnal bladder control: an 8 year longitudinal study. Pediatrics. 1986;78:884-890.
(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. 1990:216-217, 440-441, 349,217.
(3)Listernick R. A Thirteen-Year-Old Girl with Anemia. Pediatric Annals. 2003.32(3);139-148.(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1407.
(5)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:495-501.
(6)Mercer R. Dry at Night. Advance for Nurse Practitioners. 2003. February:26-30.
(7)Maizels M, Rosenbaum D, Keating B. Getting to Dry: how to Help your child Overcome Bedwetting. Boston, Mass: The Harvard Common Press; 1999.
(8)Sacharyczuk C. Psychological implications of nocturnal enuresis demand treatment. Infectious Diseases in Children. 2006. April:72.

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

Pediatric Advice For Parents

Saturday, October 28, 2006

Green Stools

Dear Lisa,

My 6 week old nephew has been given Mylicon for gas/colic. He is a formula baby and we have given him prune/apple juice for constipation. His poop color is dark green, almost black and a little watery. Why is his poop this color?

“Concerned Aunt”

Dear “Concerned Aunt”,

The stools of bottle-fed infants can vary in color. The colors change according to what the baby eats or due to the medications that he takes. Normal colors include shades of green, brown or yellow depending upon the formula. (1) Some shades of green may appear almost black in color. On the other hand, babies that are exclusively breast fed and not taking iron vitamins are not expected to have green stools. Green stools in this case may be a sign that the baby is not receiving enough milk.(1) Any infant with very light colored stools, grey stools, black stools or stools with visible blood should be evaluated by a Health Care Professional.

Therefore your nephew’s stools sound like they are normal. If you are not sure if the color is black it would be a good idea to bring this the Doctor’s attention. His doctor may need to visually inspect the stool to see if the stools are truly black. Since black colored stools may be a sign that there is blood in the stool, the doctor may want to test the stool.

Blood in the stool turns black when it is not fresh blood. This occurs when the blood enters the system high in the gastrointestinal tract. (2) For example, this can occur if blood enters the stomach or the small intestine. The stool turns black during the transition to the large intestine.

Testing stool for blood can be done with a very simple test called the Hemoccult or Guaiac test. (2) In order to test stool for blood the specimen should be obtained from fresh stool collected on three consecutive days (three days in a row). This is simple when a child is still in diapers. Simply remove the diaper when the infant has a fresh stool and label it with the date. It is important to collect a fresh specimen because the test will not be accurate if the stool is mixed with urine or water. (2)

For older children who no longer wear diapers, the stool can be collected by putting plastic wrap (i.e. Saran Wrap) over the rim of the potty or toilet bowl. The child can have a bowel movement and the plastic wrap will catch the stool and prevent it from mixing with the water in the toilet.
Once the stool specimen is obtained, small specimens collected from two different spots of the stool are smeared onto a guaiac card. A couple of drops of a reagent solution are put on the specimen card and if the window turns blue it means there is blood in the stool. (2)

(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 291.
(2)Kozier B, Erb G. Fundamentals of Nursing. Concepts and Procedures. 2nd Ed. Menlo Park, California: Addison-Wesley Publishing Company.1983:688-700.

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

Pediatric Advice About Keeping Infants Healthy

Friday, October 27, 2006

Chronic Ear Infection

Dear Lisa,

My child has had an ear infection for six weeks now she is four years old. She has been on four different medications. That is a concern but what I have also noticed is that her hair is thinning out and she wakes up complaining about a pain in her leg. Can all this be related somehow?


Dear “Granny”,

Otitis Media is the infection of the middle ear cavity and is commonly referred to as a Middle ear infection. It is a common childhood ailment and accounts for 20% of all visits to the doctor during the first five years of life. (1) The symptoms include earache, sensation of “blockage” of ears, rubbing or pulling ears, hearing loss, fever, irritability, upper respiratory symptoms, vomiting or diarrhea. (1)

Risk factors for developing Otitis Media include daycare attendance, exposure to secondhand cigarette smoke, pacifier use, formula feeding as opposed to breastfeeding, bottle propping practices, having more than one sibling, Native American ancestry, and a family history of Acute Otitis Media. (1) Eighty percent of cases of Acute Otitis Media resolve without antibiotics. When antibiotics are used there is an earlier resolution of pain, reduced risk of developing a middle ear infection in the opposite ear and the reduced risk of developing complications. (1) On the other hand, Antibiotic use may contribute to bacterial resistance. (1)

There are two treatment options for children with Otitis Media; antibiotics or a wait and see approach. The American Academy of Pediatrics recommends antibiotic treatment for children less than 6 months old, children with serious illness, children who cannot be followed up, children with chronic medical conditions, children with a recurrence of Otitis Media in the previous 30 days and children with chronic Otitis media with effusion. (1,2), Children not belonging to these categories can be watched and reassessed in 48-72 hours. If at that point the child is still symptomatic and has Otitis Media upon physical examination, antibiotics are recommended.

Research has shown that children under two years old diagnosed with Otitis Media and treated with an antibiotic have a higher rate of recovering and a decreased rate of recurrence. (3) In addition children in daycare and children with a history of several cases of Otitis Media were found to have higher failure and recurrence rates. (3)

When an antibiotic is prescribed there should be a response to therapy within 48-72 hours. If no improvement is noted after this time the antibiotic typically is changed to a different type. Research studies show that microorganisms that cause refractory cases or severe cases of Otitis Media can be eradicated in 96% of children when high dose amoxicillin-clavulanate is used. (4) Once an inner ear infection is treated, fluid can remain in the ear for 90 days after the acute infection has resolved.(5) This fluid many times resolves on its own and is not considered an infection.

I can see why you are concerned about your child’s ear infections. An ear infection that lasts six weeks and does not respond to 4 different types of antibiotics is not normal. Children who experience an ear infection that does not resolve with repeated antibiotic treatment or those with a high rate of recurrence should be referred to an Otolaryngologist or Ear Nose and Throat Specialist.(6)

Complicating factors such as Eustachian-tube blockage or dysfunction, allergic rhinitis, enlarged or chronically infected adenoids and inefficiency of palatal muscles need to be ruled out.(1,6) Careful evaluation of risk factors should also be evaluated. Depending on your social situation, whatever measures that you can take to eliminate risk factors such as stopping the use of a pacifier or switching to a smaller day care setting may be helpful. (5)

In regards to your question about your child’s hair, hair thinning in a child may reflect normal developmental changes. In some cases the thinning of hair can be due to an underlying problem or condition. Most of the time, normal hair growth patterns are responsible for what appears to be hair thinning.

Hair replacement occurs according to a cyclic pattern alternating between growing and resting phases. Hair on the scalp grows steadily and continuously for 2 to 6 years. Then the hair enters a resting phase in which the hair stops growing. After three months of no hair growth the hair starts to fall out. Following this hair shedding period, the hair rests for an additional 3 months and then new hair growth resumes.

Both this rate of growth and the replacement cycle may be altered by many factors. These factors include; illness, diet, high fever, major illness, surgery, blood loss, drugs, radiation or severe emotional stress. (7) Your child has had an illness and this could be an explanation for the hair thinning that you are seeing. If she had high fevers with her ear infections this could be another explanation.

Diffuse hair loss or hair loss throughout the head can be due to thyroid disease, systemic disease, anorexia nervosa, low ferritin levels and drugs. (8) therefore, if your daughter’s hair thinning is dramatic or doesn’t improve, it would be a good idea to have her checked by her Primary Care Physician. Your doctor will be able to determine if your daughter’s hair changes are due to thinning or from patches of hair that are missing and guide you accordingly.

Children complain or muscle aches for a multitude of reasons. Muscle aches many times accompany an illness or can be a sign of injury or overuse. A child with persistent leg pain associated with fevers presents a particular concern. Children are susceptible to developing Osteomyelitis or a bone infection.(9) Osteomyelitis occurs when germs or microorganisms from the blood deposit into the bone.(9) Children with leg pain and fevers need to be evaluated and Osteomyelitis should be ruled out. Other concerning signs include leg pain that involves a joint, limping, increase in pain intensity and persistence of pain despite palliative treatment. Children with these symptoms should also be evaluated by their Physician.

(1)Alper B, Fox G. Acute Otitis Media. The Clinical Advisor. 2005. April:78-86.
(2)American Academy of Pediatrics/American Academy of Family Physicians Subcommittee on Management of Acute Otitis Media. Clinical practice guideline. Diagnosis and management of acute Otitis media. Pediatrics. 2004;113:1451-1456.
(3)McCormick DP. Watchful waiting in non-severe AOM: How to select cases, and does it work in young children. Session 2600 Update on treatment options for acute Otitis media. Presented at: pediatric Academic societies’ 2006 annual Meeting; April 29- May 2. San Francisco.
(4)Bell E. Acute Otitis media treatment guidelines: Are prescribers using them? Infectious Diseases in Children. 2006. August:14.
(5)Carlson L. What’s New in the Guideline? Therapeutic Spotlight. 2004. June:11-13.
(6)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:489-492.
(7) Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984: 112-113.
(8)Stephenson M. Effective Treatments available for alopecia areata, vitiligo. Infectious Diseases in Children. 2006. May:20.
(9) Bautista S, Gholve P, Pediatric Musculoskeletal Infections: Advances in Diagnosis and Management. Consultant for Pediatricians. 2006.Aug:481-494.

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

Pediatric Advice For Sick Children

Thursday, October 26, 2006


Dear Lisa,

My 2 year old child recently had an MRI to make sure that the cause of his Strabismus was strictly the eyes and nothing more. His MRI results revealed white matter on the brain of an unknown cause that could be progressive. He was sent to the lab where blood & urine were taken to check his amino acids, organic acids, and for very long fatty chains. The amino & organic test results have all come back normal. We are just waiting for the other test. My question is, is it possible to have an abnormal MRI revealing this, but it not be anything to worry about? My son has no other medical problems besides the strabismus and has had breath holding spells when he was younger.

“Concerned Mom”

Dear “Concerned Mom”,

Strabismus is the misalignment of the eyes due to the lack of muscle coordination. (1) About 50% of all children with Strabismus have a family member with the condition. (2) Symptoms of Strabismus include difficulty seeing at close range, deviation of the eye, squinting, headache, lack of coordination, double vision, closing one eye, and head tilting. (2) The most common cause of strabismus is imbalance of the muscle alignment of the eyes. Other less common causes include retinoblastoma, loss of vision, myasthenia gravis, cataracts, infection and brain tumor.

In infancy, it is normal for infants to experience intermittent Strabismus due to the immaturity of their eye muscles. (1) This type of Strabismus is called Congenital Infantile Esotropia and is found in approximately 1 – 2% of infants. (1) These infants present with an intermittent inward deviation of one or both eyes. (1) By the age of three months normal ocular movement is usually established. (3) By six months old the infant’s symptoms should be totally resolved. An infant who displays symptoms beyond this point needs an evaluation by a Pediatric Ophthalmologist. Any child with a constant deviation, even if they are under 6 months old, also needs an evaluation by a Pediatric Ophthalmologist. (1)

Congenital Exotropia is a type of Strabismus that is less common. In this condition the eye turns away from the midline. It is usually noticed when a child is fixating on a distant object, daydreaming or fatigued. This condition tends to be associated with an underlying neurological problem such as Periventricular Leukomalacia or other neurological disorders. (1)

Early detection and treatment of Strabismus is essential to prevent Strabismus Amblyopia. (1, 2) Strabismus Amblyopia is the loss of vision in the deviating eye of a child with Strabismus. Visual loss occurs because of the body's attempt to suppress the double vision experienced by the child with Strabismus.

Some childhood disorders are associated with other conditions. When a child is diagnosed with one disorder, diagnostic testing is commonly performed in order to rule out potentially associated findings. Just because a particular condition may be associated with another disorder, does not necessarily mean that every child will develop that problem.

Without knowing your son’s diagnosis, complete history, physical findings or physically seeing your child I cannot offer you any specific information about his condition that may be helpful for you. I can only tell you that generally speaking white matter changes on an MRI of the brain can be associated with neurological conditions. In some conditions, white matter changes are associated with structural brain changes. Cognitive function can be impaired in patients with additional structural brain changes. (4) In general, cognitive function can be normal in children with isolated white matter changes. (4)

The significance of the white matter on your son’s Brain MRI can best be determined by his neurologist who reviewed the films and is familiar with his condition. It is important to remember that a child’s Neurological development with any type of neurologic anomaly can be quite variable and depends upon the extent of the malformation. (5)

Your doctors have performed a comprehensive work-up and in time will be able to give you the answers that you need. It is reassuring to know that the amino acid tests are normal so far. This type of testing typically ascertains the probability of an inborn error of metabolism or genetic syndrome. It is also good news that your son is not presently displaying any abnormal neurologic signs or developmental delays. Although waiting for test results and a diagnosis is extremely stressful, it may be helpful to concentrate on the positive findings that you know so far.

I wish you and your son well.

(1)Wagner R. Understanding Strabismus in the Pediatric Patient. The Diagnosis and Treatment of Ophthalmic Abnormalities in Children: an update. Infectious Diseases In Children. 2002. May:S13-15.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:2048-2051.
(3)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:338-339.
(4)Mercuri E. Longman C. Congenital Muscular Dystrophy. Pediatric Annals. 2005. 34(7):560-568.
(5) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:652.

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

Pediatric Advice For Parents

Wednesday, October 25, 2006

Growing Pains

Dear Lisa,

My 10 year old son has had muscle twitches for about 1.5 months. They are only painful when he tries to stretch them out. He will be sitting there and suddenly his arm or leg will start jumping and jerking. Are these just regular growing problems or could it be more?

"Son with Muscle Twitches"

Dear "Son with Muscle Twitches",

Growing pains are pains that children experience in their extremities. The pains typically occur in the calves or the shins of both legs and do not include any joints. Commonly the pains occur at night and may even wake a child from his sleep. By the next morning the pain disappears and the child walks, runs and plays normally as if nothing ever happened.

Growing pains are more common in the 3 to 5 year and in 8 to 12 year age groups. (1) Upon inspection of the legs or extremity there should be no abnormal findings; no bruising, no swelling and no deformity. The exact cause of growing pains is unknown but they are thought to be caused by swelling of the muscle bodies within the tight fascial sheaths during periods of activity or overuse. (1) The treatment for growing pains is heat, massage and Acetaminophen (Tylenol). (1)

From the description you gave about your son’s symptoms it does not seem that he is experiencing growing pains. There is no involuntary jumping, twitching or jerking involved with growing pains. It may be possible though, that your son has a growing pain and then moves his leg back and forth voluntarily in response to the pain. If your son is having movements which are out of his control, then the symptoms are not due to growing pains.

Fibromyositis on the other hand can cause local muscle spasms or twitching. Fibromyositis is characterized by pain, tenderness and stiffness in the joints, muscles or surrounding structures. When the thigh is involved it is called a “Charleyhorse”. A Charleyhorse is caused by bruising and tearing of the muscles fibers resulting in a collection of blood. (2)

The pain usually has a sudden onset, is aggravated by motion and muscle spasms are noted. The symptoms disappear with rest, heat and massage. Occasionally Charliehorses can become chronic or recur at frequent intervals. (2) The symptoms you described may be consistent with a Charleyhorse. You stated that your son has muscle twitches and then has pain when he tries to stretch it out. Charleyhorses tend to cause pain with movement.

Tetany is another health condition that causes muscle twitches, spasms and may also cause convulsions. Tetany is caused by a calcium deficiency. The Parathyroid gland is located in the neck and is attached to the thyroid gland. This gland is responsible for the balance of calcium in the body. Children who have had surgery on the thyroid gland, have Parathyroid disease, infection or injury can develop Hypoparathyroidism which causes calcium deficiency. (2) Tetany is not common in childhood, but should be strongly considered if your child has had an operation or injury to his neck or thyroid gland.

Without physically examining your child and witnessing the events it is not possible to determine the cause of your son’s symptoms. The best way to diagnose your son is to have him evaluated by his Primary Care Physician. I recommend keeping a diary of the events, writing down the time and duration of the twitching and pain, the part of the body that is affected, the pain severity, any associated symptoms and what measures relieved the episode. It would also be beneficial to make a video recording of the episode so that your Doctor can witness the event in case it does not occur in the office.

It is important that you seek medical attention because it is not normal for a child’s extremities to involuntarily jump and jerk.

(1)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:566,572.
(2)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984: 219, 416.

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

Pediatric Advice Website -Updated Daily

Tuesday, October 24, 2006

Sports Injury

Dear Lisa,

I have an eight year old daughter who has begun to love swimming for her swim team. She swims year round and it is hard to get her out of the pool. Recently she has complained of popping and slight pain in her elbow when swimming free and back and knee popping when swimming breast. Is this just a growing thing or should I be concerned. Are there exercises she can do to strengthen these areas?

“Daughter on the Swim Team”

Dear “Daughter on the Swim Team”,

Younger children normally are flexible with the movement of their joints. As children mature they naturally lose this flexibility and their muscular strength increases. (1) Because they are so flexible, children may be able to move their joints in such a manner that it makes a popping sound.

Some children have loose ligaments which also lends itself to popping of the extremity with movement. If the ligaments are too loose and the child has too much laxity, a joint may be subject to injury due to the inadequacy of the supporting structures around bone and muscle. (1) Therefore if you notice popping sounds and/or joint instability it is a good idea to have it evaluated by a Health Care Professional.

In some children, maturity alone is all that is needed to alleviate the symptoms. In others stretching, muscle strengthening exercises or both are needed to rectify the situation. (1) Your daughter’s Primary Care Physician will be able to asses your daughter’s musculoskeletal condition, strength, flexibility and joint stability and determine if she needs further intervention. A referral to a Pediatric Orthopedic Specialist or Physical Therapist for an evaluation may be necessary. In some cases the expertise of a Sports Medicine Doctor is indicated when a child encounters musculoskeletal injuries or complaints during their sport. (1)

What starts out as normal movements in a flexible child can turn into a habit. Some children discover that their body can move in such a manner and continue to force the movement to occur out of habit. You may want to observe your daughter to see if the popping occurs as a result of her purposeful movements, or if the frequency increases during a specific activity or stress. This would be important information to relate to your daughter’s Doctor. It would also be a good idea to ask your daughter if she has control of her movements. If she does you should reinforce the need to stop this activity.

It is wonderful that your daughter has developed such a great interest in a sport. Her continued participation not only will benefit her physically, but the lessons of Camaraderie and working in a team will be carried with her for the rest of her life. As with any sport, it is important to always follow measures that prevent injuries. These measures include; proper warm-up, stretching, conditioning, appropriate protective equipment that is the right size for the athlete and participation at the appropriate level. (2)

By following these measures, keeping open communication with your daughter’s coach and maintaining yearly physical examinations by your Primary Care Physician you can ensure that your daughter experiences a healthy and safe sports environment. Some parents prefer not to have their child participate in organized sports because they are fearful that they will get hurt. It is reassuring to know that statistics show that children younger than 10 years old sustain more fractures and catastrophic injuries in recreational activities than they do in organized sports. (2)

Good luck on the Swim Team!

(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. 1990:140.
(2)Setphenson M. Pediatricians play an important role in sports injury prevention, treatment. Infectious Disease in Children. 2006. May:46.

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

Pediatric Advice About Keeping Kids Healthy

Monday, October 23, 2006

Infant with Diarrhea

Dear Lisa,

My daughter is 12 weeks old and has went from one stool a day to many. She was on antibiodics...Zithromax and Flagyl in the last month. Her poops sometimes have mucus in them and she is going up to 10 times a day. I was told to change her formula from Good Start to Nutramigen. She has become extremely irritable since switching her? She used to sleep though the night and is waking up again. Fussy all day long and never used to be.

“Help! Any Suggestions?”

Dear “Help! Any Suggestions?”,

It is very concerning when an infant has such a marked increase in the amount of stools per day, especially when the stool contains mucus. Since your baby’s bowel movement and feeding pattern were previously normal, it would be important to have an evaluation by your Doctor to determine the cause. A common cause for a change in stool pattern as you described can be due to a virus or infection. It is also reasonable to consider your daughter’s antibiotic use as a potential factor. Although Antibiotics are necessary to treat infections, unfortunately they do not come without side effects.

Everyone has intestinal flora or normal germs in their gastrointestinal (GI) tract. These germs serve to fight other microorganisms that enter the GI tract and prevent the new germs from causing an infection. When a patient receives antibiotics, the antibiotics alter the flora in the GI tract by killing the normal flora which is meant to be protective. (1) This makes the patient more susceptible to the invasion or overgrowth of other germs which can lead to infection. Therefore, when a child develops a change in stool pattern after antibiotic use, this alteration in the child’s intestinal flora should be considered.

In treating an infant’s diarrhea, Doctors and Nurse Practitioners may recommend temporarily switching the infant’s formula. Formulas such as Nutramigen are chosen because they are easier to tolerate. The milk proteins are chopped into smaller pieces which makes the formula easier to digest. In some cases a rice based diarrhea formula or soy based formula may be recommended because they tend to bind the stool and slow down the diarrhea. Mothers who are breastfeeding are recommended to continue to do so because the components in breast milk protect the baby.

Lactoferrin, a potent bacteriostatic is abundant in breast milk. This in combination with other antibodies and anti-infective enzymes, found in breast milk helps to destroy the pathogens that cause diarrhea. (2) Lactobacillus bifidus is also naturally present in breast milk. It promotes the growth of beneficial bacteria in the gut and discourages growth of other germs.(2)

Some Health Care Practitioners recommend that children with a diarrhea illness take Probiotics such as Lactobacillus. This recommendation is based on the information from a multitude of studies that show the benefit of supplementing a child’s diet with Probiotics for the treatment of diarrhea.(3) A meta-analysis of nine randomized , controlled studies demonstrated that Lactobacillus is safe and effective in the treatment of children with acute infectious diarrhea, much of which was due to rotavirus.(4)

Because of this evidence that Probiotics are beneficial, scientists are in the process of creating a drink for children who suffer from diarrhea. In order to duplicate the effects of the protective enzymes found in breast milk, scientists have added Lactoferrin and Lysozyme to an oral electrolyte solution. Their research thus far has shown that this new formulation significantly reduced the duration of diarrhea and also reduced the rate of recurrence of diarrhea in children.(5)

Although this information about Probiotics is very promising, it is important to use caution when giving a child Probiotics. The current products on the market today are not approved by the U.S. Food and Drug Administration, which means they are not regulated. Since the manufacturing and labeling is not regulated, a product purchased may not have the ingredients as labeled. In a British study of 13 Probiotic brands, only two contained the ingredients as labeled and the other 11 brands did not contain the listed Lactobacillus acidophilus ingredient, contained extra species, lacked a listed species or included ingredients less than 0ne-tenth of those advertised.(6) Therefore it is important to follow your Doctor’s recommendations regarding Probiotic use.

The Gastrointestinal specialists that I worked with commonly prescribed Probiotics for children with diarrhea. In some cases they recommended them for younger infants if the situation warranted. Even though Priobiotics are considered a good treatment for diarrhea in children, it is important to remember that their long term safety is not known. In addition, Probiotics should not be given to children with diseases that alter their immune system. There have been case reports of immunocompromised children who took Probiotics and became ill with a blood infection.(3)

In regards to your daughter’s condition it is important to have repeat follow up visits with your Doctor in order to monitor her condition. If her symptoms continue, your doctor may need to assess her for dehydration, an electrolyte imbalance or weight loss. In addition, changes in her diet or laboratory testing may be required. In some cases Doctors may order stool cultures, urine testing or bloodwork in order to determine if she has dehydration or an infection. During the follow-up visit it is a good time to discuss the possible effect that the antibiotics may have had on her condition and your Doctor’s opinion of Probiotics.

If your daughter has a fever, vomiting, listlessness, feeding difficulties, is inconsolable, has excessively foul smelling bowel movements, a dry mouth, a sunken soft spot, lacks tears, decreased urine output, blood in her stool, signs of abdominal pain or increased frequency in her bowel movements it would be important to see your doctor without delay.

I hope your daughter has a quick resolution to her symptoms and is back to herself soon.

(1)Rosenthal M. C. difficile is more virulent, more resistant and affecting younger, healthier patients. Infectious Disease in Children. 2006. Aug:35.
(2)Riordan J. A Practical Guide to Breastfeeding. St. Louis Missouri: The C.V. Mosby Company. 1983:36.
(3)Zangwill K. Protecting against rotavirus disease and its complications. Infectious Diseases in Children. The Management and Prevention of Rotavirus. 2006. March:S9-13.
(4)VanNiel CW, Feudtner C, Garrison MM, Christakis DA. Lactobacillus therapy for acute infectious diarrhea in children: a meta-analysis. Pediatrics. 2002.109(4):678-684.
(5)Zavalet N. Abstract #3855.2 Presented at: The Pediatric Academic Societies' Annual Meeting; 2006:San Fransicisco.
(6)Hamilton-Miller JMT, Shah S, Smith CT. “Probiotic” remedies are not what they seem. BMJ. 1996;312:44-60.

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

Pediatric Advice for Infants

Sunday, October 22, 2006

Enlarged Testicle

Dear Lisa,

Why would a 3 year old have an enlarged testicle?

“Three year old with an enlarged testicle”

Dear “Three year old with an enlarged testicle”,

A child’s testicle could appear enlarged for a few reasons. A child with Cryptorchidism, can present with the appearance of one testicle being enlarged. Cryptorchidism is the absence of a testicle from the scrotal sac. Therefore the side of the sac that has a testicle would appear larger than the side of the sac without one. Cryptorchidism occurs when a boy has an Undescended testicle or Retractile testes.

An Undescended testicle occurs when the descent of the testicle from the abdomen to the scrotal sac does not occur. A delay in the descent of the testicle from the abdomen can occur in up to 4% of full term newborns and in up to 30 % of premature males. (1) Within the first few months of life about 80% of all undescended testes will be in the scrotum. (1) Spontaneous descent does not usually occur after one year of age. (2). If a testicle does not descend within this time frame medical intervention is indicated.

A testicle may not be able to descend because of a mechanical barrier such as a short spermatic cord or a narrow inguinal canal. Adhesions or fibrous bands may also prevent a testicle from descending. (1,2) In some cases the descent of the testes is diverted to another area in the perineum or femoral area.

Cryptorchidism can also occur due to Retractile testes. Retractile testes can be felt at any level along the line of decent and can be manipulated into the bottom of the scrotum. (1,2) These testes are usually descended, but are pulled back up due to a hyperactive cremasteric reflex. The testes are retracted into the upper part of the scrotum in response to cold, pain, fear or touch.

The appearance of an enlarged testicle may also be due to a Hydrocele or Inguinal hernia. A Hydrocele is a non-tender, fluid filled mass in the scrotal sac. (3) Before a baby is born the testes travel from the abdomen down into the scrotum. The testes descend through a special sac of peritoneal tissue called the processus vaginalis. Once the testes reach the scrotum this sac naturally closes. Freqeuntly at birth some residual peritoneal fluid is left in the scrotal sac after closure of the processus vaginalis. A Hydrocele is the accumulation of this peritoneal fluid in the scrotal sac. The fluid gradually absorbs during the first year of life.

A Hydrocele in a child with a closed processus vaginalis is called a Non-communicating Hydrocele. Non-communicating Hydroceles are full, fluctuant and tense. If a beam of light is directed from behind the scrotum in a dark room, the testicle will transilluminate. This means the light appears as a red glow with clear fluid. No blood or tissue should be seen. (4)

A Communicating Hydrocele occurs when the process vaginalis does not close. If this is the case, fluid in the scrotal sac is not noticed until some time after birth. In this type of Hydrocele, the scrotum appears flat in the morning and increases in size as the day goes on. (4) Since there is an opening between the scrotal cavity and the abdominal cavity communicating hydroceles are frequently associated with Inguinal Hernias. (4)

An Inguinal Hernia occurs when the abdominal contents descend down through the patent process vaginalis and into the scrotum. Inguinal Hernias occur most often during the first 10 months of life. (1) They are painless and tend to increase in size when a baby cries or coughs. (1)

On the other hand an acute onset of painful scrotal swelling may be a sign of a more serious health problem such as epididymitis, acute orchitis , torsion of the spermatic cord or a strangulated inguinal hernia. (3) These conditions require immediate medical attention. If a hernia becomes strangulated or incarcerated the child experiences colicky abdominal pain and the scrotal area becomes more swollen and reddened. When an incarcerated hernia occurs the hernia is not able to be reduced which means that the contents cannot easily slide out of the scrotum and back into the abdomen. (2)

If you notice that your three year old has an enlarged testicle, he should be evaluated by your Doctor so that the proper diagnosis and treatment plan be instituted. Signs such as redness, pain, abdominal pain, increased swelling or limp are concerning. If your son’s scrotal swelling is an acute problem, especially if it is associated with pain or an illness, you should visit your Doctor without delay in order to rule out a more serious condition.

(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:828,790.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1520,1459.
(3)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:380, 376.
(4)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:473-474.

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

Pediatric Advice Updated Daily

Saturday, October 21, 2006

Baby with Cold Symptoms

Dear Lisa,




The treatment for an infant with an upper respiratory infection is a cool mist vaporizer. (1) The cool mist loosens nasal secretions and shrinks the swelling of the tiny nasal passages. The administration of saline nose drops also loosens nasal secretions. If your baby has a lot of thick nasal discharge, you may need to suction it out of the nostrils with a nasal aspirator or bulb syringe.

When using a nasal aspirator, first support your baby’s head and neck with one hand. Next instill one to two drops of saline into your baby’s nostril. Then deflate the bulb portion of the nasal aspirator by depressing it with your thumb. You should do this before you put the nasal aspirator into your child’s nostril. Once the bulb is deflated, then put the tip of the nasal aspirator into your baby’s nostril. Quickly remove your thumb from the bulb. The suction created will remove the nasal secretions from your baby’s nasal passages.

Since the nasal passages of a baby are sensitive, it is not a good idea to use the bulb syringe too often. The nasal aspirator should be used when you can actually see nasal secretions occluding the opening. A good time to use it is when the baby wakes in the morning, before a feeding or before bedtime. If you use the bulb syringe too often it can irritate the nasal passages.

Over the counter cough and cold preparations are not recommended for infants, especially when they are under 6 months old. (2,3,4) The reason why they are not recommended is because there is no research data that supports their effectiveness. (2,5 ) In addition, cough medications can have serious side effects in children. (2) In particular cough preparations containing codeine or dextromethorphan are not recommended in young children because of their potential to cause breathing difficulties or respiratory arrest. (2,3,4)

It is not a good idea to supress an infant's cough. A cough is a protective mechanism that protects the airway. When an infant coughs, it helps thin secretions and clear them from the airway. By masking a cough you may be falsely reassured that your baby’s condition is improving when he is not. A worsening cough is a sign that a baby needs to be evaluated by a health care professional.

Instead, it is important to monitor your daughter's symptoms. Watch for vomiting with coughing, increased frequency of coughing, rapid breathing, increased work of breathing, listlessness, fever, difficulty with feedings, retractions (the skin over the ribs suck in during breathing), grunting, pale color or irritability. These signs may represent a condition more serious than the common cold and warrant an evaluation by your baby’s Doctor or Nurse Pactitioner.

Yes, women who are breastfeeding do take medications that are necessary. Most medications taken by nursing mothers are found in some degree in breast milk. After the first couple of weeks of life, a full term infant is able to metabolize and excrete drugs. (6) These processes develop much later in infants who were born prematurely.

It is important to remember that most of the information about drugs used by nursing mothers is from anecdotal reports or stories told by those mothers who used the drug while breastfeeding. The information is not based on actual clinical research performed on nursing mothers. There are obvious reasons why this type of research has its limitations. Therefore it is important to measure the risk benefit ratio when considering taking medications while nursing.

The first step is to establish the need for a medication during breastfeeding. Certainly there are mothers with chronic medical conditions that need to take certain medications because without them their health would fail. In other situations, it is a good idea to try natural measures first and resort to medications only if they are necessary.

Some natural measures to treat cold symptoms include gargling with warm salty water, drinking extra fluids which will help loosen respiratory secretions and drinking sugar and lemon drinks which can help soothe the throat. (2) Other helpful measures include irrigating your nasal passages with saline, using steam to treat nasal congestion and sinus pressure and using lozenges and menthol cough drops to soothe an itchy sore throat and reduces cough sensitivity. (2) In addition, the heat from chicken soup and hot tea serves to soothe a sore throat and loosen nasal secretions.

If these natural remedies do not help alleviate your symptoms, an evaluation by your Doctor may be necessary. More serious conditions such as a sinus infection, throat infection or pneumonia may need to be ruled out.

Many over the counter cough and cold preparations contain ingredients that can make your baby irritable or drowsy. Another common side effect of these medications is reduction in the mother’s milk supply. (6) For this reason, these medications are avoided if possible. On the other hand, Acetaminophen (Tylenol) use in breastfeeding women is considered relatively safe. (6)

When both a mother and baby are sick, it is a good time to recruit help from other family members and freinds. Don’t hesitate to ask people for assistance because a helping hand can make a world of a difference. Getting rest can help you regain the strength that is necessary for you to get better.

I hope both you and your baby are feeling better soon.

(1)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 699.
(2)Pediatric Update. Chronic Cough in Children: New Guidelines Offer New Direction. 2006. Apr:251-256.
(3)Chang AB, Glomb WB. Guidelines for evaluation chronic cough in pediatrics. ACCP evidence-based clinical practice guidelines. Chest 2006;129:260S-283S.
(4) Stephenson M. Be aware of the myriad conditions that trigger chronic cough in children. Infectious Diseases in Children. 2006. March:38.
(5)Taylor JA. Efficacy of cough suppressants in children. J Pediatr. 1993;122:799-802.
(6)Riordan J. A Practical Guide to Breastfeeding. St. Louis Missouri: The C.V. Mosby Company. 1983:138-140.

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

Pediatric Advice Updated Daily

Friday, October 20, 2006


Dear Lisa,

My 3 year old son has been suffering from head pain and visual disturbance for about the past 2 months. These "episodes" happen every day up to 6 times a day and last about 5 minutes or so. He complains that his head hurts and that he is "blind". He asks for a washcloth to rub his eyes while he is experiencing the pain. He rubs his forehead, however, favors the right side (temple) and eye. He has had a CAT scan and EEG and an MRI. The CAT scan & EEG appeared normal. The MRI showed increased white matter on the right side of the brain, but I was told that this would not be the cause of his head pain and vision disturbances.

I have now been instructed to have him seen by a psychologist to find out what "stresses" could be causing his symptoms. I'm not sure if I should get a second opinion from a pediatric headache doctor or a more thorough eye exam? I just know my son is not an attention seeker and I firmly believe he is truly having head pain and vision problems. He will rub his head and eyes several times a day everyday, even when he doesn't know I am even looking. I have been reading a little bit on cluster headaches, and thought it might be possible he is having these. What would you suggest I do to look into this further? I am worried every day.

Dear “Worried Mom”,

Your son has had a quite extensive evaluation for his headaches and visual disturbance. The good news is that his MRI and CT scan of the brain is normal which rules out a brain tumor or mass which is most parent’s greatest fear. You did not mention if he had an evaluation by your Primary Care Physician or screening blood work performed.

It would be important to see your son’s Pediatrician for his headaches if you haven’t done this yet. Sometimes headaches are caused by other health conditions outside of the neurologic system. For example cervical spine abnormalities, vascular malformations, medication side effects, dental abnormalities, sinusitis and tick born illnesses can all cause headaches. (1, 2) You did not mention any medication, over the counter products or herbal supplements that your child is taking. In some cases headaches in children can be due to a side effect of a medication or supplement.

A complete evaluation by your son’s Primary Care Physician can review these issues and rule out these conditions as possible causes of your son’s headaches. Assuming that the evaluation by your Pediatrician and blood work was normal, at this point it would be a good idea to see both a Pediatric Ophthalmologist and a Pediatric Neurologist who specializes in headaches.

A Pediatric Ophthalmologist can evaluate your son’s vision, and eye structures, including the retina. In some cases a Retina specialist or Neuroophthalmologist may also be consulted in order to get to the root of a child’s visual disturbance. A second opinion with a pediatric Neurologist who specializes in headaches will be able diagnose the type of headaches that your son has.

Before seeing a specialist it would be a good idea to record your son’s symptoms in a Headache Diary. The Headache Diary should include specific information about the headache such as; the time of day that the headache occurs, the part of the head that hurts, the duration of the pain, the intensity of the pain, a description of the pain (throbbing, sharp), diet, activity, factors that aggravate the headache, accompanying symptoms and location where headache occurred (i.e. sunny room). Knowing this information, your doctors will be able to pinpoint the type of headache that your child is having, determine its cause and subsequent course of treatment. (3,4)

In regards to your question about Cluster headaches, they tend to occur in the adult population. The average age of patients diagnosed with Cluster Headaches is 27 to 31 years old. (5) This type of headache is rarely seen in children less than 10 years old. (3)

Cluster headaches are headaches that occur once to several times per day over the period of several weeks to months. (3) There are headache free periods between the Cluster headaches. The pain is throbbing, severe and unilateral or occurring on one side. Cluster headaches are associated with nasal congestion, a red eye and tearing or the eye. (3). The pain typically lasts 30 minutes to an hour and can occur any time of day. The cause of cluster headaches is unknown, but can be precipitated by alcohol consumption, exercise, hot baths, elevated environmental temperature during an attack period.

The Diagnostic Criteria for Cluster headaches developed by the International Headache Society includes:

At least five headache attacks meeting two criteria:
1. Severe unilateral pain (pain on one side of the head) lasting 15 to 180 minutes
The presence one or more of the following:
a. restlessness
b. conjunctival injection (red eye), tearing, nasal congestion, runny nose, eyelid swelling, sweating, miosis (constriction of the pupils), ptosis (drooping of the upper eyelid).
2. Attack frequency ranges from one to eight headaches per day.
3. Other disorders ruled out. (5)

From your description it doesn’t seem that your son fits the criteria for Cluster headaches. Although, a full history and physical examination performed by a Headache Specialist would be the best person to rule this out and determine the cause of your son’s headaches.

Migraines headaches are the type of headaches that are more prevalent in the pediatric population. Headache specialists agree that the majority of the pediatric patients who seek consultation for recurring, disabling headaches have Migraines. (6) The average age of onset for Migraine headaches in boys is 7.2 years old and in girls is 10.9 years old. (7) Migraine Headaches are characterized by symptoms of intense, recurrent headaches separated by pain-free intervals. They are often associated with other complaints such as nausea or vomiting. Migraine Headaches tend to be exacerbated by exertion and often resolve after vomiting or with sleep. (8) Ninety percent of the pediatric patients diagnosed with migraine headaches have at least one primary relative who also has Migraines. (6)

The main difference between Migraine Headache in adult and in children is that children tend to have shorter episodes of pain. (8) The diagnostic criteria for Migraine headaches in the pediatric population according to the International Headache Society includes:

At list five attacks with the following criteria:
1. Headache lasting 1 to 72 hours
2. Headache has at least two of the following symptoms:
a. location in the frontal or temporal areas (not the back of the head)
b.pulsing quality
c. moderate or severe pain intensity
d. aggravation by or causing avoidance of routine physical activity
3. During the headache at least one of the following:
a. nausea/vomiting
b. photophobia or photophobia
4. The headache is not attributed to another disorder. (9)

You mentioned that your son will be seeing a Psychologist in order to address any “Stressors” in his life which may be causing his symptoms. When the results of the physical examination and test results are normal it is common for Doctors to consider a psychological cause. This reflects their effort to be thorough and investigate all possible avenues. It is common for children to develop somatic complaints such as stomachache or headaches when they are under stress. Therefore investigating this area is many times necessary. Having an evaluation by a Psychologist is a sometimes a necessary step so that a psychological cause can be ruled out and other areas can be considered.

Parents usually know their child best. Parents are the ones who spend the most time caring for their child and they are the ones who know their child’s personality the best. If you believe that your son is not using his headaches to get attention and is truly experiencing pain then other causes of headaches should be investigated.

Your son is very lucky to have a mom who is so concerned about him. I hope you find the answers to all of your questions and your son is pain free soon. Keep up the good work!

(1)Linder S. Understanding the Comprehensive Pediatric Headache Examination. Pediatric Annals. 2005. 34(6):442-446.
(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. 1990:480-481.
(3)Rubin D, Suecoff S, Knupp K. Headaches in Children. Pediatric Annals. 2006. 35(5):345-353.
(4)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:918-919.
(5) Alper B, Passarelli C. Cluster Headaches. The Clinical Advisor. 2006. Aug:85-86.
(6) Perlman EM. Managing migraine in children and adolescents. Prim Care. 2004;31:407-415.
(7) Lewis D, Ashwal S, Hershey A. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004;63(12):2215-2224.
(8)Unger J. Pediatric Migraine: Clinical Pearls in Diagnosis and Therapy. Consultant for Pediatricians. 2006. Sept:545-551.
(9)Olsen J. The international classification of headache disorders. Cephalagia 2004;24(Suppl 1):1-160.

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

Pediatric Advice For Parents with Sick Children

Thursday, October 19, 2006

Infant Constipation

Dear Lisa,

My baby is 3months, 2 weeks old (born September 29th) and is having constipation issues. He was born a big baby (11lbs. 8oz.) so pretty much since birth we’ve given him both breast milk and formula, but I have now stopped breastfeeding. We are going on the 3rd week of no breast milk and his constipation has been an issue pretty much ever since.

We were giving him some cereal previously but we thought that was causing the constipation so we stopped and decided to wait until next month to try it again when he can have fruit too. But he’s still constipated on just formula. We’ve been giving him some remedies to help his constipation and they’re working (we’re switching on and off from #1- 2oz water mixed w/ 1 tsp brown sugar and #2- 1oz prune juice mixed w/ 1oz water). The constipation he had on cereal seemed to affect him and bother him. But the constipation since he’s been off cereal isn’t like that. He’s not really agitated by it; it doesn’t seem to hurt him. He’s still a happy smiley baby and sleeping well.

My main concern is why he’s constipated. Is it that his body/digestive system is still adjusting to switching to solely formula? He’s been on the same formula since birth; can he have an issue with the type of formula now all the sudden? He does spit up, but don’t all babies to some degree? I’m concerned that if he’s constipated now on just formula, what’s going to happen when he goes to solid foods in a couple weeks? Could his stools possibly be changing with the only formula diet, meaning less frequently and thicker? Should we just stick with what we’re doing now by trying to thin out his stool withthe remedies mentioned and wait and see?

“Need Help With Constipation!’

Dear “Need Help With Constipation!”,

If your baby is 3 weeks old, born on September 29th, then the only food that is recommended is Breast milk or formula. It is not recommended to introduce food, cereal or fruit until the child is between 4 to 6 months old. (1) The early introduction of food into an infant’s diet can lead to food allergies. (2) I would not worry that you did your baby any harm by giving food early, but from this point on, it would be important to wait until he is at least 4 months old before introducing any solids.

A babies stool pattern normally changes when there is a change in the diet. Babies that are breastfed are expected to have many stools per day for the first month or two. (3) In some cases breastfed babies can have a bowel movement after every feeding. The appearance of the stool is loose, seedy and yellowish in color. As the infant gets older the bowel movements usually slow down to one stool per day or one stool every few days. (3)

Babies that are bottle fed normally have thicker, less frequent stools. They tend to have two to four stools per day in the first month progressing to one to three stools or less per day. (3) The stool is “soft” in nature as compared to the watery stools found in breast fed babies. (3)
The changes in your baby’s stool pattern are most likely related to his dietary intake and transition to formula. In addition, some formulas tend to be more binding than others.

For example, children who ingest soy based formula tend to have thicker stools and may become constipated. Rice cereal also tends to be binding for many babies. Therefore it would be expected that an infant’s bowel movements become thicker when he ingests rice cereal or soy formula.

Just because a baby has thick, infrequent stools does not mean that there is anything wrong or that he is constipated. Constipation is defined as hard, rocklike bowel movements. (3) Frequently constipation is accompanied by straining and difficulty passing stools. Many parents of young infants misinterpret normal straining and grunting as signs of constipation. Infants normally strain and grunt with passage of stools because their abdominal musculature is not developed enough to pass stools easily. This straining does not necessarily mean that the infant is constipated. The frequency of stools also does not determine if a child is constipated or not. The frequency of stools can change in response to a diet change, according to the amount of fluid a child gets and a child’s activity level.

There are a few ways that you can prevent your child from becoming constipated. First make sure the formula is prepared correctly. When preparing baby formula it is very important to accurately follow the directions on the label. (4) If the correct proportions of water are not added to the powder and the mixture does not contain the correct amount of fluid, the baby may become constipated. In addition, many cans of baby formula appear the same. It is easy to confuse “Concentrated Formula” with the “Ready toFeed ” formula.

“Concentrated Formula” requires the addition of water in order to have the proper balance of fluids and nutrients. “Ready to Feed” formula does not require the addition of water. An error in this area can be dangerous to the child and is very easy to make since the writing on the can is typically quite small. This mistake can bring about an osmotic shift leading to dehydration and possibly renal crisis. (4) This is why is very important to follow directions carefully.

It is also very important to prepare the powdered formula with tap water as the formula company recommends. Tap water in the United States is monitored and regulated as opposed to bottled water or spring water which is not. (5) The exact components of bottled water are not known. Therefore the amount of minerals found in bottled water may be too much for an infant. For example, if the bottled water contained an increased amount of aluminum, this could lead to constipation. An excess in Magnesium can lead to diarrhea. (6) Besides the unknown levels of minerals, microorganisms can also be unknowingly present in bottled water.

Lastly, make sure your child is receiving the correct amount of formula per day and the correct amount of fluids. If a baby does not receive enough fluid in his diet, his body will compensate by holding in stool so that fluid can be taken from the stool and absorbed into the body where it is needed. Therefore, not giving enough formula can lead to constipation.

From your description, it seems that your baby is having normal bowel changes due to alterations in his dietary intake. Since he is not agitated or in pain, and his bowel movements aren’t hard balls, it would be a good idea to just monitor him at this time. It is also important to expect a decrease in the number of bowel movements per day as your son gets older. The sugar water and prune juice that you gave your son for his constipation seemed to alleviate the problem. These are both good choices for babies who are constipated. Although feeding your baby these items may no longer be necessary. You should discuss with your your son's Doctor.

Yes, it is true that many babies experience spitting up or Gastroesophageal Reflux (GER) symptoms in infancy. Evidence has shown that spitting up or Gastroesophageal Reflux may occur in up to half of all healthy infants from 0 to 3 months old. (7) As long as the spitting up is not associated with fever, excessive irritability, respiratory symptoms, abdominal distention, difficulty feeding, is not bilious and is not projectile there is no need for concern.

In regards to your son’s present diet, it would be a good idea to leave him on his present formula and let his body get used to it. It also would be important to not introduce any solids until he is older. Since your baby is a large baby, his calorie requirements are higher, so it is expected that he will drink more formula than other babies his age. If your baby’s stools become very firm, consist of hard balls, his abdomen becomes distended, he begins to vomit, becomes listless or has difficulty feeding, you should bring him to the Doctor's for an evaluation. It is also very important to check with your baby’s Doctor before making any dietary changes, especially during the first year of life.

If you are interested in reading more stories on the Pediatric Advice Website about Infant Feeding topic log on to:

The amount of formula a baby should take.

Food Allergies

(1)Grassia T. Pediatricians: Discuss healthy nutrition during well child checks. Infectious Diseases in Children. 2006. Aug:54.
(2)Bassett C. What to do when Foods become allergens. The Clinical Advisor. 2005. Dec:43-47.
(3) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 291, 784.
(4)Riordan J. A Practical Guide to Breastfeeding. St. Louis Missouri: The C.V. Mosby Company. 1983:7.
(5)John Hoptins Bloomberg School of Public Health. Public Health New Center. Researchers Dispel Myth of Dioxins and Plastic Water bottles. Available at:
http://www.jhsph.edu/PublicHealthNews/articles/Halden_dioxins.html. Accessed Oct 2006. (6)Brunner L, Suddarth D. Textbook of Medical-Surgical Nursing. 5th ed. Philadelphia, PA: J.B. Lippincott Company.1984:793.
(7)Hassall E. Decisions in diagnosing and managing chronic Gastroesophageal reflux disease in children. J Pediatr. 2005. 146:S3-S12.

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

Pediatric Advice About Keeping Babies Healthy

Wednesday, October 18, 2006

Influenza Vaccine

Dear Lisa,

Is it necessary to get my five year old the flu shot this year?

“Flu shot?”

Dear “Flu shot?”,

The Advisory Committee on Immunization Practices (ACIP) recommends annual vaccination for healthy children aged 24 to 59 months. (1,2) The ACIP also recommends that household contacts and out- of-home caregivers of children aged 6 months to 6 years receive the influenza vaccine . (1,2) Decisions made by the ACIP influence the pracitce of health care practitioners throughout the country.

Just so you know who is making this recommendation, the ACIP consists of 15 experts in fields associated with immunization. These experts have been selected by the Secretary of the U. S. Department of Health and Human Services. The ACIP provides advice and guidance to the Secretary, the Assistant Secretary for Health, and the Centers for Disease Control and Prevention (CDC) on the most effective means to prevent vaccine-preventable diseases. The overall goals of the ACIP are to provide advice which will assist the Department and the Nation in reducing the incidence of vaccine preventable diseases and to increase the safe usage of vaccines. (3)

In the United States, epidemics of influenza have been associated with an average of approximately 36,000 deaths per year during 1990—1999. (1) Between January and June 2005, 36 pediatric deaths associated with laboratory-confirmed influenza infection were reported to the CDC. (3) The interesting thing is that many of the casualties were otherwise healthy children. (4) This is why there is an interest in vaccinating all children, and not just those with chronic medical conditions.

The rates of serious illness and death from Influenza are highest among persons older than 65 years and children aged less than two years old. Children particularly at risk for developing complications from Influenza infection include those with chronic heart disease, chronic lung disease (Asthma), chronic metabolic disease (Diabetes), chronic Kidney disease, blood disorders (Sickle Cell Anemia) and immunosupression (HIV or cancer). (5) Despite the long standing CDC recommendation that call for annual influenza vaccination of children with Asthma, estimates show that only 1/3 of this high-risk population receives the vaccine.

Efforts in preventing Influenza in children and controlling flu outbreaks stem from the reports that children are more susceptible to complications and serious illness from influenza infection. These complications include respiratory and non-respiratory complications. Respiratory complications include Croup, Bronchiolitis, secondary bacterial Pneumonia, Sinusitis and Otitis media (middle ear infection). Non-respiratory complications include myositis, myocarditis, encephalitis and febrile seizures (4)

In children the symptoms of Influenza include a sudden onset of symptoms. These symptoms include high fever, headache, malaise, muscle aches, runny nose, cough, nausea, vomiting and abdominal pain. (4) Influenza is spread via respiratory secretions, by droplets from sneezing or coughing or by direct contact with articles contaminated with respiratory secretions. (4) Respiratory secretions from persons with influenza are most infectious 24 hour before the onset of symptoms and during the entire symptomatic period. (4) The best ways to prevent spread of the Influenza virus is to vaccinate and practice good hand washing. Frequent cleaning of toys and other contact surfaces should be carried out in daycare centers. (4)

In regards to your question, is it necessary for your five year old to get the flu shot this year? It is highly recommended if your child has a chronic disease or health problem that puts him at risk for complications from the flu. In addition, it would be a good idea to get the flu shot if your child is in day car or school. It is in these situations that children have a greater risk of exposure to the flu.

Basically, the flu shot is a recommendation. It is not mandatory to get the vaccine in order to attend daycare or school. So it is your decision if you want your child to receive the vaccine, knowing the complications and risk of contracting the flu at a young age. In making this decision, I recommend talking to your child’s Doctor or Nurse Practitioner. They are the ones that know your child’s history and social situation best and can discuss your child's risk.

In my practice, I frequently came across parents who preferred not to give their child the Flu vaccine. Most of these parents came to this conclusion because of their child’s low risk of contracting the Flu. Many of these children did not attend daycare or school and the primary care giver did not work outside of the home. If this is the case, I would recommend that the adult who works outside of the home get vaccinated so that they do contract the Flu from their place of employment and spread it to their family.

I hope you and your child stay well this Flu season.

(1)CDC. MMWR Recommendations and Reports. Available at:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5510a1.htm?s_cid=rr5510a1_e. Accessed Oct 2006.
(2) CDC. National Immunization Program. Advisory Committee on Immunization Practices. Available at:

http://www.cdc.gov/nip/ACIP/. Accessed Oct 2006.
(3)Centers for Disease Control and Prevention. Update: Influenza activity- United States and world-wide, 2004-2005 season. MMWR.2005;54:631-634.
(4) Nield l, Kamat D. “Flu” Season: Here We Go Again…Consultant for Pediatricians. 2005. Octorber:411.
(5)Cheung M. Lieberman J. Influenza. Contemporary Pediatrics. 2002. 19(10):82-94.

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

Pediatric Advice About Keeping Kids Healthy