Thursday, November 30, 2006

Inguinal Lymph Nodes

Dear Lisa,

I have a 2 year old daughter who I have noticed has a "bird's egg" sized lump on the crease of her leg. (What adult women would consider their bikini line). I have read articles about boys having this, but I wasn't sure if it were the same thing in a girl. I haven't noticed any sign of rash or infection in that area that would cause a swollen lymph node, but wasn't sure what else it may be. Also, how soon do I need to get her in to see the doctor? We have an appointment for one week from today, isthat soon enough?

“Concerned Mother”

Dear “Concerned Mother”,

The examination by your physician will be able to tell you if the lump that you are seeing is a normal lymph node, an enlarged lymph node or something else. The inguinal area or bikini line is one of the areas that superficial lymph nodes can be seen and felt.(1) The swelling of an inguinal lymph node can represent the break down of cells or infection in the area. Lymph nodes in the inguinal area drain different parts of the body depending upon where the lymph node is located.

Yes it is true that a skin rash, bug bite, scratch or skin infection could cause a lymph node to enlarge. The enlargement of a lymph node can also represent a condition that may not be readily seen. Inguinal lymph nodes in the horizontal group are located high in the anterior thigh and drain the superficial portions of the lower abdomen and buttock, the external genitalia (but not the testes in males), the anal canal and perianal area and the lower vagina. (1) The inguinal lymph nodes in the vertical group are located below the horizontal group and drain the area around the thigh. Therefore a condition affecting the anus which may not be noticeable to a parent can cause swelling of the inguinal lymph nodes. That is why it is necessary to have a doctor perform a complete history and physical examination on a child with enlarged lymph nodes in order to determine the cause.

I have seen many young children who were brought to the office because their parent noticed a lump in the groin area. In most of the cases the lump turned out to be a normal lymph node. I found that the inguinal lymph nodes were more readily seen by a parent when the child was thin.

What you read about boys and lumps in the groin area most likely was referring to Inguinal Hernias. Inguinal hernias are the most common type of abdominal hernia. (2,3) The type of swelling caused by a hernia is much different than the swelling caused by an enlarged lymph node. A lymph node is an oval shaped rubbery, movable nodule located just under the surface of the skin. When a lymph node enlarges, the capsule becomes more visually noticeable and can easily be felt. A hernia on the other hand is more of a protrusion. The protrusion from a hernia looks like a bulge. This bulging increases in size when a child cries, coughs, engages in strenuous activity or has a bowel movement.(2)

Although Inguinal hernias are found in both boys and girls, they are much less common in girls.(1) The physical findings of a girl with an inguinal hernia are also different. Typically females present with a bulge in the area of their labia not in the crease of the leg.

If your daughter has no other symptoms it is reasonable to wait a week for an appointment. If she has a fever, swollen lymph nodes in other parts of her body, weight loss, pain or itching in her rectal area, problems having a bowel movement, change in her urinary pattern, increasing size of the lump, pain in the area, limping or redness around the area, then you should make an appointment sooner.

If you are interested in reading other Pediatric advice stories concerning this topic:

Lump in the Groin

(1)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:438,400.
(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. 1994:422.

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

Pediatric Advice For Parents

Wednesday, November 29, 2006

Flexible Joints

Dear Lisa,

My 2 ½ yr old child, for the past year, curls her body into a U shape, stretching her limbs 3 or 4 times a day (approximately 4 to 6 hours apart) lasting each time about 3 to 5 minutes and making a straining sound each time she stretches. She is able to stop at will, but does this each day consistently. Is this something to be concerned about or is this normal behavior in some children?

“Stretchy Girl”

Dear “Stretchy Girl”,

First, it would be important to know if your daughter’s stretching and straining sounds are related to passing a bowel movement. Since her stretching started at such a young age this may be a consideration. Sometimes children may put their bodies into a different position in order to help push their stool out (or for some children to hold the stool in). Straining in particular is commonly found in children with hard stools or constipation. If your daughter engages in these stretching activities around toileting time or if she has a history of constipation, you may want to discuss her stooling pattern with her doctor. If it is determined that her stretching is not related to having a bowel movement then others reasons for her stretching can be considered.

Children are very flexible and are able to move their joints in a way that adults can’t. As children grow older, they lose this natural flexibility. As their flexibility decreases, their muscular strength increases.(1) By the time a child reaches adolescence they lose the flexibility in the movement of their joints that they experienced when they were younger.

In most cases, the flexibility that parents notice is normal flexibility due to their child’s young age. Some children experience more laxity than others. There is a concern if a child has too much flexibility, too much joint laxity, muscle weakness or low muscle tone. If a joint has too much laxity a child is at risk for injury due to the inadequacy of the supporting structures around the muscle and bone. (1) For some children, marked joint laxity and muscle weakness can be a sign of a musculoskeletal problem.(2) Your daughter's Pediatrician will be able to tell you if her level of flexibility is normal for her age.

Since your daughter has control over her movements and her activity can be stopped when asked, she could be mimicking activities that she has witnessed. It is very common for toddlers and preschoolers to copy the behavior of their parents or siblings. This is a normal step in childhood development. Children may copy their parents by make believing that they are cleaning the house, talking on the telephone or playing dress up. (3)

Your daughter may be stretching because she is trying to act like someone in the house who exercises. The only part that doesn't make sense is the length of time this has been going on. If she started this behavior a year ago, she would have been quite young to be imitating behavior.

You did not mention how your daughter behaves during the rest of the day. Information about a child's developmental status and social development is needed whenever there is a question about a particular behavior. Normally by the time a child is 2 ½ years old she should be able to run quickly with only a few falls, walk down steps holding on to a rail, stack six blocks, turn pages of a book, use a spoon successfully, turn a doorknob, engage in pretend play, use two-word sentences and dress with help.(3)

If your daughter is engaging in these activities and is not experiencing any physical or social development delays there is probably nothing to be concerned about. Although, the only way to be sure is to ask the physician who performs regular physical examinations on your daughter. He will be able to tell you if her physical development, muscle strength, flexibility, coordination and behavior are normal for her age.

Concerning signs include; uncontrollable movements, shaking, jerking of the extremities, staring spells, unintentional extension of an extremity, muscle rigidity or marked laxity. (2) I would suggest showing your daughter's Doctor this stretching behavior that she is having. A physical examination performed by your doctor can tell you if your daughter’s behavior is normal for her age. A Video recording of your daughter’s stretching can give your Doctor the visual information that he needs to make his assessment.

(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)El-Bohy A, Wong B. The Diagnosis of Muscular Dystrophy. Pediatric Annals. 2005.34(7):525-530.
(3)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:203,190-191.

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

Pediatric Advice About Childhood Development

Tuesday, November 28, 2006

Rocephin Reaction

Dear Lisa,

Have you ever heard of this happening? My son received 2 rounds of Rocephin injections for an ear infection. Upon receiving the 2nd dose, he had a severe reaction that caused him to literally throw a 15 hour tantrum. He would not eat, sleep, or stay still! He was kicking us, hitting us, and knocking his head against the crib and wall. He threw up and finally fell asleep. He is two but this was NOT my son. Our pediatrician said she had never heard of this happening. Please help! My son is better now but I am very curious what happened. Thanks.

“Reaction to Rocephin”

Dear “Reaction to Rocephin”,

The reaction that your son had to Rocephin (Ceftriaxone) is not a typical one. The symptoms that you are describing sound more like the type of reaction some children have to steroid medications. It would be important to know if your child was on any other medication at the time that could have caused this reaction.

If your child was only on Rocephin, then it would be safe to say that the reaction that he had was a rare side effect to Rocephin. Each individual child is different, and different people can experience different side effects or reactions to medications.

When a child has a reaction to a medication it is much more difficult to determine exactly what is bothering him. For example, a two year old does not have the ability to describe his symptoms or tell you where pain is coming from. Therefore irritable behavior, acting out, change in personality and excessive crying can be a child’s response to a side effect such as nausea, abdominal pain or headache. If an adult experienced these symptoms, he would be able to describe the side effects and treat them accordingly. A child on the other hand cannot explain that they have a belly ache or that they feel nauseous. Instead they may present with crying and inconsolability.

Rocephin is generally well tolerated in children and most children do not experience any side effects at all. The most common side effects encountered include; pain and swelling at the injection site (1%), hypersensitivity rash (1.7%) and diarrhea (2.7%). (1)

Rarer side effects include; headache or dizziness(less than 1%), nausea and vomiting (less than 1%), vaginitis or vaginal yeast infection (less than 1%), sweating and flushing (less than 1%), jaundice (less than 0.1%), gallbladder sludge (less than 0.1%), sugar in the urine (less than 0.1%), blood in the urine (less than 0.1%), abdominal pain (less than 0.1%), dyspepsia or heartburn(less than 0.1%), colitis (less than 0.1%), flatulence or gas (less than 0.1%), biliary lithiasis or gallstones (less than 0.1%), nosebleed (less than 0.1%), palpitations(less than 0.1%) and anaphylaxis or severe allergic reaction (less than 0.1%). (1)

Through my many years of experience treating children I have never seen a child have such a severe reaction to Rocephin. I have seen children have severe reactions similar to what you are describing due to steroids. The majority of patients that I saw who received Rocephin had no reaction at all. In the few cases where children did have a reaction, the most common side effects that I saw included; pain at the injection site, vaginitis, vaginal yeast infections, diarrhea and abdominal pain. I have also seen a few isolated incidents of gallbladder sludge and gall stones. They happened to be in younger children.

The reason why gall bladder sludge and gallstones occur as a side effect to Rocephin is because of the way that the medication is excreted or removed from the body. Forty percent of the Rocephin that is injected into a patient is excreted unchanged into the bile. Because of the medication’s high calcium-binding ability, there is a potential that stones can form in the bile. (2)

Echocardiograms performed on patients treated with Rocephin found biliary lithiasis present in 12-45% of the patients. (2) These gallstones were found as early as the second day of treatment. (2) If gallstones develop as a side effect to Rocephin administration they typically do not cause any symptoms and in most cases go away on their own without treatment. There have been some cases documented in the literature where patients experienced symptoms from their biliary lithiasis and also required treatment. (2) Researchers in Spain reviewed the cases of four children who in 1999 developed biliary lithiasis between the second and fourth day of Rocephin treatment. These children were asymptomatic (had no symptoms) and their gallstones resolved within 1 to 4 months.(2)

Unfortunately, you may never know what exactly your child was experiencing when he reacted to the Rocephin. At least your son’s symptoms are gone now and you know that he has a sensitivity to Rocephin and should not receive it again. If he has a return of his symptoms or develops abdominal pain he should be re-evaluated by his Physician.

(1)Physician’s Desk Reference. 2004. Montvale, NJ. Thomson PDR at Montvale:2940.
(2)Alvarez-Coca Gonzalez J, Cebrero Garcia M, Vecilla Rivelles MC, Alonso Cristobo M, Rorrijos Roman C. Transient biliary lithiasis associated with the use of ceftriaxone. An Esp Pediatr. 2000.53(4):366-8.

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

Pediatric Advice For Parents with Sick Children

Monday, November 27, 2006

"Sick for a Month"

Dear Lisa,

I have a 15 month old son, who has been sick now with a cold, sore throat, a little diarrhea, and he isn’t eating much, and hasn't eaten much in the past 2 days, and he can't sleep b/c of his coughing and congestion. He also has had a fever of 103 degrees and fluctuates to 100 degrees, and I have been rotating Tylenol and Motrin, and yes it helps with the fever, but he seems to have a little discomfort when he coughs, and dry heaves b/c of the congestion running from his nose and throat, the Doctors won’t give him anything and say he'll get over it. But he's been sick on and off for a month.

“Sick on and off for a Month”,

Dear “Sick on and off for a Month”,

It makes me feel so sad when I hear about a little one who is so sick, especially for such a long time. Most parents agree that there is nothing worse then to have a sick child. The stress and exhaustion can affect the whole family. An illness that lasts so long can be particularly stressful, especially if there doesn’t seem to be any improvement in your child’s condition.

It seems that you are not satisfied with the answer that your Doctor gave you, that “he’ll get over it”. As in most professions, each professional in the field practices a little differently or has a different approach to care. Some doctors stop their recommendations at the point it is decided that a child has a virus and an Antibiotic is not needed. Other practitioners give additional recommendations about how to alleviate a child’s symptoms and give suggestions about how to care for a child during an illness.

It is true that if a child has a virus, that Antibiotics will not treat the infection. Instead the child’s own body fights the infection. Just because a child has a virus does not mean that there are no measures that you can take to help your child feel better. Information about how to keep hydrated, comfortable, sleeping well and breathing easily is needed. There are also natural remedies and practices that can be followed that can help a child get through their illness.

The measures that you can take to keep your child from becoming dehydrated include giving him cold liquids. Cold liquids are recommended because the cold will numb the child’s painful sore throat and as a result there is a better chance that he will drink. Ice pops, sherbet, Jell-O, cold applesauce and cold drinks are all good choices that should make a child’s throat feel better. It is also a good idea to give a dose of Tylenol or Motrin 30 minutes before a meal. These medications do not only treat the fever, but also treat pain. There is a better chance that a child will eat or drink if their pain is controlled.

In order to help clear a child’s nasal secretions you can try bringing him into the shower or using a cool mist vaporizer. Directly exposing a child to hot steam is not recommended because this can result in burns.(1) Elevating your child’s head during sleep by putting a pillow under the mattress can also help your child sleep at night. Using saline nose drops and giving a child extra fluids to drink can help loosen your child’s nasal secretions. By loosening nasal secretions it makes them easier to remove.

Prescription medications such as Rynatan and Viravan can help decongest the nose and dry up a post nasal drip. These medications can temporarily help a child breathe better through the nose. If a child has so much mucus that they can not eat, sleep or breath well he may be a candidate to receive these medications. You can ask your doctor if your child’s condition would be helped with the use of these medications.

Measures to help soothe a child’s cough include menthol rubs on the chest, and sugar and lemon drinks which help soothe the throat.(1) Your son is too young for a cough drop, but he could have a lollipop which serves a similar purpose.

A product found in most households can also be given to help a child with a cough. This product is caffeine. In the 1800's, coffee was the treatment of choice for Asthma.(2) The caffeine found in coffee and tea is a natural bronchodilator. The purpose of bronchodilators is to open the bronchial tubes and help a person breathe easier. Today, bronchodilators are the first line treatment for people with Asthma. In a large Italian study, it was found that adults that drank two to three cups of coffee daily had about 25% less Asthma than adults who abstained. (2)

Theophylline is one of the modern day prescription medications used to treat Asthma. It is chemically related to the caffeine found in tea and coffee. (2) Therefore it can not hurt a child to have a cup of warm tea (not too hot, because you don’t want him to get burned!) or iced tea when he is coughing a lot.

It is also important to know that a cough that lasts 4 weeks needs to be evaluated by a Physician in order to determine and treat its cause. It is important that the cause of a persistent cough is determined, especially when there is a fever involved. (1) A sore throat accompanied by fever should also be evaluated. Strep throat is a common childhood illness that presents as a sore throat and fever.(3) A child with a sore throat and fever should have a throat culture performed in order to rule out Strep. (3)

Any fever in a young child that lasts more than 5 days should be re-evaluated in order to rule out a secondary bacterial infection. It is common for a child to begin their illness with a virus and because their immune system is taxed, become secondarily infected with Bacteria. A Bacterial infection requires treatment with an antibiotic. Because of this, it is important to know which specific symptoms and what timeframe requires a visit back to the Doctor’s office. If a child takes a turn for the worse; becomes lethargic, stops eating, has difficulty breathing or develops a worsening temperature, he should be re-evaluated.

Young children with poor oral intake and diarrhea can develop dehydration. Signs of dehydration include decreased urine output, non-elastic skin, dry mucus membranes (a dry mouth), decreased amount of tears, a fast heart rate, irritability, weight loss, lethargy, sunken eyeballs and a sunken fontanelle (soft spot). A young child who is not eating and having diarrhea should be evaluated by a health care professional for dehydration.

The most important thing that I can tell you is to trust your own instincts. If you think that your child is sick and that there is something wrong then you are probably right. Parents who spend 24 hours with a child and know there child’s personality can much better assess how sick their child is. It is not possible for a Doctor who spends about 10 minutes in the office with the child to understand the breath and depth of a child’s symptoms and illness unless a parent gives them specific details about what is going on at home.

Sometimes it is necessary to write down all of your child’s complaints and problems before you get to the Doctor’s office so that you can communicate all of your concerns. In other words if a child visits the office and the parent says, "my child’s not feeling well", it can be interpreted many ways. If a parent explains to the doctor that my child is so sick that he can’t sleep at night, he can’t breathe because of all of the mucus coming out of his nose and mouth, he can’t eat because his throat hurts so much, he is coughing so much that he can’t catch his breath and he is so lethargic and tired that he won’t get up and put his clothes on, then the doctor should take your concerns more seriously.

If you have given every effort to explain how ill your child is and your doctor does not seem to take your concerns seriously, then it would be important to let your doctor know how you feel. The optimal relationship with your child’s doctor should involve open communication, trust, feelings that your concerns are taken seriously, honesty and compassion. If you do not feel that your relationship fulfills these basic requirements, it may be time to search for a Doctor that practices in a manner that you are comfortable with. After all, something as precious as your child’s health should be managed by a Doctor who you can trust.

I hope your son recovers soon.

(1)Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics. ACCP evidence-based clinical practice guidelines. Chest. 2006;129:260S-283S.
(2)Kemper K, Lester M. Alternative asthma therapies: An evidence–based review. Contemporary Pediatrics. 1999.16
(3):162-195.(3)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.

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

Pediatric Advice For Parents with Sick Children

Friday, November 24, 2006

Nipple Confusion

Dear Lisa,

Is there such thing as nipple confusion when not breastfeeding, if so what is it?

“Nipple Confusion”

Dear “Nipple Confusion”,

The term “Nipple Confusion” refers to the difficulty breastfeeding babies have when they switch back and forth between breastfeeding and bottle feeding. Not only is the look, feel and the texture of the nipple different, but the process of sucking requires different mechanisms for each.

The term, “Nipple Confusion” is not typically used to describe babies that exclusively bottle feed. Although, I have taken care of plenty of babies that get used to one nipple, for example the Evenflow nipple and then refuse a different shaped nipple. The same goes for an infant who becomes used to one particular pacifier.(1) This preference for a certain type of nipple or pacifier can cause the parents a lot of grief. If the particular type of nipple or pacifier is not avialable to the baby, the parents experience difficulty feeding and soothing their child.

This like or dislike for a certain shaped nipple is different from the “Nipple Confusion” that occurs in breastfeeding babies who receive a bottle. A breastfeeding baby needs to suck vigorously, using the cheek muscles to draw the nipple well back into his mouth and against the hard palate in order to get milk. (2) The milk from a bottle on the other hand, flows out much more readily from the nipple with a lot less sucking effort. (2)

The bottle fed baby needs to place the tongue in a different position during a feeding. When bottle feeding the tongue needs to be placed more anteriorly against the tip of the nipple to control the flow of fluid. Some babies cannot make this transition back and forth between breast and bottle and as a result may develop problems breastfeeding. In order to prevent this “nipple confusion” and avoid the risk of a baby refusing the breast it is typically recommended to exclusively breastfeed a baby for the first 6 weeks of life.

It is more difficult for a baby to breastfeed because the milk typically does not come out as readily and the procedure requires more “work”. Formula flows out of the nipple more readily and less effort is needed in order to eat. Many parents and breastfeeding advocates fear that if a baby receives a bottle that they will then refuse breastfeeding because it is more difficult to do.

Many parents find success supplementing their breastfeeding baby with a bottle without encountering “Nipple Confusion”. Supplementing offers the other parent the opportunity to be more involved with the infant’s care and encourages parent infant bonding. For example, a mother may choose the 6 p.m. feeding to be a bottle feeding so that the father can feed the child when he gets home from work. As long as the same feeding time is skipped each day and the schedule is consistent the mother’s system will accommodate and not produce milk at that hour and instead produce milk for the next feeding.

If parents choose to supplement with a bottle they should first make sure that the infant has a successful breastfeeding routine established. Once a mother experiences a regular milk let down and maintains an adequate milk supply; and the baby has the ability to successfully suck from the breast and is gaining weight then the bottle can be introduced. In general a waiting period of 6 weeks to 8 weeks is needed before this can be attempted.

In some scenarios, an infant may need to be introduced to a bottle during the early weeks of life. This can occur when a mother is ill and not able to breastfeed, or if the baby has a medical condition that warrants the introduction of formula or a nipple. When this occurs it is important that mothers do not become discouraged.

If “Nipple Confusion” does occur there are measures that parents and health care professionals can take to deal with the problem. The first step is to remove the artificial nipple. Next the infant should be given the opportunity to go to the mother’s breast at frequent intervals. When the baby is at the breast the baby can be stimulated to develop a stronger suckle. (2) A consultation with a Lactation Consultant or Occupational Therapist can assist in this task. In the majority of cases, the babies accomplish breastfeeding successfully and overcome any problems they may encounter with “Nipple Confusion”.

Premature babies, babies with low muscle tone, babies with facial deformities and babies with oral-motor dysfunction tend to have more difficulties suckling. (1) Therefore parents of babies who fit into these groups should avoid switching feeding and suckling techniques if possible. It is a good idea to stick with the same nipple and pacifier in these situations. In addition, children experiencing these issues can benefit from the expertise of an Occupational therapist who specializes in infant feeding.

(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:583.
(2)Riordan J. A Practical Guide to Breastfeeding. St. Louis Missouri: The C.V. Mosby Company.1983:26,47,218.

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

Pediatric Advice About Infant Health

Wednesday, November 22, 2006

Prescription Medications

Dear Lisa,

I have three children and two ill parents. One of my children has Asthma and is on a lot of medication. My parents are also taking many prescription medications. I am worried about side effects and medication interactions. Is there a book that I can buy with information about prescription medications? Before I give my family medication I like to read about it, find out how the medicine works, what the side effects are and if the medication interferes with any of the other medications that they are on. The Doctor really doesn’t explain what the medications are for and what the side effects are. With all of the commotion and rush in the doctor’s office, it’s hard to remember to ask the doctor all of the questions that I have. What prescription medication book do you recommend?

“Need information about Prescription Medications”

Dear “Need information about Prescription Medications”,

I agree with you, it is very important that you understand the purpose, side effects and interactions of the prescription medications that you give your family. Unfortunately, because of time constraints in the Doctor’s office, many times consumers are left with the responsibility of educating themselves when it comes to medical information. It is also very difficult to concentrate in the Doctor’s office when your child is sick, crying or uncomfortable. Many parents do complain that they don’t think of the questions that they have for the Doctor until they get home.

The Physician’s Desk Reference (PDR) is a great resource. It provides information about prescription medications including; the drug class, how the medication works, the ingredients included in the medication, the side effects, interactions with other medication, warnings, proper dosage, clinical research data and information for pregnant and nursing women. The PDR also provides an illustrated product identification guide where you can see a picture of the medication and pills up close.

The PDR has up to date information about medication side effects and post marketing research findings. A new publication comes out yearly and therefore information about new medications can be readily found. Doctor’s, Nurse Practitioners and other Health Care Professionals frequently use the PDR as a medication reference guide. Since the PDR is intended for health care professionals, the terminology is quite technical and may be too complicated for the general public to read. This does not prevent patients from using the PDR as a resource because plenty of lay people own and use a PDR.

The downside of using The PDR is that it is a large hard covered book that is cumbersome to handle and the writing is small and may be difficult to see. Since it is updated yearly, a family would need to purchase a PDR yearly in order to receive up to date information. This can be quite costly since the price for one publication is $90.00. This is not a feasible option for many families because of the cost.

There is a condensed version of the PDR which is geared towards the lay public. It is called the PDR Pocket Guide to Prescription Drugs published by Pocket Books. I recommend this version for parents because it comes in a soft cover, the font is easy to read, the terminology is understandable and it is easy to handle. The information in the book provides the information that a patient needs, including information about the purpose of medications, side effects, warnings, food and drug interactions and information about how to properly administer the medication.

The PDR Pocket Guide is available at a very reasonable price, about $8.00 for the soft covered book. It can be purchased at your local bookstore or at a CVS Pharmacy.

Another way to get information about prescription medications is to ask your Pharmacist. Each prescription is accompanied by a packet insert which is typically glued on the side of the package. This package insert may not automatically be provided to you unless you ask your Pharmacist for it. The good thing about the packet insert is that it is free of charge and contains a summary of the information that is printed in the PDR. The downside of package inserts is the writing is quite small and may be difficult to read.

It is very smart of you to be concerned about the medications that you give your family, their purpose, interactions and side effects. This is especially important when patients are prescribed multiple medications from different doctors. Your Doctor may not necessarily know the names and dosages of all the medication that you are taking.

The Pharmacy has this information in the computer database and your Pharmacist should be able to provide you with information about potential medication interactions. If you fill your prescriptions at different Pharmacies this would not be possible because the Pharmacist will not have the information about all of your medications.

By keeping yourself informed about your families prescription medications, you can cut down on the chance that a medication error will be made. Reading reference books and package inserts about prescription medications is also very wise because you never can be too informed when it comes to medicating the people that you love.

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

Pediatric Advice Website

Tuesday, November 21, 2006

Exposure to Cold Air

Dear Lisa,

Is it okay to take a child out into the night air?

“Child exposed to Cold Air”

Dear “Child exposed to Cold Air”,

Many parents are concerned about bringing their children outdoors during the cold winter months. This is a legitimate concern because children are at risk for cold related illness and proper precautions should be taken.

Many parents feel if they take their child outdoors that their child will “catch a cold”. This old wives tale is not 100% true but definitely has some wisdom. Viruses and colds are transmitted through the exchange of respiratory secretions. They are spread through respiratory droplets such as coughing and sneezing. Theoretically, the cold air doesn’t have anything to do with a child “catching a cold”. Although it is true that many viruses thrive in the cold weather and are more prevalent during the winter months. For example, the Influenza virus thrives in the freezing cold weather and is more prevalent in the United States between the months of October and March.(1)

In addition, the body of a child that is exposed to cold is put under a lot of stress to maintain a normal body temperature. A child’s defense mechanisms can become inadequate during periods of stress and therefore make him more susceptible to acquiring an infection. Therefore, in a sense, it is true that a child who goes out in the cold is more at risk for developing an infection. So it is understandable why people through the generations have commonly associated “catching a cold” with the cold air.

It is important to remember that children are more than just tiny adults. Like most systems in their body, their temperature regulatory system is not fully developed. Children's bodies are not able to readily adapt to the extreme changes in temperature the way that adults can. Their temperature control systems are not matured. This is particularly true for newborns, premature babies and low birth weight babies. (2)

Infants lose their heat quickly when exposed to cold air because they have a large body surface area as compared to body mass, a thinner layer of subcutaneous fat and a lower metabolic rate. (2) Young children also have a greater body surface area-to- mass ratio.(3) These characteristics put children more at risk for Hypothermia (a temperature of 95 degree Fahrenheit or less) as compared to adults.

Therefore care needs to be taken regarding the proper dress and prevention of heat loss in young children when exposed to the cold night air. In particular, infants under one year old need to wear a hat at all times when they go outside in the cold air. They lose most of their heat from their head and can very quickly become Hypothermic if they go out in the cold air without a hat.

Appropriate outdoor clothing for children includes layers of light clothing under appropriate outerwear.(4) Children playing outdoors should wear two pairs of socks, a hat, and mittens. It is also important to not let young school age children play outside in extremely low temperatures. Older children should be taught the early signs of Frostbite which include tingling and loss of skin sensation. (3,4) When they experience these symptoms, they should come indoors.

So to answer your question, children can go out in the night air for short periods of time if they are properly dressed and closely monitored by an adult. It is a good idea to limit Infant’s exposure to the cold night air because they are at the highest risk for cold related illnesses. Prolonged or extended exposure in any child regardless of the age is not recommended because children are at a particular risk for Hypothermia. In addition, parents should take into consideration the wind chill factor and precipitation, since water and wind increase a child’s risk for developing a cold related illness.(3)

Hypothermia should be taken very seriously because it can be life-threatening. The majority of deaths due to Hypothermia occur during the months, November through February. Even though children under 1 year old are at the highest risk, older children can also develop Hypothermia. Children at high risk include boys in early adolescence and inadequately dressed older adolescents who abuse alcohol or illicit drugs. (3)

Children exposed to extreme cold can also develop a localized cold injury such as Frostbite.(3) Frostbite is the freezing that occurs when a body part is exposed to extreme cold. Local damage occurs when the tissue temperature drops to 0 degrees Celsius or 32 degrees Fahrenheit.(3) The most common places on the body to develop Frostbite include the ears, nose, toes and fingers.(3) It is important for parents to remember that children are at particular risk for developing Frostbite because they do not know how to sense early signs of exposure. Since they do not sense the early signs of exposure, they continue to play outdoors in an environment that puts them at risk.(4)

The tissue damage that occurs because of Frostbite is similar to a burn. Frostbite is categorized into different types, first degree being the mildest and fourth-degree being the most severe. Signs of first degree Frostbite also known as “Frost nip” include shivering, redness of the skin, swelling but no blistering. A child with second degree Frostbite experiences a partial or full thickness injury that results in the formation of blisters and pain after rewarming. A child with third degree Frostbite or deep Frostbite experiences death of the tissue layers of the skin, loss of sensation and pain when rewarmed. Fourth degree Frostbite is the most serious type. It can lead to gangrene, permanent disability, arthritis and the loss of a body part.(3)

Those children at risk for Frostbite include inadequately dressed toddlers, children with poorly heated homes, hikers, skiers, lost mountain climbers and near drowning victims.(3) Exposures to wind and water also increase the risk of Frostbite. (4,5)

If you suspect that your child has a cold related illness such as Hypothermia or Frostbite, the first step is to remove the child from the cold environment. All wet clothing should be taken off and the child should be dried and warmed with a blanket. It is a good idea to put a child’s hands under an adult’s armpits. Vigorous massaging and rubbing should never be done because this can cause more tissue damage. (3) Thawing should not be attempted if refreezing is a risk because this will only cause more tissue damage.(3) Any child experiencing a cold related injury should be evaluated by a Physician as soon as it is physically possible.

It is also important to mention that children with Asthma are affected by the cold air. The cold air as well as changes in temperature are potential triggers for an Asthma Attack. (6) All children with Asthma need to be closely monitored for worsening of their condition during situations of extreme temperature or temperature changes. It is recommended that children with Asthma wear a face mask or scarf over their mouth to prevent them from breathing in the cold air when they are outdoors. This will ensure that the air is warmed before it reaches their lungs and can help prevent a bronchospasm.

A common recommendation for children with Croup is to “go outside into the cold air”. Croup or Laryngotracheobronchitis is a common condition in childhood that involves the inflammation of the upper airway. It can be caused by bacteria, but in most cases a virus is the culprit.(7) Croup accounts for more than 15 % of the respiratory illness in children.(7) Children between 6 months to 6 years old are affected most often, boys more commonly than girls.

Because the most important goal in treating Croup is maintaining the airway, measures to keep the airway open are a priority.(7) Mist therapy, exposure to cold air, inhaled epinephrine and corticosteroids are all traditional treatments for Croup. These measures are typically recommended by health care professionals with the goal of maintaining the patency of the airway. (4,7) The assumption is that the cold air shrinks the swelling of the upper airway and relieves the symptoms. Even though mist therapy has been widely used successfully, recent studies have questioned its efficacy.(7)

I hope this infomation answers your questions about bringing children out into the cold night air. Be sure to keep warm this winter!

(1)Cheung M, Lieberman J. Influenza. Update on strategies for management. Contemporary Pediatrics. 2002. 19(10):82-94.
(2)Bellack J, Bamford P. Nursing Assessment A multidimensional approach. Belmont, CA:Wadsworth Inc.1984:285.
(3)Nield L, Nanda S. Cold Injuries. Consultant for Pediatricians. 2005. Oct:427-434
(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:2096-2099, 1215.
(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: 636.
(6)Rance K, Blaiss M. Optimal Clinical and Counseling Strategies for the Pediatric Asthma Patient. The Clinical Advisor. 2006. Aug:S3-15.
(7)Bradin S. Croup and Bronchiolitis: Classic Childhood Maladies Still Pack a Punch. Consultant for Pediatricians.2006.Jan:23-28.

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

Pediatric Advice About Keeping Kids Safe

Monday, November 20, 2006

Tylenol Dosage

Dear Lisa,

My son was just released from the hospital yesterday. He has RSV. The pediatrician told me he would run a fever and also told me that the infant can only have Tylenol infant drops (only Motrin after the baby is 6 months old). He has started to run a fever and I was wanting to know how much Tylenol infant drops I can give him and how often. He is now on Bromhist (cough medicine), Albuterol (breathing treatment), and Pulmicort (breathing treatment).


Dear “4mtholdmommy”,

I’m sorry to hear that your child is sick. Your question is the most common pediatric question parents ask. The Tylenol (also known as Acetaminophen) dosage for each child needs to be calculated according to the child’s weight. The recommended Tylenol dosage is a range; between 10 to 15 mg of Tylenol per Kg of weight per dosage. (1) When calculating and figuring out how much medication to give you must be aware that the concentration of Tylenol differs between products. There is a different amount of Tylenol in each product that you buy.

The amount of Tylenol or Acetaminophen in each product is listed on the package and can be read right underneath the product name (if you have good eyesight!).

Infant’s Tylenol contains 80 mg of Tylenol per 0.8 ml (1/4 fl. Ounce)
Children’s Tylenol contains 160 mg per 5 ml(one teaspoon)
Children’s Tylenol Chewable Tablet contains 80 mg per tablet
Children’s Tylenol with Flavor Creator contains 160mg per 5 ml(one teaspoon)
Children’s Tylenol Meltaways contain 80mg per tablet
Jr. Tylenol Meltaways contain 160mg per tablet

When figuring out the dosage you first need to convert the child’s weight in pounds to kilograms. To do this, take the weight in pounds and divide it by 2.2. For example, for a 13 pound child, you would take 13 and divide by 2.2 which equals 5.9. Rounding this number off, a 13 pound child weighs 6 kilograms. Take 6 and multiply it by 10 which equals 60; then take 6 and multiply by 15, which equals 90. Therefore a 13 pound child should receive between 60 and 90 mg of Tylenol per dosage. Using the Infant’s Tylenol drops you should give 0.8ml or one dropperful which equals 80 mg.

An easier method to follow is the schedule recommended by Johns Hopkins Hospital, The Harriet Lane Handbook and the company that makes Tylenol. (1,2)

Infant’s Tylenol:

0 to 3 months old or 6 to 11 pounds = 0.4 ml or ½ dropperful
4 to 11 months old or 12 to 17 pounds = 0.8 ml or one dropperful
12 months to 23 months or 18 to 23 pounds = 1.2 ml which is equal to 1 ½ dropperfuls

It is recommended that you use the measuring device (dropper or measuring cup) provided by the company.(2) All dosages of Tylenol may be repeated every 4 hours, but should not be given more than 5 times per day.(2) You should always consult your Physician before giving Tylenol to a child under 2 years old.

When treating a child with Tylenol for a fever your Doctor should be consulted if the fever gets worse. Tylenol should not be given for more than three days for fever unless directed by your Doctor. (2) The reason for this recommendation is, a fever in a child that lasts for more than three days can be very serious. A fever for three days duration needs to be re-evaluated by a Physician so the cause can be determined and treated.

When treating pain with Tylenol, if the pain worsens or lasts for more than 5 days, your Doctor should be consulted. It is not recommended to give Tylenol for more than 5 days when treating pain, unless instructed to do so by your Doctor. The reason for this recommendation is a child with pain for 5 or more days needs to be re-evaluated by a Physician in order to determine and treat the cause. Continued or increased pain may be a sign of worsening of a child’s condition.

The recommended Tylenol dosage for children over 2 years old is written on the package. For older children, it is important not to exceed the recommended adult dosage of 325mg to 650mg per dosage, regardless of the weight of the child. An over dosage of Tylenol can be quite serious and can lead to Liver damage or in some cases even death. (1,2) Early symptoms following potentially hepatotoxic overdose may include nausea, vomiting, sweating and general malaise.(2)

If your child accidentally receives the incorrect amount of Tylenol, contact the Poison Control Center at 1-800-222-1222 right away. When an over dosage is suspected, it is recommended to seek medical attention even if the child is not exhibiting any symptoms.

Tylenol should not be used if you are giving your child other products containing Acetaminophen. (2) Children with G6PD deficiency should not receive Tylenol or any products containing Acetaminophen. (1)

I hope you son is feeling better soon.

(1)Greene M. The Harriet Lane Handbook. St. Louis, Missouri: The Mosby-Yearbook, Inc. 1991:150.
(2) Physician’s Desk Reference for Nonprescription Drugs, Dietary Supplements, and Herbs. 2007. Montvale, NJ. Thomson PDR at Montvale:679-681,757.

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

Pediatric Advice For Parents with Infants

Friday, November 17, 2006

Ear Wax Removal

Dear Lisa,

My child went to the Pediatrician for a high fever. The Pediatrician was checking the ears and said he couldn't see bcuz of wax. He used something to scrape or dig some very hard wax out and the ear was bleeding. Not to mention the fact he said there was an ear infection. Is this standard procedure? Then he said just give Tylenol for the pain and use a tissue to stop the bleeding and prescribed antibiotics for the ear infection.


Dear “Earache”,

Unfortunately, it is very difficult to see into a child’s ear because the canal is so small and because they tend to move during the examination. To complicate matters, wax blocks the view of the ear drum. The only way to be certain that a child has a middle ear infection is to visualize and ascertain the mobility of the tympanic membrane(ear drum). (1)

Many times this is a catch 22 situation, because if the wax is not removed, a child could have an undiagnosed middle ear infection. If the wax is removed, it can be uncomfortable for the child and the procedure can sometimes cause a scrape on the inside of the ear canal.

Although it is not the norm, a scrape inside the ear canal during cerumen (wax) removal unfortunately sometimes does occur. If the curette used to remove the wax rubs against the side of the ear canal during the procedure, a scrape and subsequent bleeding can occur. (2) The tiniest scrape can cause a lot of bleeding and can usually appear a lot worse than what it is. The good thing is that the bleeding should stop within a couple of minutes and the scratch heals within a few days.

Children with a lot of wax or hard wax are at the risk of having their canal scratched during cerumen removal. In order to prevent this from happening, it is a good idea to keep the ears clear from excessive wax build up. This is especially important in a child with a history of recurrent ear infections because of the liklihood of subsequent visits requiring visualiation of the ear drum.

To keep the ears free from wax build up a hydrogen peroxide and water mixture can be instilled into a child’s affected ear.(2) Equal parts of hydrogen peroxide and water can be measured and poured into a small medicine cup. Four to five dropperfuls of the solution should be instilled into the affected ear twice per day. The child should be lying down on their side when the drops are instilled.(2)

The child needs to remain still for approximately 30 minutes after the drops are instilled so that the drops won’t roll out onto the cheek. Providing the child with a book or a favorite television show may help pass the time. For very young children or for children who move a lot you may need to instill the drops when the child is sleeping. It is a good idea to wait until the child is asleep for at least 30 minutes before trying to instill the drops.

If a parent prefers to use the hydrogen peroxide solution already prepared, Debrox can be purchased. Debrox comes with in its own dropper bottle and can be found over the counter.

The drops should to be instilled for 4 to 5 nights in a row and used on a monthly basis for children with chronic problems. Many parents report discontinuing the drops when they didn’t see any wax come out of the ear, thinking that the drops didn’t work. Just because wax doesn't come out of the canal, does not mean that the drops are not working. The purpose of instilling the hydrogen peroxide solution is to soften the wax so that it can more easily be removed. (2) In most cases, you will not see any wax come out of the ear.

In some cases wax may come out of the ear canal and stick to the outer ear. When this occurs, care should be taken when removing it. If a Q-tip is put into the ear canal and twisted this can cause the wax to be pushed back further which can worsen the condition.(2) In addition, inserting a Q-tip into the ear canal runs the risk of an injury such as a perforated ear drum. Instead, wax on the outer ear should be gently wiped away and the Q-tip should only be used on the external ear.(2)

Parents can also bring the drops to the Doctor’s office and if it is found that the child’s wax is obstructing the view of the ear drum, the drops can be instilled 15 minutes prior to the wax removal. (2) For children with impacted cerumen or excessive wax build up, irrigation or evacuation may be needed.

Ear irrigation can be quite messy and can frighten the child.(2) The irrigation of the ear is a very simple procedure and can be carried out in the Pediatrician's office. A spray bottle filled with warm water and hydrogen peroxide is squirted into the ear using a special adapter. In some cases a Water Pik may be used. (2) The water squirted into the child’s ear loosens and removes the wax build up. This procedure is not recommended if a perforated ear drum is suspected.(2)

Older children and adults have reported that this procedure feels uncomfortable, but is not painful. I have also had older children tell me that their ear felt much better when the wax was removed. Very young children many times have a different response. I found that young children tend to cry and resist the procedure. When I asked if they preferred the irrigation bottle or the manual scraping, most of them prefer to have their ear wax manually removed with a curette.

Some children with chronic build up of extensive amounts of wax need to see an Otolaryngologist and have their ears evacuated. This is not the norm but may be necessary in children with excessive amount of wax that cannot be removed by other means. Children with myringotomy tubes in their ears should not have any drops or medication instilled into the ear without approval of the specialist who inserted the ear tubes.

It must be upsetting to see your child’s ear bleed after it is examined for an ear infection. Unfortunately, this is one of the risks of removing wax from the ear canal. The good thing is that your daughter’s ear infection was discovered and antibiotic therapy was initiated which will hasten the resolution of her symptoms. Her ear canal will heal and she should be back to herself soon.

(1)Carlson L. What’s New in the Guideline? Therapeutic Spotlight. 2004. June:11-13.
(2)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 706-707.

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

Pediatric Advice About Treating Sick Children

Thursday, November 16, 2006

Enlarged Lymph Nodes

Dear Lisa,

My two and a half your old son developed a swelling on both sides of his neck or should I say enlarged lymph nodes in the neck as a result of pus filled sores on his scalp, which eventually healed, this took place in the care of a nanny. The Doc prescribed antibiotics and he completed the course, and he warned us that the lymph nodes would remain enlarged months after the infection has healed, it has been 6 months and they have slightly reduced in size but are still large, he is healthy, is gaining weight steadily, but I am still concerned. Should these lymph nodes be drained? They are not painful, and move around when you touch the swelling, excuse my English, hope you do understand my problem.

“Swollen Lymph Nodes”,

Dear “Swollen Lymph Nodes”,

Lymph nodes enlarge as a normal response to infection. Being that your child had a skin infection on the scalp, it would be expected that the lymph nodes at the nape of his neck or in his cervical area appear enlarged. Once lymph nodes increase in size due to an infection, it can take weeks for the size to return to normal.

The purpose of lymph nodes is to remove bacteria, foreign material and cell debris from the lymphatic system. Sometimes the number of microorganisms entering the lymph node is so great that the node cannot detoxify the germs the way that it should. When this occurs the node becomes infected.(1) The signs of a lymph node infection include warmth to touch, pink or red color, enlargement of the node, pain and fever. When this occurs in the neck or cervical area it is called Cervical Adenitis.

Cervical Adenitis can occur in children with a Streptococcal infection(strep throat), a Staphylococcus infection, Epstein-Bar Virus (mononucleosis), a Mycobacteria infection(Tuberculosis) or Cat Scratch Disease. The treatment for Cervical Adenitis is antibiotics and in some cases incision and drainage. (2)

From your description it doesn’t sound like there is an infection of your son’s lymph nodes. Of course, this can only be determined by a Physcian who performs a history and physical examination on your child. In response to your question about draining his lymph nodes, this is typically reserved for lymph nodes that are infected. Since your son doesn't have a fever, his scalp infection has cleared and his lymph node size has decreased after antibiotic therapy it does not seem that there is an indication for drainage of his lymph nodes. In addition, his lack of pain and the mobility of the lymph nodes are also normal findings. If you are concerned that your son’s lymph nodes are infected, you should discuss this with his Physician.

You reported that your son's lymph nodes are still enlarged, but slightly reduced in size since the infection. The best way to determine if the size of a lymph node is normal is to have it measured by his Physician. Lymph nodes in children are expected to be 2 cm in diameter or less.(2) It is important to have a healthcare professional measure the lymph node because sometimes what appears to be an enlarged lymph node to a parent may actually be normal for a child’s age.(2)

Some important questions to ask are; “Why did your son develop pus filled sores on his head in the first place?” "Does your child have a skin condition on the scalp such as Eczema, Seborrhea or Ringworm of the scalp that became secondarily infected from scratching? " "Has your son been ill or has he been scratching his head a lot?" "Did he have blood work to check his immune system? Since your son's lymph node enlargement seems to be persisting, it would be a good idea to discuss these questions with his Doctor. It is also a good idea to have the Doctor examine your son's scalp, checking for a skin condition that may be contributing to lymph node enlargement.

Children with a dry itchy scalp or scratching of the scalp can have Tinea Capitis or Ringworm of the scalp. Ringworm is a fungal skin infection that occurs on the face, body or scalp. The symptoms of Ringworm or Tinea Capitis include a dry itchy scalp, scaling, crusting, inflamed nodules, hair loss and tender enlarged lymph nodes on the neck. (3,4) Because of the scratching that is involved with the condition it can become secondarily infected with a bacterial infection.(4)

Many parents fear that enlarged lymph nodes could be a sign of Cancer. (2) Although this is commonly the case in the adult population, this is not necessarily the case for children. Most lymph nodes noticed in the neck of children are normal or can be due to local infection. (2) Common causes of cervical lymph node swelling in children include acute Tonsillitis, outer ear infection, and Mononucleosis.

On the other hand, an enlarged lymph node that is accompanied by fever of an unknown cause or weight loss can be a sign of a more serious condition, such as a malignancy. Children with these symptoms should be evaluated by a Physician without delay. (2)

All children with lymph node enlargement should be evaluated and followed by a Physician. A comprehensive history and physical examination needs to be performed in order to find the cause.

I hope your son remains feeling well and his lymph node enlargement resolves soon.

For more information about the topics discussed read the following Pediatric Advice Stories:

Rubbery Lump

Lumps in the Neck

Lump in the Groin

(1)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:520-521.
(2) Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company.1991:592-593.
(3)Kaplan D. Tinea Capitis. Consultant for Pediatricians. 2006. August:521.
(4 ) Ringworm. Consultant for Pediatricians. 2006. Jan:44.

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

Pediatric Advice Website

Wednesday, November 15, 2006


Dear Lisa,

I went to the Pediatrician’s office for a four month old visit for my son and the doctor told me that my son has Plagiocephaly. I noticed that his head was flat in the back, but I didn’t think that it was a big deal. I don’t understand why he got this and my two other children didn’t. I handled all of them the same way. Why did this happen to him and not my other two?

“Son has a Flat Head ”

Dear “Son has a Flat Head”,

Plagiocephaly is a distortion of the shape of an infant’s malleable skull due to external molding. Positional Plagiocephaly develops when pressure or forces cause an infant’s soft skull to become misshapen, asymmetrical and flat in certain areas. Positional Plagiocephaly is a very common condition found in nearly 10% of all children.(1)

There are many factors that contribute to the development of Positional Plagiocephaly. A restrictive uterine environment is considered one of the leading risk factors.(1) Other risk factors include; prematurity, low birth rate, a baby with a large head, multiple births, breech presentation, increased uterine or abdominal muscle tone, small maternal pelvis, medical conditions that predispose infants to maintain their head in a consistent position and “back to sleep positioning”. (1)

In particular there has been an increased incidence of Positional Plagiocephaly in recent years. This finding is attributed to the practice of putting babies “Back to Sleep”. This increase in the incidence of Positional Plagiocephaly coincides with the introduction of the American Academy of Pediatrics “Back to Sleep” positioning recommendation instituted in the early 1990’s. (2,3) This recommendation was made with the goal of decreasing the risk of Sudden Infant Death Syndrome. The campaign was a success because there has been a decrease in the incidence of Sudden Infant Death since the recommendation was made.

This change in sleep position resulted in babies spending much more time on their backs. Spending a significant amount of time on the back contributes to the formation of a flat occiput and positional molding leading to Positional Plagiocephaly. The good thing about Positional Plagiocephaly is that it is not a life threatening disorder and if treated early, it can be corrected.

The reason why one sibling develops Positional Plagiocephaly and another doesn’t can be due to a multitude of factors. First of all, boys are more commonly affected then girls. Secondly, your son’s intra-uterine environment could have contributed to his condition. Perhaps his position in utero lent it self to pressure on certain spots of his skull. Secondly, his head size may be different from your other two children. Or perhaps, after delivery your son spent more time flat on his back as compared to your other two children. The important thing is that the problem was identified early so that measures can be taken to improve his Positional Plagiocephaly.

You can ask your Pediatrician about measures that you can take in order to correct your son’s misshapen head. The key to successful management of infants with Deformational Plagiocephaly is early diagnosis and treatment. (4) Since 80 % of skull growth takes place before 12 months there is a small window of opportunity available to provide treatment. Typically, the earlier the deformity is identified and treated, the greater chance of correcting the problem completely. (5)

Most interventions rely on redirecting symmetrical growth of the skull. (4) The measures that can be taken to accomplish this include repositioning the head off of the flat spot, position changes, environmental changes and supervised “tummy time”. A parent can reposition the infant’s head by turning the head to the side, off of the flat spot. This is quite difficult when a child is awake because they tend to maintain a position of comfort and resist re-positioning. (4) A good time to re-position the head is 30 minutes after a child falls asleep. At this time there is less resistance to change in position and the greater chance that the head will remain the way it is re-positioned.

The parents should alternate arms when holding and feeding the infant. This will prevent the child’s head from remaining in the same constant position at all times. (4) The infant’s environment should also be changed frequently. Parents should rotate the position of the toys in the room and the placement of the infant seat. (4) If an infant is put in the infant seat in the same spot of the room each day, he will learn to tilt or turn his head in the same direction in order to see the main activity in the room. By frequently changing the placement of an infant in the room, it forces him to tilt his head and stretch his neck in different directions in order to see the activity.

Putting the baby down to sleep on alternating sides of the crib each night also encourages symmetric growth of the skull. This way, each morning the infant will need to look in a different direction to see mom and dad come into the room. The frequent change in head position encourages range of motion of the neck and rotates the pressure sites on the skull which promotes a more symmetric shape.

Supervised “tummy time” during the day is also recommended. Spending time on the belly helps the baby develop muscles in the abdomen, upper chest, neck and arms. Tummy time takes the pressure off of the back of the head and encourages symmetrical growth of the skull. Many parents report that their baby cries when they put their baby on the belly and because of this immediately put the baby on the back again. (4) Parents who encounter this problem can try positioning toys or a child-proof toy mirrors in front of the child during “tummy time” to help keep the baby in the position for a longer time.

I found in my practice that babies who engaged in “belly time” since birth seemed to be used to the position and tended to have less crying. This is one of the reasons why it is important for all babies to have supervised “tummy time” starting early in infancy.

Physical therapy and neck stretching exercises play an important part in treating Positional Plagiocephaly. Most children with Positional Plagiocephaly also have some form of neck dysfunction. (4) Neck stretching exercises can alleviate the restriction in movement and allow the infant to alter its head position more freely.

Children with severe deformities that do not improve with more conservative measures can benefit from Orthotic management with the use of a helmet or band. (6) The helmet works by applying a mild constant pressure on the most anterior and posterior prominences where growth is undesirable. At the same time room is left in the flattened regions in order to encourage the cranium to grow. The helmet is adjusted frequently to monitor improvement and ensure proper growth of the head. Numerous clinical studies have demonstrated the success of this technique.(5,7)

I have had plenty of parents who were concerned that the helmet would hurt the infant or interfere with the child’s movement. From my experience, infants tolerated the helmet very well and moved as if there was nothing on their head at all. I also found that the parents were very pleased with the final results.

For more information about Positional Plagiocephaly read the following Pediatric Advice Story:

Infant with Neck Hung to the Side

(1)Carson, B., Munoz, D., Gross, G. An assistive device for the treatment of positional plagiocephaly. J Craniofacial Surgery. 2000;11(2): 77-183.
(2)Komotar, R., Zacharia, B., Ellis, J., Feldstein, N., Anderson, R. Pitfalls for the Pediatrician: Positional Molding or Craniosynostosis? Pediatric Annals: 2006;35(5):365-375.
(3)Peitsch, W., Keefer, C., LaBrie, R., Mulliken, J. Incidence of cranial asymmetry in healthy newborns. Pediatrics. 2002;110(6):e72.
(4)Littlefield T, Reiff J, Rekate H. Diagnosis and Management of Deformational Plagiocephaly. BNI Quarterly. 2001. 17(4):1-8.
(5)Kelly KM, Littlefield TR, Pomatto TK. Importance of early recognition and treatment of deformational plagiocephaly with Orthotic Cranioplasty. Cleft Palate Craniofac J. 1999. 36:127-130.
(6) Komotar R, Zacharia B, Ellis j, Feldstein N, Anderson R. Pitfalls for the Pediatrician: Positional Molding or Craniosynostosis? Pediatric Annals. 2006. May:365-374.
(7)Littlefield TR, Beals SP, Manwaring KH. Treatment of Craniofacial asymmetry with dynamic Orthotic Cranioplasty. J Craniofac Surg. 1998.9:11-13.

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

Pediatric Advice For Parents

Tuesday, November 14, 2006

Speech Delay

Dear Lisa,

I am worried about my 2 year old son because he is not talking yet. He calls me “ma ma” when he wants me. The only other words he says is “da da” for his father and “ta ta” for his sister. Otherwise he doesn’t say anything else. If he wants something he just points to it. When he wants milk, he just walks into the kitchen and points to the refrigerator. I am starting to get worried. Should I get his hearing checked?

“Worried about my son not talking yet”

Dear “Worried about my son not talking yet”,

Speech and language development play a very important role in a child’s learning and development. Speech development is needed so that a child can communicate with the outside world. The most critical period for speech development is between the ages of 9 and 24 months. (1) It is important to pick up on cues that indicate a delay during this period. If a child demonstrates a lack of progression of speech and language development a comprehensive evaluation is necessary in order to identify and treat the problem.

Language development includes receptive milestones and expressive milestones. Receptive language includes the child’s ability to understand speech. Expressive language involves the child’s ability to express or speak verbally. A Speech Therapist evaluates a child’s receptive and expressive speech and language development. The evaluation includes obtaining information about a child’s ability to interact, communicate, socialize, play, identify pictures, and carry out simple commands.

When a child is found to have a speech delay, an assessment of other areas of childhood development should also be evaluated. A comprehensive evaluation is necessary because a Language delay in childhood can be a presenting symptom of another problem such as a global developmental disorder. (1) A child’s coordination, sensory skills, neurological status, perceptual-motor function, neurologic status and hearing should all be evaluated. This comprehensive assessment many times involves a team approach involving specialists in areas of speech, education, and psychology.

Many parents ask the question, “What should my child be saying at this age?” It is important to remember that Speech and Language development begins in infancy. The development of Speech and Language is a continuum that slowly develops over time. The first signs of speech and language development begin early in infancy when a baby responds to sounds. By four months old an infant turns its head in response to his mother’s voice and by 9 months old the infant understands the word “no”. These receptive language skills progress to the point where an infant can differentiate between different sounds. An infant’s communication skills are expected to develop at nine months old. A delay noted during this time should be referred to an early intervention program. (2)

Expressive language also begins in infancy. Signs of expressive language development in infancy include cooing sounds at 2 months of age and babbling at 6 months of age. By the time a child is 12 months old he should be able to express the words “ma ma” and “da da”. A one year old child should be able to express 3 additional words besides “ma ma” and “da da”. Jargoning develops between 12 and 18 months old. Jargoning sounds like the child is speaking a foreign language. (1,3) As a child speech progresses, they begin to slip a real word in between jargoning. This tends to occur between 15 and 18 months old.

A language burst is expected to occur between 20 and 24 months old. At this time a child develops a vocabulary of 50 words and new words are demonstrated on a daily basis. This language burst is following by two word combinations in which the child puts two words together while talking. By the time a child is two years old, he should be able to respond to simple commands such as “give me that”, “sit down” and “sit up”. The child should also be able to understand and point on command to mouth, nose, hair and ears.

A twenty-five month old child should be able to express up to 270 words with an average of 75 words spoken per hour during free play. At this age a child should use phrases in their speech by putting two words together such as, “want cookie”, “up daddy” or “all gone”.(3)

As with all areas of child development, some children progress through the stages of development quicker and some children progress through the stages slower. As long as a child shows progression in speech development it is okay if a child is not exactly on target. Close follow up and continued monitoring of speech development is the key. On the other hand, a marked delay, a regression in speech, loss of previously gained milestones or lack of speech development are all signs that a child’s condition needs to be investigated further .

It is understandable that you are concerned about your son’s speech since he did not reach the point of jargoning yet and he is two years old. Since he has not met the speech and language milestones that are expected for his age, it would be reasonable to have him evaluated by a Speech therapist. A developmental evaluation by your Primary Care Physician is also necessary in order to determine if there are delays in other areas of his development.

For those children who are speech delayed, a Speech Therapist can set up a program to improve a child’s expressive and receptive language skills. In addition to therapy received during a session, the Speech Therapist can give you and your child exercises to perform at home to help promote speech.

There are some measures that parents can take that can help promote speech development. These measures include; reading books to your child, feeding your child food which require a lot of chewing, having your child use a cup without a top, and blowing bubbles. Giving your child sandwiches made with soft bread also helps. When a child eats a sandwich, the bread gets stuck on the roof of their mouth and on their teeth. In order to remove the bread from these areas, the child needs to move their tongue in such a manner that requires strength and coordination. These types of mouth exercise help develop the muscles in the mouth and tongue that are needed for speech.

Reading picture books, slowly annunciating each sound and pointing to objects on the page can also promote speech. An important part of speech and language development involves the child’s ability to comprehend and identify words. By 2 years old a child should be able to identify pictures of objects such as a dog, ball, train, bed, doll, cup, chair, box, car and fork. By reading picture books with your child while pointing to these objects, it can help your child’s speech and language development.

Your question about having your son’s hearing tested is a very good one. The ability to hear is critical for the development of speech, language and learning. (3) Therefore children who develop a speech or language delay should have a hearing evaluation to determine if a hearing deficit is contributing to the problem.

Children at risk for hearing loss include those with a family history of hearing loss, a maternal history of infections with Rubella, Syphilis or Cytomegalovirus in the early months of pregnancy, an anatomical malformation of the head or neck (such as abnormalities of the external ear or cleft palate), a history of bacterial meningitis, a history of being exposed to chronic loud noise, treatment with ototoxic drugs in infancy (such as Streptomycin or Neomycin), chronic nasal obstruction and history of fluid accumulation in the ear.
Another good indicator that a child may have a hearing loss is a child who does not pay attention to parental requests. A hearing evaluation is recommended in children who don’t respond to their parent’s commands, in children who received drugs that may have affected their hearing and in children with repeated middle ear infections. (3)

It is essential that delays in any area of development be identified and treated early. Early intervention can prevent a child from developing emotional, social and cognitive deficits that can affect their relationships and future school performance. (2,4)

(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:2074.
(2 )Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics. Bright Futures Steering Committee and Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorder in the medical home an algorithm for developmental surveillance and screening. Pediatrics. 2006. 118:405-420.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:933-955.
(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. 1990:696-697.

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

Pediatric Advice About Keeping Babies Healthy

Monday, November 13, 2006


Dear Lisa,

Should a 14 year old who has had strep for the past six weeks have his tonsils taken out? What are the benefits/risks?


Dear “Tonsillectomy?”,

Tonsillectomy and Adenoidectomy have been performed on children for over a century. There are no definitive criteria established as absolute indication for surgery.(1) A child’s Physician makes this decision based on the child’s clinical history and physical findings. Otolaryngologists (ENT Doctors) are the type of specialists that evaluate children with recurrent Strep or Tonsillitis and decide if surgery is necessary.

One of the major reasons for surgery is recurrent infections with tonsillitis, adenoiditis or adenotonsillitis. (1) Although each individual specialist has different criteria for surgery, generally children with ten Strep infections or episodes of tonsillitis in a period of one year are considered good candidates for surgery.

Tonsillectomy is strongly considered in children with a Peritonsillar Abscess which fails to respond to antibiotic therapy. A child with a Peritonsillar Abscess who has a past history of recurrent tonsillitis is also recommended to have surgery.(1)

Tonsillectomy may also be recommended for children with Strep infections deep within their tonsils. Infections deep within the tonsillar crypts are often difficult to culture and completely cure with antibiotics. (1) Children with this condition tend to complain of chronic sore throats and may frequently have negative Strep culture results. It is difficult to obtain a throat culture of these deep seeded infections and as a result these patients can have throat cultures that remain negative even thought they have a bacterial infection. Tonsillectomy is recommended in these patients because of the inability to eradicate the infection.

In rare situations, asymmetry in tonsillar size may be an indication for surgery. One tonsil can become slightly larger than the other due to an infection. A slight difference in size is not alarming, but a marked difference in size or sudden enlargement should be evaluated by an Otolaryngologist. Although rare in childhood, a sudden enlargement of one tonsil may be indicative of a tumor.(1) In such a scenario, tonsillectomy is recommended.

Infections are not the only reason why children have their tonsils removed. During childhood, tonsils and adenoids become enlarged in response to infections in the upper respiratory tract.(2) In most children this enlargement is tolerated and there are no consequences. In some cases, the enlargement can obstruct the airway and lead to symptoms of upper airway obstruction or Obstructive Sleep Apnea (OSA). Chronic upper airway obstruction and Obstructive Sleep Apnea are major indications for surgery.(1,3)

Signs of upper airway obstruction include mouth breathing, difficulty swallowing, and failure to thrive. (1) Obstructive Sleep Apnea occurs when a child has decreased amounts of oxygen and a disruption in their sleep.(3) Symptoms of OSA include snoring, pauses in breathing during sleep, daytime sleepiness, impaired concentration, impaired attention, morning headaches, bedwetting, dry mouth, interrupted sleep, depression, irritability, and abnormal sleep positions. (1,3)

Obstructive Sleep Apnea is a major health concern because most cases go undetected. The long term effects of untreated OSA can be quite serious.(3) The consequences of having Obstructive Sleep Apnea include glucose intolerance, elevated cholesterol levels and Hypertension. Obstructive Sleep Apnea has also been linked cardiovascular disease and its complications.(4,5) Children with Obstructive Sleep Apnea are strongly recommended to have Tonsillectomy.

The benefits of having a Tonsillectomy in this situation prevents the development of heart changes that lead to cardiovascular disease, improvement in bedwetting, more restful sleep, improvement of concentration and attention during the day. Tonsillectomy also improves jaw alignment in mouth breathers, weight gain in children with failure to thrive, and reduction in the number of infections in children with recurrent Strep infections, tonsillitis and peritonsillar abscess. (1)

If your child’s Physician recommends that your child has a Tonsillectomy, you may want to discuss the reason for this recommendation. Has your child had a long standing history of recurrent tonsillitis or Strep infections? Does he have signs of chronic upper airway obstruction or Obstructive Sleep Apnea? Your doctor will be able to discuss the criteria for surgery as well as the benefits of the risks involved.

Common post-operative complications of Tonsillectomy include throat pain, dehydration, bleeding and reactions to anesthesia. (2) Children who undergo Tonsillectomy experience a lot of throat pain after surgery which typically needs to be controlled with pain medication.(2) In some cases, children refuse to eat or drink because their throat hurts so much. This pain, along with a fear of swallowing puts them at risk for dehydration.

Bleeding is also a risk of Tonsillectomy and is a major concern in children with anemia and bleeding disorders. Tonsillectomy is contraindicated or not recommended in children with certain bleeding disorders because of the risk of hemorrhage.(2)

From my experience, the post operative period is quite demanding on the parents, because of the child’s increased need for attention, pain management and coaxing to drink. Most of the children that I took care of post op did well with the encouragement and assistance from their parents.

When Tonsillectomy is recommended, it is normal for parents to seek out more information regarding the necessity of the procedure as well as the risks and benefits. Many times parents seek a second surgical opinion when Tonsillectomy is recommended in order to make an informed decision.

I hope this information helped and your child is feeling better soon.

(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: 805.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1211-1213.
(3)Butler D. An underdiagnosed cause of daytime fatigue. The Clinical Advisor. 2006. Sept:48-52.
(4)Yaggi HK, Concato J, Kernan WN. Obstructive Sleep Apnea as a risk factor for stroke and death. N Engl J Med. 2005. 353:2034-2041.
(5)Mehra R, Benjamin EJ, Shahar E. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep heart Health Study. Am J Respir Crit Care Med. 2006.173:910-916.

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

Pediatric Advice for Parents with Sick Children

Friday, November 10, 2006

Body Mass Index- BMI

Dear Lisa,

My son is 100 pounds. He is 9 years. What is the right weight for him?

“Percentile for Weight”,

Dear “Percentile for Weight”,

Children’s weight and height are plotted on grids to determine their percentiles for age. (1) In order to determine your child’s percentile for weight, his weight is plotted against his age on a growth chart. Physicians and Healthcare providers typically use growth charts to monitor a child's height and weight and screen for potential abnormalities. The purpose of determining your child’s percentile is to compare his weight or height to the established norms for his age.(2)

Growth charts are helpful when a pattern is obtained over time. One isolated measurement of height or weight is not sufficient to make a determination about your child’s health. (2) Growth patterns that move from one percentile to the next, or cross over percentile lines offer more information and are usually the first sign of a problem. For example if a child was consistently at the 75th percentile for weight and then dropped to the 25th percentile, this can be a sign of a medical, social or emotional problem. (1)

A boy who is 100 pounds and 9 years old is above the 100th percentile for weight for his age. What this means is, if you put him in a room with 100 boys his age he would weight more than each individual in the room. Looking at this reading independently would imply that your son is overweight. But this assumption cannot be made without more information.

Your son’s height would need to be taken into consideration. For example there are some very large children whose height and weight are both above the 100th percentile for age. In this scenario the above average percentile for weight is congruent with the above average percentile for height and does not mean that the child is overweight. On the other hand, if your son is in the 25th percentile for height and above the 100th percentile for weight this would be concerning and would warrant further investigation.

It would also be important to know if your son has gradually increased to this point over time. Following a trend over time is more clinically significant than one isolated reading. If your son has always been above the 100th percentile for weight this may also be normal for him. A better way to determine if a child is overweight is to determine the Body Mass Index (BMI) or measure skin fold thickness. (1)

The BMI is also known as the Quetelet’s index is a commonly used tool to assess obesity in children. (3) It can be compared with normal data based on age, sex and race. (1) The BMI does not overestimate body fatness in short individuals or underestimate it in tall individuals.

In order to calculate a child’s BMI the child’s weight in pounds is divided by the height in inches. That number is then divided by the height in inches again. This answer is then multiplied by 703. The answer that you get is your child’s BMI.

When working with Kilograms, the child’s weight in kilograms is divided by the square of the height in meters. (3)

For example: A teenager who is 5 foot 4 inches tall and weighs 140 pounds:
140 (pounds) divided by 64 (inches) = 2.1875
2.1875 divided by 64 (inches) = 0.034
0.034 X 703 = 23.9, rounded to a BMI of 24


140 pounds = 63.5 Kilograms
5 foot 4 inches = 1.625 meters
Meters squared = (1.625 X 1.625) = 2.641
63.5 (Kilograms) divided by 2.641 (Meters squared) = 24.04, rounded to a BMI of 24

Some people prefer to use a BMI calculator. The BMI calculator calculates your child's BMI automatically. All you have to do is input your child’s height and weight and the BMI will be calculated for you.

Once you determine the BMI, the number should then be plotted on a BMI Growth Chart for Children according to their gender. (3) Overweight or Obesity is defined as BMI at or above the 95th percentile. BMI between 85th and 95th percentiles are considered at risk for obesity. (3)

You can also use the following chart as a general guideline to interpret your child’s BMI:

A BMI of
18.5 to 24.9 is considered normal
25 to 29.9 means a person is overweight
30 to 34.9 is “class 1” Obesity
35 to 39.9 is “class 2” Obesity
Above 40 is “class 3” or severe Obesity

Another accurate way of determining if your child is obese is determining skin fold thickness. Skin fold thickness correlates highly with other measures of body fat and is more accurate than physical assessment or weight for height in diagnosing obesity. (1,3) Skin fold thickness can be evaluated by a Dietician or Physician who specializes in obesity.

To access the tools discussed click on the following links:
Girls Growth Chart for Height and Weight

Boys Growth Chart for Height and Weight

Girls BMI Growth Chart

Boys BMI Growth Chart

BMI Calculator

(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. 1990:81,59,114.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:72.
(3)Someshwar J, Someshwar S, Perkins K. The Obese Adolescent. Pediatric Annals. 2006.35(3):181-186.

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

Pediatric Advice For Healthy Kids