Skin Infections

Dear Lisa,

My daughter has been having these out breaks on and off. She has had an abscess removed from her chin last winter. She had what appeared as pimples on her back, that went away on its own. But what started to worry me, is when she broke out on her vagina. It started out like a diaper rash and slowly progressed into, what appeared to be boils, very painful. We brought her to the Doctor, and they had diagnosed her with a Staph infection. Prescribed her Antibiotics and they went away. Just last week, I noticed pimples forming on her left side of her stomach, in a cluster, she stated that they had been itching her. My first response was "Chicken Pox", but to my dismay, she was once again diagnosed with Staph infection. What is causing this recurring Staph infection? Why hasn't it affected me or my husband? Is there something we can do to prevent further outbreaks?

“Vivimart721”

Dear “Vivimart721”,

Superficial skin infections occur when a germ or microorganisms enters the body through a break in the skin integrity. This disruption to the skin may be due to a bug bite, a scratch, trauma to the area or an underlying skin disease such as eczema. (1) Once the skin barrier is open, microorganisms can readily enter, replicate and cause an infection. Warm weather has also been associated with an increase incidence of skin infections. (1)

Bacterial skin infections are one of the most common reasons why clinicians prescribe antibiotics for children. In most cases, childhood skin infections resolve on their own or in some cases require a short course of topical or systemic antibiotics. (1) Occasionally, recurrent skin infections do occur. When a child has recurrent skin infections, antibiotic resistance and autoinoculation need to be considered.

Autoinoculation occurs when a child harbors an organism in their nasal passages or from their rectum and then transfers the germ to their skin via their hands.(2,3) Whenever there is a break in skin integrity such as in the case of a rash or small cut, the germs which are considered normal flora in these other parts of the body cause an infection of the skin. This is common in childhood because children frequently touch their nose and then touch or scratch their skin.

In order to determine if autoinoculation is occurring, your child’s doctor can take a culture of your daughter's nasal passages and rectum in order to determine the types of organisms that she is harboring. If the microorganism found in the nasal passages or rectum is the same organism responsible for her skin infection, then autoinoculation is suspected.

In some cases other family members or even dogs can become infected or colonized and serve as a reservoir for the bacteria that is responsible for causing a child’s recurrent skin infections. (4) So it is possible for a parent who is harboring a microorganism in their nasal passages to transfer the microorganism to their child. Therefore a parent does not necessarily need to have a wound or rash in order to spread an infection in their child. In cases of recurrent skin infections in children, it may be necessary for the family members to be tested to see if they are colonized and potential reservoirs for infection.

Impetigo is one of the most common skin infection. It is very contagious and is usually caused by Staphylococcus aureus or Group A beta hemolytic Streptococcus. Other strains of beta hemolytic Streptococci such as type B, C and G can also be responsible for the infection. (1)

Impetigo lesions appear as red papules that may develop vesicles or fluid filled sacs that can easily be broken. Once the vesicle breaks a clear fluid emerges and develops into a honey colored crust surrounded by a rim which is red in color. When impetigo is caused by a Staph infection it appears as a discrete superficial blister that easily breaks and forms into a glistening flat oozing plaque. (5) These lesions occur in clusters and can typically be found on the face, arms and legs. It is also possible for Impetigo to develop anywhere on the body.

Furuncles develop when an infection of a hair follicle evolves into nodules and eventually abscesses. These lesions are quite painful and tend to occur on the face, neck, underneath the arms, on the buttocks and thighs. Staphylococcus aureus is usually the microorganism responsible for furuncles and abscesses. Diabetes mellitus as well as other underlying diseases put a child at risk for developing Furuncles and Abscesses. Furuncles and Abscesses are also commonly found in healthy children that have no underlying medical problems.

The treatment for Furuncles and Abscesses include antibiotic therapy and warm compresses. Applying warm compresses is a very important part of the treatment because they help drain the wound. An incision and drainage needs to be performed by a physician in some cases, especially if the abscess is large.

If a child’s skin infection, abscess or wound does not respond to antibiotic therapy, the microorganism Methicillin Resistant Staph Aureus (MRSA) is most likely the cause. There has been a recent emergence of Methicillin Resistant Staph Aureus (MRSA) in the community. Traditionally, MRSA has been a hospital acquired illness found in chronically ill patients with prolonged hospitalizations, in nursing home patients and in patient with repeated exposure to antibiotics. (1) This however has not been the case over the last few years.

Children with no know risk factors such as previous hospitalization, contact with those in hospitals or long term treatment facilities have been acquiring the disease. Recent research has found that MRSA is now infecting young children, previously healthy individuals, athletes, children in daycare, Native Americans, and military recruits. (6,7)

Most Staphylococcal skin abscesses are now caused by MRSA. (6) Outbreaks of MRSA infection have become common across North America. In the San Francisco Bay area, the incidence of MRSA infections more than quadrupled between 1998 and 2002. (6) More than half of cultured skin and soft-tissue infections seen in Oakland, California emergency departments are now caused by MRSA. (6)

MRSA is not only a concern in the United States, but has become a problem all over the world. In the past few decades MRSA rates have increased worldwide. (2, 7) MRSA is the most commonly identified antibiotic –resistant pathogen in many parts of the world, including Europe, the Americas, North Africa, the Middle East and East Asia. (2)

The problem with a MRSA skin infection is that it is difficult to treat because the organism is resistant to many antibiotics. The organism can be carried in a child’s nasal passages and cause the skin infection to reoccur. (3) In addition, MRSA often colonizes family members and close contacts of the infected patient which can lead to reinfection. (6) The greatest concern about MRSA infections is the risk of disseminated disease. A small percentage of patients with MRSA skin infections can develop disseminated disease or disease which spreads throughout the body that can be life threatening. (8)

Since your child is having recurring skin infections, it may be a reasonable to discuss the possibility of autoinoculation and the presence of a resistant organism such as MRSA with your Doctor. You and your husband may also need to be checked to see if you are harboring MRSA in your nasal passages. If you have a family pet, it would be a good idea to also have it checked by your Veterinarian.

If your child is diagnosed with a MRSA skin infection or colonization of MRSA, your doctor can prescribe systemic antibiotics to treat the problem. If the organism is found in your child’s nasal passages a medication called intra-nasal Bactroban may be prescribed in order to decolonize the area. In addition, environmental measures should be taken in order to prevent the spread of infection to other people.

Since MRSA skin infections as well as other types of skin infections are contagious it is important to follow certain measures to prevent spread of disease. Draining wounds should be covered with clean, dry bandages at all times and items contaminated with drainage from a wound should not be re-used. Contaminated bandages and towels should be discarded appropriately. Towels, bedding bar soap, razors and athletic equipment that may have become contaminated should not be shared. (6)

Handwashing with warm soapy water is recommended especially after handling bandages or touching the affected area. Clothes that have come into contact with a wound should be washed after each use and dried completely. (6) Children should have their nails kept trim and any underlying skin condition such as eczema should be controlled. Activities that involve skin to skin activity (such as contact sports) should be avoided until a skin wound or infection is healed. (6)

Since items and surfaces that come into contact with microorganisms can transmit the germ it is necessary to clean equipment and all other surfaces that come into contact with bare skin. Detergents and disinfectants that specify Staphylococcus aureus on the product label are recommended. (6)

Specific recommendations for outbreak control are available at the following Web site:

http://lapublichealth.org/acd/MRSA.htm

For more information about MRSA log on to:

http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html


References:
(1)Pong A. Managing Bacterial Skin Infections and MRSA: An action Plan. Pediatric Skin Care. 2004. Spring:8-11.
(2) MRSA now global health threat. Infectious Diseases in Children. 2006.Sept:46.
(3)Rosenthal M. Treatment of skin and soft tissue infections changing in an age of MRSA. Infectious Diseases in Children. 2006. April.52.
(4)Rosenthal Marie. Zoonosis reversal: Animals contracting MRSA from humans? Infectious Diseases in Children. 2006. August:33.
(5)Dermclinic. Bullous Impetigo. Consultant for Pediatricians. 2006. April:214.
(6 )Elston D. More MRSA infections are headed your way. The Clinical Advisor. 2006. July:67-69.
(7)Stephenson M. Community-acquired MRSA a “new normal”. Infectious Diseases in Children. 2006. Sept:68.
(8)Rosenthal M. Steps to Manage CA-MRSA skin and soft tissue infections. Infectious Diseases in Children. 2006. August:40-42.

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

Pediatric Advice-Updated Health Information

Cough and Sore Throat

Dear Lisa,

Hello, I wanted to know my 3 in a half year old had a temperature of 101.2 last night, I gave her children's Tylenol. This morning her temperature went down, but she had a coarse cough. When she tries to cry its like she struggles to cry aloud, I'm guessing she has a sore throat. She coughs a lot in small periods of the time. What should I do to soothe her? Should I take her to the doctor, she not running a fever. She still seems happy she tries to laugh, talk, and giggle throughout the day.

“Daughter with a cough and sore throat”

Dear “Daughter with a cough and sore throat’,

Symptoms including a low grade fever, sore throat and cough in a 3½ year old who otherwise is playful, eating well and acting normal most likely represent a virus. One of the viruses that can cause such symptoms is Adenovirus.

There is an increased incidence of respiratory infections from Adenovirus during the late winter, early spring and summer months. The symptoms of Adenovirus include pharyngitis(throat infection), cough, respiratory symptoms and conjunctivitis. In some cases Croup, Pertussis-like syndrome, Bronchiolitis and Pneumonia may develop.(1,2) Laryngitis or the inflammation of the voice box which causes a child to have a haorse "voice" may also occur. Severe Pneumonia can develop in younger infants and less commonly in older children and adolescents. The disease is often more severe in immunocompromised children.

Adenovirus is spread through respiratory secretions, from person to person contact, or from contact with surfaces harboring the germ. Adenovirus can also cause Gastroenteritis symptoms such as vomiting and diarrhea. The strain that causes gastrointestinal symptoms is transmitted via the fecal oral route. Good hand washing after toileting and proper disposal of diapers is necessary in order to prevent the spread of this type of infection.

The incubation period (the time a takes a person to catch the disease) for respiratory infections due to Adenovirus varies from 2 to 14 days. The incubation period for Gastroenteritis caused by Adenovirus is 3 to 10 days. Adenovirus infections are most communicable during the first few days of acute illness but persistent shedding of the germ for longer periods does frequently occur.(1)

Other viruses that can cause a sore throat, cough and fever include the Parainfluenza virus, Respiratory syncytial virus(RSV), Influenza and the Measles virus. Children who have been immunized with the MMR vaccine are not likely to have the Measles.

Since your daughter no longer has a fever, she seems happy and is giggling throughout the day it is unlikely that her condition warrants an urgent evaluation. Supportive care and monitoring of her symptoms are measures that are necessary at this time.

Giving your daughter a lot of fluid to drink not only can help soothe her throat, but will liquefy her respiratory secretions and prevent her from becoming dehydrated. Children with a sore throat can benefit from drinking chilled fluids or ice pops. The coldness of the fluid will numb the area and relieve pain. Sugar and lemon drinks can also be given and can help soothe the throat. (3)

To help your daughter with her cough you can use a Menthol chest rub. Menthol rubs are appropriate for a 3 ½ year old child with a cough. Menthol has shown some ability to reduce cough sensitivity in laboratory studies. (3) If your daughter continues to cough, develops shortness of breath, increased work of breathing, wheezing, fast breathing or difficulty breathing you should bring her to the doctor for an evaluation.

Other concerning symptoms include the return of a temperature, disinterest in eating, vomiting with coughing, drooling, lethargy, irritability or a persistent sore throat. These symptoms may represent worsening of her condition or a different condition and should be evaluated by a Physician or Nurse Practitioner.

If your daughter has a history of a chronic condition such as Asthma, Diabetes, cardiac defect, immunodeficiency or musculoskeletal disease it is important to have her evaluated by her Physician. Viruses and illnesses can exacerbate underlying chronic medical conditions and lead to complications.

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

Cough

Sore Throat

Gastroenteritis

Temperature Reading

References:
(1)American Academy of Pediatrics. Adenovirus Infections. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:130-131.
(2) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1214.
(3)Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics. ACCP evidence-based clinical practice guidelines. Chest. 2006. 129:260S-283S.

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

Pediatric Advice Questions Answered

Vomiting after Eating

Dear Lisa,

My name is Carrie and I have a 5 year old boy that he will eat supper and at times he will throw up. Usually it is his favorite food to eat. Can you help me understand why he is doing that?

“My boy vomits”

Dear “My boy vomits”,

There's a multitude of reasons why a 5 year old child vomits. Some children have a hyperactive gag reflex. A gag reflex is the normal response that everyone has when food or water touches the back of their throat. Children gag when something touches the back of the throat in order to protect their airway and prevent them from choking or aspirating. In some children this reflex is so overactive that the smallest amount of food can touch the back of the throat and cause such a forceful gag that it causes the child to vomit.

One of the most common causes of acute vomiting in children is Gastroenteritis or viral infection. (1) The symptoms of Viral Gastroenteritis include vomiting (which usually appears like undigested food), hyperactive bowel sounds, fever and abdominal pain.(2) Viral Gastroenteritis typically has a short course lasting approximately 1 to 5 days and many times is accompanied by watery diarrhea.

In most cases of Gastroenteritis, the vomiting phase lasts approximately 8 to 12 hours, subsides, and then is followed by diarrhea. Once the virus is over the vomiting should not return. Chronic or recurrent vomiting represents a different problem. Many times children who develop Gastroenteritis have a history of having contact with another person with the virus although the condition may also be spread through contaminated food or infected air droplets.(3)

A common cause of recurrent vomiting in childhood is Gastroesophageal Reflux (GER). GER occurs when the contents of the stomach travels up the food tube and in some cases shoots out of the mouth in the form of vomit. Older children with GER may present with new onset of recurrent vomiting, heartburn, anemia, chronic cough, recurrent pneumonia, non-seasonal Asthma, loss of appetite, difficulty eating or weight loss.(4) Anything that increases intra-abdominal pressure and intra-gastric pressure can exacerbate a child’s underlying Gastroesophageal Reflux disease.(1) Examples of conditions that increase intra-abdominal pressure include constipation, overeating or activities that apply force to the abdominal area.

A Food sensitivity cannot be overlooked as a possible cause of vomiting in children. Since your child’s symptoms seem to occur after a meal, this is a legitimate concern in your case. A Cow’s milk allergy is a common food sensitivity that presents with vomiting, diarrhea, gas and abdominal pain. (1) Anemia, malabsorption and failure to thrive may also occur in a child with a food sensitivity. Cow’s milk is present in many foods that may not be necessarily obvious to a parent so it is common for the correlation between the food and the symptoms to be overlooked.

Other food sensitivities such as a wheat intolerance can also cause similar symptoms. It is a good idea to keep a food and symptom diary for 2 weeks and bring it to your doctor’s office so that a food sensitivity in your child can be ruled out.

One of the less common causes of vomiting in a child is a Hiatal Hernia. A Hiatal Hernia is a condition where there is a prolapse of a portion of the stomach into the thoracic cavity. When this occurs, the top of the stomach slides through a weakened opening between the food tube and stomach. The symptoms of Hiatal hernia include regurgitation, vomiting, failure to thrive, intermittent colicky abdominal pain and GERD symptoms.

Certain respiratory conditions may also cause a child to vomit. Pneumonia, Asthma, Pertussis and Otitis Media (middle ear infection) are examples of conditions that can cause a child to vomit. (1) During a respiratory infection or Asthma, mucus is produced in the airways and can be swallowed by the child. As a result a stomach ache from the gastric irritation and vomiting develops. (1)

Cyclic vomiting is another cause of recurrent vomiting in childhood. Cyclic vomiting is defined as a cycle of vomiting that involves a high frequency of vomiting per hour during attacks with a few attacks ocurring per month.(5) The symptoms usually begin in the early morning hours.

Cyclic vomiting attacks usually occur every 2 to 4 weeks and the duration of each episode averages 24 to 40 hours. (5) The child then has a period free from vomiting for a few weeks and then the cycle begins again. The vomiting in this condition occurs on such a regular basis that many times parents can predict within a few days when the next episode will occur.(5)

The average age of onset for Cyclic Vomiting is 5 years old. It is considered an early childhood form of migraine which can evolve into abdominal migraine and later typical adult type migraine.(5) Even though a significant proportion of children will have symptoms through adolescence and young adulthood, many will outgrow their symptoms by age 10. (5)

Whenever a school age child develops vomiting on a regular basis it is a good idea to keep a record of the episodes. The child’s diet, activity, weight , time of day, duration, eliciting factors and associated symptoms should all be recorded and brought to the Pediatrician’s office for an evaluation. This way the doctor can make a determination if the vomiting is related to GER, a food sensitivity or another disorder.

Concerning symptoms include acute onset of vomiting with severe abdominal pain, intractable (continuous) vomiting , abdominal distention, projectile vomiting (vomit shoots outs forcefully), fever, bilious vomiting (greenish thick and foamy vomitus), blood in vomit, vomiting with excessive coughing, vomiting in a child with Asthma or vomiting accompanied with weight loss. (1) These symptoms can be related to more serious problems and require an evaluation by a Physician.

For information about topics discussed read other Pediatric Advice Stories:

Gastroesophageal Reflux

Gastroenteritis

Vomiting

Fever and Vomiting

Failure to Thrive

References:
(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. 1990:353-355.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1419.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:793.
(4 )Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006. 35(4)259-266.
(5) Lewis D, Pearlman E. The Migraine Variants. Pediatric Annals. 2005. 34(6):486-500.

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

Pediatric Advice About Childhood Symptoms

Body Piercing

Dear Lisa,

I've had my tongue and eyebrow pierced for about a year now, and they've healed perfect, and it's been fine up until now. Just this week they've been sore, and oozing. I don't know what could've made this happen. It would be greatly appreciated if you could answer this. Thank you.

“Bmesarah”

Dear “Bmesarah”,

An Infection is the most common complication arising from piercing. (1) Local infection and bleeding are reported in 30% of piercings.(2) It is possible for a skin infection to occur at a piercing site at any time. In particular piercing sites that have more movement, sites that are more restricted (such as those under tight clothing) or sites prone to moisture are more likely to become infected.(1)

The signs of local infection include redness, swelling, warmth, pain, and drainage from the site.(1) Local infections often can be managed with good hygiene and topical antibiotic treatments, although some cases may require antibiotics given by mouth.(1) When it is suspected that a piercing site is infected, it is important to replace the jewelry after cleaning the area. By leaving the jewelry in place it allows drainage of the site and prevents abscess formation.(3)

An infection at a jewelry site can develop complications, therefore suspected cases need to be cared for and monitored by a Physician or Nurse Practitioner. Cellulitis or abscess formation are two of the possible complications that can develop. Rarer complications, such as infective endocarditis and cerebellar brain abscess have also been reported. (4,5)

A sensitivity to jewelry can also cause a reaction at the piercing site. If your rash began after a switch in jewelry, the composition of the metal should be ascertained. Some popular cosmetic decorative pieces have a high content of nickel or brass which can trigger a hypersensitivity reaction.(6) Other metals such as cobalt and chromium can also cause problems in some people.(1) If a sensitivity is suspected, the removal of the jewelry and replacement with a different type should resolve the irritation. Choosing jewelry containing non-allergic metals such as titanium, silver or gold are a better choice for teenagers with metal sensitivities.(7)

Jewelry of the incorrect size or length can also create problems. A stud of inadequate length can exert pressure on the surrounding tissue, decrease circulation and decrease exposure to air.(8) If you recently switched jewelry and the pieces are a different length or size you may want to switch back to see if the irritation resolves.

Tongue piercings in particular initially require a longer, temporary barbell to accommodate swelling. After the initial healing the barbell should be replaced with a shorter, permanent barbell. This is especially important in order to protect the teeth.(9) If you haven't swithed to a smaller barbell since your initial piercing you may need to check to see if the size is appropriate.

Trauma from contact sports can also cause complications when a teenager has a tongue piercing. If you are involved in sports and recently had a blow to the face or mouth, the piercing could have been affected. An evaluation by your Physician is necessary if this is the case.

The recent trend of “stretching” a piercing site may also lead to complications. The process of stretching by gradually increasing the size and gauge of the jewelry can lead to pain, redness or drainage at the site. (8) If you recently have been increasing the size of your jewelry to stretch your piercing site, it would be a good idea to discontinue this process. Pain, redness and discharge at a piercing site that has been stretched can lead to dislocation or tearing of the surrounding tissue.(10) Although this problem has commonly been found in stretching of the earlobe, stretching of any piercing site can lead to similar complications.

In other cases, problems can originate from the recurrent removal and insertion techniques or from cleaning methods. In some cases irritation can occur from repeated or improper removal and insertion of jewelry. In other cases, cleaning solution may have become contaminated which can cause an infection at your piercing site. This may be a possibility in your case, since you previously had no symptoms and now have symptoms at both sites. I would recommend discarding your present cleaning solution in case it has become contaminated and purchasing a new one.

It is important to always wash your hands first with warm soapy water before cleaning your piercing sites. Discard any cloths, cotton balls or Q-tips used after one application. You should also refrain from touching the cleaning solution container with the swabs after they touch your piercing sites. All of these measures can help prevent your cleaning solution from becoming contaminated.

If your symptoms persits, you develop colored discharge from the site, increased swelling, a fever, increased pain, induration or increased redness, you should contact your Physician.

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

Tongue Piercing

Painful Earlobes

References:
(1)Larzo M, Grimm Poe S. Adverse Consequences of Tattoos and Body Piercing. Pediatric Annals. 2006.35(3)187-192.
(2)Mayers JB, Judelson DA, Moriarty BW, Rundell KW. Prevalence of body art(body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clinic Proc.2002.77:20-34.
(3)Koenig LM, Carnes M. Body piercing: Medical concerns with cutting-edge fashion. J Gen Intern Med. 1999. 14(6):379-385.
(4)Martinello RA, Cooney H. Cerebellar brain abscess associated with tongue piercing. Clin Infect Dis. 2003. 36:e32-e34.
(5 )Keogh TJ, O’Leary G. Serious complication of Tongue Piercing. J Laryngol Otol. 2001.115:233-234.
(6)Ehrlich A, Kucenic M, Beisito DV. Role of body piercing in the induction of metal allergies. Am J Contact Dermat. 2001.12:151-155.
(7)Grassia T. Treatment of skin issues requires knowing the patient’s needs. Infectious Diseases in Children. 2006.June:42.
(8)Thiem LJ. Body Piercing. Clinicians Review. 2005. 15(1):30-34.
(9)Dunn WJ, Reeves JE. Tongue Piercing case report and ethical overview. Gen Dent. 2004.52:244-247.
(10)Niamtu J 3rd. Eleven pearls for cosmetic earlobe repair. Dermatol Surg. 2002;28:180-185.

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

Pediatric Advice For Teenagers

Stuffy Nose

Dear Lisa,

My son is 1 month old and has a stuffy nose and seems congested. I brought him over to my mother’s house and he was breathing fine. Could it be that my house is too dry?

“Sunshine13”

Dear “Sunshine13”,

Nasal stuffiness in an infant is a very common problem. In most cases it is a benign condition not caused by infection or allergy. (1) The anatomy of the nose of an infant lends itself to becoming easily congested. The diameters of the nasal passages are so small that it only takes a small amount of mucus to cause a lot of upper airway congestion and noise. In addition the lining of the nasal passages are very sensitive and easily swell in the response to environmental conditions.

Newborn nasal congestion tends to become more pronounced during the winter months due to the heat in the environment. The heating system in most homes causes drying of the nasal passages in the newborn. (1) In order to combat this problem it is recommended to keep the heat set in the home below 72 degrees Fahrenheit. A thermostat temperature setting between 68 to 70 degrees Fahrenheit is sufficient as long as the infant is clothed in a warm outfit such as terrycloth pajamas.

It is also recommended to use a cool mist vaporizer in the infant’s bedroom. (1) The cool mist from the vaporizer shrinks the swelling of the nasal passages and helps the infant breathe easier. When using a cool mist vaporizer it is important to follow the company instructions regarding cleaning in order to prevent the build up of mold in the system. (1)

Avoidance of irritants in the home also helps prevent an infant’s nasal passages from becoming irritated and congested. Refraining from the use of candles, incense, ceiling fans, air fresheners, powder and perfume in the house will ensure the air in the home is clean and easier for the infant to breathe. Exposure to Cigarette smoke, especially in a closed winter home not only exacerbates a newborn’s nasal congestion but also has been linked to Sudden Infant Death. (1,2)

Since your infant had nasal congestion in your home that seemed to be relieved by a trip to your mother’s house it could mean that the environment in your house is contributing to the problem. If your thermostat setting is set above 72 degrees or if you have forced hot air heat, your house may be too hot and dry. You also should consider that simply taking your child out into the cool air during the visit may have cleared his nasal passages. Temporary exposure to cold air can shrink the swelling of a child’s airway. So the relief that your child experienced may have nothing to do with the environment in your mother’s house, but instead had to do with going outdoors.

There are other reasons for nasal congestion in a newborn besides environmental factors. An infant can develop nasal congestion because of an upper respiratory infection, Otitis Media (Middle Ear Infection) or Gastroesophageal reflux. (3,4) Sinusitis is a concern in older children, and is usually not found in infancy. An infant’s sinuses are not fully developed and therefore sinusitis is typically not a consideration.

In some cases, chronic or persistent nasal congestion in infancy can be due to an anatomic obstruction. One of the common causes of obstruction is enlarged adenoids. The adenoids are lymphoid tissue located superiorly in the midline of the posterior wall of the nasopharynx. The purpose of the adenoids is to trap infection from the upper respiratory tract. During early childhood, it is normal for the adenoids to enlarge when exposed to an infection. Sometimes this enlargement blocks drainage and leads to nasal symptoms and Otitis media. (5)

Choanal atresia is another potential cause for nasal obstruction in the newborn period. Each nasal cavity connects to the nasopharynx by posterior nasal openings called choanae. Choanal atresia is an obstruction of one or both of these openings due to an anatomic anomaly. An infant with bilateral Choanal atresia develops problems breathing at birth. This condition is readily identified when a newborn infant’s respiratory distress is alleviated by the opening of its mouth.

Unilateral or one sided Choanal atresia on the other hand, may be overlooked. Unilateral Choanal atresia is typically asymptomatic (without symptoms) until the child develops a respiratory tract infection. When an infant is well, he is able to compensate for this partial airway obstruction because the problem occurs only on one side. When an infant with Unilateral Choanal atresia develops a cold, their body can no longer compensate for the partial obstruction and as a result respiratory distress occurs. The symptoms of unilateral Choanal atresia are pronounced nasal obstruction and nasal discharge from the involved side.

In most cases, newborn congestion is normal and does not represent an underlying problem. If a newborn’s congestion interferes with the child’s eating, suckling or sleeping this warrants further investigation. These signs as well as nasal congestion associated with a cough or fever need to be evaluated by a Physician.

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

Newborn Congestion

Baby with Cold Symptoms

Nasal Congestion

Gastroesophageal Reflux

References:
(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. 1990:30-31.
(2)The United States Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. June 27, 2006. Available at:
www.surgeongeneral.gov/library/secondhandsmoke/. Accessed: Dec 2006.
(3) Kontiokari T, Koivunen P, Niemela M. Symptoms of Acute otitis media. Pediatric Infectious Disease J. 1998;17:676-679.
(4 )Strople J, Kaul A. Pediatric Gastroesophageal reflux disease-current perspectives. Curr Opin Otalaryngol Head Neck Surg. 203. 11:447-451.
(5)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1211-1214.

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

Pediatric Advice For Parents with Infants

Temperature Reading

Dear Lisa,

This time of year it seems our family and especially our kids come downwith colds and flu bugs along with fever frequently. My husband and I usually take their temperatures (Or Try) but so often they mouth breathe and cough, which cause slow readings. We just bought an ear thermometer and I hate it! We have three boys ages 6-14 and all of them seem unable most of the time for an oral reading, even with a digital type. Usually I do an underarm temp with my 10 and 14 yr. old, when they can't take it orally.

I have in the past taken their temps rectally when their Oral reading was low. Which they aren't thrilled about but do cooperate. My 6 yr old hasn't mastered the oral temp yet, and underarm temps with him are poor. My Question is when I can't take a good enough oral reading is rectal ok, if they agree and cooperate, or is underarm good enough? Thanks.

“Can’t get a temperature reading”

Dear “Can’t get a temperature reading”,

One of the most difficult things to do is get a temperature on a child, so I can understand your concern. Children do tend to move a lot and many of them have difficulty keeping a thermometer in their mouth. Children over three years of age are old enough to understand the importance of cooperating for a temperature reading. Fortunately an exact rectal temperature reading is not essential in order to make a diagnosis of an illness in older children. Older children can better describe their symptoms and show other signs, besides a temperature, showing that there is a problem. Therefore an exact rectal temperature reading is not necessary on an older child with a mild illness such as a cold or a virus. An oral or axillary temperature is sufficient in a child over three years old unless your doctor tells you differently.

The story is much different for children 3 years old and younger. Young children many times cannot describe their symptoms or localize their pain. Therefore an accurate temperature reading is many times necessary in order to diagnose a problem. An exact temperature reading is essential in young infants, because a temperature in this age group can represent a serious condition. In young infants, a temperature sometimes is their only symptom and may represent an infection such as a urinary tract infection, meningitis or bacteremia.

In my practice, it is very rare that I ever took or required a rectal temperature reading on a child over 3 years old. The common childhood illnesses that occur in this age group typically can be diagnosed with other information such as a history or physical examination. There are some circumstances where a developmentally delayed child or a child with a medical condition such as mental retardation, autism, cerebral palsy or severe ADHD needs a rectal temperature. In these scenarios it may be impossible to determine a temperature using any other route.

In addition, there are some children who have medical conditions that require an exact temperature reading because an increase in temperature could represent a complication. These conditions include HIV, cancer, neutropenia and sickle cell anemia. Even in these cases many times an oral or axillary temperature is a sufficient screening device.

When taking your child’s temperature it is important to let your doctor know what route you use. The expected reading is different for each route taken. A normal oral temperature is expected to be 98.6 degrees Fahrenheit ( 37 degrees Celcius). If a temperature is taken rectally, it is expected to be one degree higher; therefore a normal rectal temperature is 99.6 degrees Fahrenheit ( 37.5 degrees Celcius). If a temperature is taken using the axillary route, it is expected to be one degree lower than the oral route; therefore a normal axillary temperature is expected to be 97.6 degrees (36.5 degrees Celcius). (1)

So as a parent, when determining whether your child has a temperature or not, you need to add one degree Fahrenheit to your reading when doing an axillary temperature. You can then compare this number to the normal oral temperature, 98.6 degrees Fahrenheit. If you do an axillary temperature and the reading is 98 degrees Fahrenheit, then your child’s temperature is considered to be 99 degrees, which is considered a normal temperature.

The other important thing to know is that a child’s temperature normally changes throughout the course of the day. This change in temperature does not mean that there is a problem. During a normal day, a child’s temperature can vary 1 to 1.5 degrees Fahrenheit.

There are a few factors that may cause this change in a child’s temperature. A child’s temperature may vary depending upon the amount of clothes they are wearing or due to the temperature of the environment. Sometimes after exercising or eating the body temperature can elevate temporarily. The lowest reading usually occurs early in the morning before rising and the highest temperature occurs between 5 to 7 pm in the early evening. (1)

The temperature may also change depending upon the amount of time that a thermometer is in place and the type of thermometer used. Therefore many times the temperature is not correct because the thermometer was not in place for the appropriate amount of time. Rectal temperatures can also be incorrect due to improper technique because of a child’s movement. (1)

Since you have normal healthy children with no medical issues, there is no reason to continue to take rectal temperatures at their ages unless your doctor instructs you to use this route. A rectal temperature is invasive, uncomfortable and invades an older child’s privacy. Attempts to ascertain a temperature should be done via an oral or axillary route. Therefore, you do not have to be concerned about getting a rectal temperature on your children.

A child 6 years old should have the capability to hold a thermometer in their mouth or under their arm. Children without medical issues should be expected to keep their mouth closed or their arm still in order to take a temperature. It may help to use a timer or count while taking the temperature in order to keep a child focused and cooperative. You can also exercise the option of having their temperature taken by the nurse at your doctor’s office during the visit. In some cases, children are much more cooperative for other people, besides their mother.

If your children are having an issue with this, I suggest purchasing an electronic thermometer that reads in 10 seconds. Even children with a stuffy nose or a cough should be able to hold their mouth closed for 10 seconds. You can purchase this type of thermometer at your local pharmacy or CVS pharmacy for approximately $10.00. This investment will save you a lot of time and worry; and your children undue discomfort.


References:
(1)Bellack J, Bamford P. Nursing Assessment, A Multidimensional Approach. 1984. Belmont California:283-286.

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

Pediatric Advice For Parents

Psoriasis

Dear Lisa,

My 1-1/2 year old daughter and 3-1/2 year old son both have rashes on their legs. It looks like it could be eczema, but I have psoriasis and psoriasis runs in my husband's family. Could it be that my kids have it too?

“Mom in N.J.”

Dear “Mom in N.J.”,

As you already know, Psoriasis is a chronic inflammatory skin condition that is characterized by well-defined round or oval plaques. The rash is caused by a hyperproliferation and abnormal differentiation of keratinocytes with an inflammatory cell infiltration. In other words there is an overgrowth of the cells of the skin. This subsequently causes abnormal skin cell growth and is accompanied by inflammation.

In children Psoriatic lesions appear on the scalp, trunk, extremities and face. In some cases Psoriasis occurs in the diaper area and presents as a diaper rash unresponsive to traditional therapy.(1) The lesions found in Psoriasis consist of a plaque with a thick silvery scale.

When the scale is removed the capillary tips are exposed and the trauma of the removal causes pin point bleeding. This is called the Auspitz sign and is characteristic of all types of psoriasis. (2) As compared to adults, the plaques found in children tend to be smaller and have a finer scale. (3)

Psoriasis affects an estimated 2-3 percent of the world's population with nearly 1/3 of the cases presenting in childhood. (4,5) It is an inherited disorder with more than 2/3 of the children with Psoriasis having a positive family history of the disease.(1) If one parent has Psoriasis, a child has about a 10 percent chance of having Psoriasis. If both parents have Psoriasis, a child has approximately a 50 percent chance of developing the disease. (5)

Although there is a genetic basis for the disease, there are environmental factors that can trigger the clinical expression of symptoms. These triggers include injury, emotional stress, infection, cigarette smoking, and certain prescription medications.(5,6) The prescription medications that have been known to trigger Psoriasis include; Indomethacin, Lithium, Antimalarials, Inderal and Quinidine.(5)

Bacterial and Fungal skin infections can aggravate a child's Psoriasis. Lesions may also appear where the skin has been scratched or at the site of a surgical wound.

Another characteristic of Psoriasis is the Kobner phenomenon. The Kobner phenomenon is the development of psoriatic lesions in a linear fashion at a site of an external trigger.(7) An example of this occurs when a child wears a belt that is too tight. The trauma to the skin can result in psoriatic lesions in a straight line where the belt applied pressure.

Guttate Psoriasis is another childhood manifestation of Psoriasis. Guttate Psoriasis presents as a generalized eruption occurring all over the body, sparing the palms and soles. The eruptions appear drop like, consisting of 3 to 7 mm papules with a fine white scale over the surface.

The development of this type of rash classically follows a case of Strep Throat, but may also occur in association with an upper respiratory infection or viral flu.(2) Guttate Psoriasis is often the first presentation of Psoriasis in the adolescent and the beginning of the life long struggle with the disease.(2)

Eczema on the other hand is much different from Psoriasis. Eczema is a chronic relapsing inflammatory skin condition. Most cases of Eczema begin before one year of age with ninety percent of the cases occurring before a child is 5 years old. This is much different from Psoriasis which tends to develop during the second decade of life. Psoriasis commonly first appears between the ages of 15 and 25, although it is possible to occur at any age. (5)

The skin of a child who has Eczema is leathery, dry and excoriated. The distribution of rash is typically in the flexor surfaces of the elbow and knee. Itching is a very prominent feature of Eczema. Actually, itching must be present in order to make the diagnosis of Eczema. (8) Psoriasis may be itchy in some children but not necessarily in all affected by the disease.

Eczema also has a genetic component. Children with Eczema usually have a family member with a history of Hay fever or Asthma. (9) If both parents have Eczema, eighty percent of their children will also suffer from the disease. (9) It is necessary to know a child’s complete medical and family history before the cause of a rash can be determined.

Your children are at risk for developing Psoriasis because both you and members of their father’s family have Psoriasis. Although, because of their young age, Eczema is the more likely cause of the rash. Psoriasis tends to develop in older children while Eczema typically begins during the earlier years.

Basically, the diagnosis depends on the appearance of the rash and a complete physical examination. Skin lesions that have definite borders are suggestive of Psoriasis. A more diffuse rash with no well defined border is consistent with Eczema. In addition, other characteristics of the rash need to be determined such as the distribution of the rash on the body and whether or not the rash is itchy.

It is important to know that Psoriasis and Eczema are not the only skin conditions that present with scaly patches or plaques. Scaly patches and plaques can be found in many pediatric skin disorders. Pityriasis rosea, fungal skin infections such as Ringworm, lichen planus, Syphillus, Lupus and Dermatomyositis are some examples of pediatric skin conditions that can present with scaling or patches.(5) The best way to determine the cause of your children’s rash is to have them examined by their Physician.

For more information about topics covered in this article you can read the following Pediatric Advice Stories:

Eczema

Ringworm

Diaper Rash

For more information about Psoriasis contact:

The National Psoriasis Foundation

References:
(1)Morris A, Rogers M, Fischer G, Williams K. Childhood psoriasis: a clinical review of 1262 cases. Pediatr Dermatol. 2001;18(3):188-198.
(2)Barber K. Psoriasis. Consultant for Pediatricians. 2006. May:285-288.
(3)Greco M, Chamlin S. An 18-month-old Girl with Chronic Diaper Dermatitis. Pediatric Annals. 2006. 35(2):79-84.
(4)Langley R, Krueger G, Griffiths C. Psoriasis: epidemiology, clinical features and quality of life. Ann Rheum Dis. 2005;6(Suppl 2):ii18-ii23.
(5)National Psoriasis Foundation. About Psoriasis. Available at: http://www.psoriasis.org/about/stats/. Accessed Dec 2006.
(6)Hunter JAA, Savin JA, Dahl MV. Psoriasis. Clinical Dermatology. 3rd ed. Malden, Mass:Blackwell Science. 2002:48-55.
(7)Kamat D. Psoriasis. Consultant for Pediatricians. 2006. February:113.
(8)Beers MH, Berkow R, Scaling popular diseases: The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station,NJ: Merck Research Laboratories. 1999:816-820.
(9)Rosenthal M. Pediatricians treating more patients with atopic dermatitis. Infectious Disease in Children. 2006. April:56.


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

Pediatric Advice for Toddlers

Mole

Dear Lisa,

I have a 2 year old who seems healthy but has recently been itching his outer thigh area in about a quarter sized patch. Initially I thought it was just dry skin however as I looked more closely there is a patch of hair growing there. It is fine and fair colored but it is only in the one spot...no where else. As I feel it I can feel a little bump under the skin. It feels the way it does after he has had immunizations but he hasn't had shots for almost a year. I would appreciate any insight you have. I feel very worried. He has no other symptoms. Thank you.

“I feel worried”

Dear “I feel worried”,

Without physically examining your child, it is impossible to tell you exactly what this skin patch is. Through my years of practice, I have had many parents telephone me describing a rash or skin condition. When the child came into the office for an exam, in most cases the findings were totally different from what I expected.

Rashes are very difficult to describe, the appearance varies depending upon the type of skin and any medications that may have been used. Therefore, the best way to diagnose a skin condition is to have an examination by a Physician. A Dermatologist, the type of doctor that specializes in skin conditions, will be able to tell you what your son’s patch is.

Having said that, I can tell you that the description you gave sounds like a mole. A Nevus or mole is a growth on the skin that children develop. Some parents are under the impression that the only way a child gets a mole is to be born with it. Yes, it is true that some infants are born with moles, but many children develop moles as they grow older. It is very common for parents of young children to report the sudden appearance of a new mole. Many times it seems that they grow overnight!

The typical brown flat appearing moles that most people are familiar with are called Congenital Melanocytic Nevi. A congenital Melanocytic Nevus is black or brown in color and flat or nodular in appearance. When a mole first develops, it can start out as a lighter tan color and darken or enlarge over time. Congenital Melanocytic Nevi happen to be present in 1% to 2% of all newborns. (1) This type of mole is benign in nature and the chance of melanoma is quite rare. (1)

The greatest concern that parents have about moles is the chance that they may become cancerous. This is a legitimate concern because some moles do have a risk of becoming malignant. A Nevus spilus is an example of a type of pediatric mole that can turn cancerous. This well demarcated lesion has an unevenly pigmented background with multiple 2 to 4 mm brown specks dispersed throughout the lesion. This type of mole is found in 2 out of every 1000 newborns. This type of lesion needs to be followed closely by a health care professional because of the possibility that it can lead to Melanoma. (2)

Another common type of mole found in the pediatric population is the Café au Lait spot. They are recognized in normal infants as “birth marks”. Café au Lait spots are exactly what they sound like; flat, light tan moles that look like coffee was splashed on the child’s skin.

It is normal for a child to have less than 5 Café au Lait spots on their body, with three being the average amount found. Children with Café au Lait spots need to be monitored by their Physician for the development of new lesions. The appearance of more than 5 Café au Lait spots is associated with fibromas, neurofibromatosis or Recklinghausen disease. (3,4) The presence of multiple Café au Lait spots can also represent other disorders. Children with more than 5 Café au Lait spots need to be followed by a Neurologist. (3,4)

Neurofibromatosis is a neurocutaneous disorder that occurs in 1 out of every 3000 births.(3)Children with neurofibromatosis have Café au Lait spots that are frequently present at birth and increase in size, number and pigmentation with age.(3) Other findings include neurofibromas, freckling in the axilla or groin area, learning disabilities, bone lesions and eye lesions. Although Neurofibromatosis is inherited, 50% of the cases that develop are attributed to a new mutation and can be found in a child with no family history of the disorder. (5)

You did mention that your child has been itching his new patch. He may be itching the area because it feels different. On the other hand, there is a particular type of mole that presents with itchiness, blushing and in some cases blistering. This type of mole is called a Mastocytoma.

A Mastocytoma is a 1 to 5 cm nodule that later turns into a rubbery pink, yellow or tan plaque. They often present on the trunk, but also may occur on the palm, sole, eyelid or vulva. Many times these types of moles resolve before adulthood, with more than half of the cases spontaneously disappearing by the age of 10.(6)

A child that develops a new mole should be evaluated by their Physician. Moles in children should be diagnosed, mapped out, measured, recorded in the medical record and followed on a regular basis by a health care professional. In some cases a consultation with a Dermatologist or a skin biopsy is necessary in order to identify the type of mole.

You did not mention if there is a family history of any skin conditions, if your child has any other health problems, skin conditions, moles or if he was using any medication. All of this information is very important to know when determining the cause of a pediatric skin condition. Along with a physical examination, a complete history needs to be obtained in order to make an accurate diagnosis.

It would be essential to know if any topical medications have been applied to the area or to other parts of the body. This is a concern if your child had used immunomodulators such as pimecrolimus and tacrolimus (Elidel, Protopic). These medications may be prescribed for children with eczema.
The FDA committee urged a black box warning on these products after questions arose about their safety in some patients. (7)

There were some children who developed skin cancer during or shortly after using this medication. In some cases the skin cancer developed at the site of application. In addition, laboratory studies showed an increased rate of skin cancer in animals when tacrolimus application is followed by sun exposure.(8)

If your child has used these medications in the past, it would be very important to show your child’s rash to his physician without delay.

References:
(1)Eichenfield L, Larralde M. Congenital melanocytic nevi. Pediatric Dermatology. Edinburgh: Mosby;2003:216-217.
(2)Dermclinic. Consultant for Pediatricians. 2006. Feb:74-75.
(3)Leung A, Lane W, Robson M. A Young Girl with Café’au Lait Spots. Consultant for Pediatricians. 2006. April:229-232.
(4)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:266.
(5)Young H, Hyman S, North K. Neurofibromatosis 1: Clinical review and exceptions to the rules. J Child Neurol. 2002. 17:613-621.
(6)Ganz J, Kim F. Infant with an “Atypical Mole”. Consultant for Pediatricians. 2006. August:511-512.
(7)Rosenthal M. Pediatricians treating more patients with atopic dermatitis. Infectious Diseases in Children. 2006. April:511-512.
(8)Connelly E, Eichenfield L. Treatment Pearls for Managing Atopic Dermatitis. Pediatric Skin Care. 2004. Spring:16-18.

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

Pediatric Advice For Parents

Head Injury

Dear Lisa,

My five year old daughter some how fell off a dining room chair and hit the bone directly above her eye. She immediately had a goose bump and bruising above her eye around to her eyelid. I immediately applied ice for about an hour and the swelling went down slightly. She showed no signs of being "out of it". She was suddenly tired. I managed to keep her awake for four hours.

Should I be concerned and call her pediatrician?

“Mother of accident prone child”,

Dear “Mother of accident prone child”,

Head trauma is a very common pediatric injury. Children are more likely to sustain injuries to their head as compared to adults for a few reasons. (1) First of all, the size and weight of a child’s head in much larger in comparison to the size of the rest of their body. The head is actually the center of gravity of a child’s body. This is why when a child has a fall; their head usually hits the ground first. In addition, a child’s level of coordination and reflexive responses are not fully developed. They do not have the ability to break their falls by putting their hands in front of them the way that adults do.

Head injuries are one of the most common causes of death and disability in the pediatric population. (2) The types of injuries that children experience as the result of a head trauma can range from something as minor as a simple scalp laceration to something as serious as a brain hematoma. Other injuries due to trauma to the head include; skull fracture, internal bleeding, Contusions and Lacerations of the brain. Problems can develop due to the fall itself or can be due to the pathological processes (such as swelling of the brain or lack of oxygen to the brain) due to the injury.

Deciphering the seriousness of a fall can be quite difficult when dealing with children. The symptoms of an intra-cranial injury due to head trauma vary greatly from one child to the next. An injury to the brain can occur without external evidence of injury or trauma. In some cases the symptoms are not displayed right away, but instead the symptoms can progress slowly or may occur hours later.

Infants and young children in particular can have this delayed presentation of symptoms. The deterioration of consciousness can occur hours after the incident, many times after what seemed to be a minor event. (3) This delayed presentation can represent a concussion, brain swelling, or intra-cranial hemorrhage. Therefore a parent can never be too careful when it comes to seeking medical attention when a child experiences a head injury. Children with head trauma should be monitored closely over a period of hours. In many cases, repeat examinations by a health care professional are needed.

Skull and brain injuries are much easier to diagnose when a child presents with obvious symptoms. These obvious symptoms include loss of consciousness, seizure activity or apnea. (4) On the other hand, younger children with milder, non-specific signs may go unnoticed. These non-specific symptoms include irritability, recurrent vomiting, fever and loss of appetite. (4) Since any young child can experience these non-specific symptoms on any given day for a variety of reasons, an examination by a health care professional is necessary in order to determine the cause of the symptoms.

Skull fractures are one of the types of injuries that can occur due to head trauma. A skull fracture may occur at the site of impact or in other areas of the skull with less strength. Some skull fractures are associated with Cerebral Spinal Fluid leaks or cranial nerve injuries. (2) Therefore any question of a skull fracture should be evaluated in an Emergency Room setting.

The Battle sign and “raccoon eyes” are two findings associated with a basilar skull fracture, one of the most serious types of skull fractures.(2) The Battle sign is the presence of bruising (a black and blue) behind the ear. The term “Raccoon eyes” refers to bruising and swelling around the eyes. Both of these signs after a head trauma are worrisome signs that need to be evaluated by a Physician without delay.

A concussion is a clinical syndrome causing immediate and transient impairment of consciousness following a head injury. Children who develop a concussion may experience visual disturbances, loss of memory, loss of appetite, pallor, vomiting, sleepiness, confusion, abnormal behavior, unsteady gait or coma. The duration of symptoms may vary from days to weeks and range in severity from mild to severe. In some cases a delayed presentation may occur, therefore a child with a head injury needs to be monitored for a concussion for hours after the actual injury.

Cerebral Contusions, Lacerations, and Hemorrhage are very serious complications that can result in significant morbidity and in some cases mortality or death.

A child who develops irritability, ataxia (unsteady gait), vomiting, loss of appetite or change in mental status after an injury to the head should be examined by a health care professional. Since your daughter became suddenly tired you need to contact her Pediatrician. Besides the concern for a concussion, an injury to the orbit(bone around the eye) or the eye itself also needs to be ruled out. The orbit can fracture in children who land on their face or in children that have a ball or object thrown at their eye.

It is important to know that not every child who becomes tired or irritable after a fall has a serious brain injury. In some cases a child becomes irritable because of pain due to a fall. Children can become tired after a fall because it is their usual bedtime or time to nap. They also may have become exhausted from all of the excitement and activity after the injury.

In regards to vomiting, one or two episodes of vomiting within the first couple of hours of trauma is often associated with mild head injury. (3) On the other hand, persistent vomiting or vomiting in association with somnolence can represent a more serious situation that needs to be evaluated without delay.

It is best to let the Physician determine the cause a child’s symptoms rather then guess and wait for the symptoms to worsen. Waiting can worsen the situation and result in secondary injury to the brain. In addition, it is important that you inform your Physician about falls resulting in injury to your child's head, even if they seem minor.


References:
(1)Bautista S, Flynn J. Trauma Prevention in Children. Pediatric Annals. 2006. 35(2):85-90.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1801-1803.
(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. 1990:621.
(4)Hymel K, Hall C. Diagnosing Pediatric Head Trauma. Pediatric Annals. 2005. 34(5):358-370.


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

Pediatric Advice About Childhood Safety

Calcium Requirement

Dear Lisa,

What vitamin and calcium doses are appropriate for a 14 month old baby? Baby absolutely refuses to drink milk in any form. Used to be breastfed.

“Baby Needs Calcium”

“Baby Needs Calcium”,

It is very common for an infant once weaned from the breast to refuse whole milk. In some cases, this refusal is temporary and a parent just needs to be patient and wait for their child to come around. In the mean time it is very important that a child receives the correct amount of calcium and Vitamin D to ensure proper bone growth.

A child from 1 to 3 years old needs 500mg of calcium per day which can be found in two cups of whole milk. If your child refuses to drink milk then other foods containing calcium need to be given. The good thing is that many products have been reformulated to contain extra calcium and can be found in the supermarket. Choosing products with extra calcium will ensure that your child receives the correct amount of calcium per day.

The types of calcium fortified foods that a 14 month old may eat include; yogurt, slices of American cheese, cheddar cheese (1 oz = 213 mg calcium), a grilled cheese sandwich, cottage cheese(½ cup = 115mg calcium), ricotta cheese mixed in pasta, sherbet, pudding, broccoli (½ cup = 68 mg calcium), and boxed fortified cereal with milk. Toddlers also tend to like juice and can receive the calcium that is required by drinking orange juice or other juices with added calcium.

Feeding toddlers is a very difficult task. Besides being very messy eaters they tend to be very picky too. One day they may eat a lot and then they can go through the next couple of days only picking at a small amount of food. The most important thing to remember is, if a toddler refuses a new food, do not give up. It is common for toddlers to refuse a new food many times before they actually eat it. There is a greater chance that a child will accept a certain food if they are exposed to it multiple times.(1) Therefore if a child repeatedly refuses a food, try it again at a latter date.

Milk contains the most amount of calcium per serving; 288 mg per cup. Therefore it may be easier to achieve your goal by adding milk to the food that your child already eats. By adding a little milk to your child’s diet throughout the day, your child should not notice the difference and will not have the opportunity to refuse it. This is also a good approach because calcium is best absorbed if spread out evenly during the day as opposed giving the recommended amount all at once.(2)

Milk can be added to oatmeal, farina, pastina, mashed potatoes, scrambled eggs and pasta. When feeding a toddler a hot meal, it is also a good idea to splash milk into the dish of warm food. This doesn’t only cool the meal down, but adds some calcium and Vitamin D to their diet.

Besides calcium, Vitamin D is needed for proper bone growth and maintenance. The correct amount of Vitamin D is needed in order for calcium to be absorbed. Vitamin D is essential for the transport of the calcium obtained from food across the lining of the intestines to the parts of the body where it is needed. Therefore, it is important to choose foods for your child that contain calcium and Vitamin D.(2) Vitamin D can be found in egg yolks, fish liver oils and milk.

Exposure to sunlight for at least 15 minutes per day is also necessary for the proper absorption of Calcium and Vitamin D. Sunlight converts Vitamin D in the body into a form that can be absorbed. Children who do not get enough sun exposure are at a risk for developing Vitamin D deficiency and rickets.(3) Vitamin D deficiency is prominent world wide and is more prominent in girls of low socioeconomic status and those whose cultural norms require them to wear veils.(4) Other risk factors for Vitamin D deficiency include exclusively breastfed infants(vitamin D is deficient in human milk), dark skin pigmentation, sunscreen use and atmospheric conditions. (1)

Most Doctors and Nurse Practitioners agree that the vitamin, Poly-vi-sol contains the proper amount of vitamins that a child requires. This vitamin comes in a liquid form for young infants and toddlers and in a chewable form for older children. Poly-vi-flor contains the same vitamins as Poly-vi-sol except it also contains Fluoride. Children who do not have Fluoride in their drinking water need vitamins with Fluoride.

Sometimes, the best way a parent can convince their child to eat healthy foods is to eat healthy foods themselves. It has been found that food preferences are influenced early by parental eating habits, and tend to remain fairly constant into adulthood.(5) So, what better way to encourage your child to drink milk then to sit in from of her and drink a tall glass of milk with a great big smile on your face.

For More Information about calcium needs and childhood nutritional requirements log onto:

American Dietetic Association

References:
(1)Grassia T. Pediatricians: Discuss healthy nutrition during well child checks. Infectious Diseases in Children. 2006. August:45.
(2)American Dietetic Association. Calcium and Vitamin D: Essential elements for Bone Health. Available at: http://www.eatright.org Accessed Dec 2006.
(3)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:132.
(4)El-Haji Fuleihan G, Nabulsi M, Tamim H. Effect of vitamin D replacement on musculoskeletal parameters in school children: a randomized controlled trial. J Clin Endocrinol Metab. 2006;91:405-412.
(5)Strauss R. Childhood obesity. Curr Problems Pediatr. 1999;29(1)1-29.

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

Pediatric Advice For Parents with Toddlers

Nasal Congestion

Dear Lisa,

My 4 year old daughter breaks out in pimples after a cold. Why is this? She seems to have very stuffed sinuses long after the rest of her cold symptoms disappear and has a very stuffy sound to her voice and even some drooling, as if it's hard to talk with her nose so clogged. However, blowing her nose gets no results, like it's all in her head. I know the stuffiness must be harboring some bacteria that spreads to her face and causes the breakouts. How can I help her with this and why does it happen?

“My Kids”

Dear “My Kids”,

The inside of a person’s nasal passages contain many microorganisms. This nasal colonization does not cause any harm to the person and is considered normal. These germs can spread to other people or to other parts of the person’s body. In some cases, these microorganisms in the nose can be transported to the person’s skin. Children who touch or pick their nose and then scratch or pick at their skin can spread the germs from their nose to their skin and cause an infection. Recurrent skin infections, pimples and boils are thought to be spread in this manner.

Your daughter’s pimples probably occur after a cold because during a cold her nasal secretions are more abundant and there is a greater chance that the secretions can spread to other parts of her face and body. The best way to prevent this from happening is frequent hand washing, face washing and encouraging your daughter not to pick or touch her nose.

I have taken care of many children who experienced this problem and the Dermatologists that I referred them to recommended applying an antibiotic ointment such as Neosporin or Nasal Bactroban around the nose and inside the rim of the nostrils to prevent this from occurring. Although I have seen younger children prescribed this medication, according to the PDR, Nasal Bactroban is recommended for children 12 years old and older. You can discuss measures that you can take to alleviate your daughter’s symptoms with her Physician.

It is important to note that pimples around the nose and mouth can be found in children with Streptococcal Pharyngitis (Step Throat). Therefore, if you notice that your daughter has pimples around her mouth and nose when she has symptoms of throat pain, difficulty swallowing, decreased appetite and fever, an evaluation for Step Throat should be performed.

In regards to your daughter’s nasal congestion, there are many potential causes. It is normal for a child to have a stuffy nose for approximately 10 days with each new cold or virus. It is also expected that a child will develop approximately 6 to 10 viruses per year. Children that attend daycare tend to develop more colds and respiratory illness than children not attending daycare.

In some cases a child’s nose may seem to chronically congested, but instead the child is actually developing recurrent respiratory infections. This is particularly prevalent during the winter months, when most colds and viruses occur. Since there is a short time between colds during the winter months a child’s nasal symptoms may be mistaken to be a chronic problem.

On the other hand, children with chronic nasal complaints, with no relief from their symptoms may be experiencing another condition. Chronic nasal congestion can be due to a variety of conditions. Sinusitis, Allergies, Adenoid hypertrophy (enlarged adenoids) and Gastroesophageal Reflux are all potential causes of chronic nasal congestion.

The National Institute of Allergy and Immunology estimates that 37 million Americans are affected by Sinusitis each year. (1) Sinusitis is defined as the inflammation of the lining of the sinuses due to an infection. The symptoms of Sinusitis include fatigue, cough, a low-grade fever, sinus headache, toothache, facial pain, colored nasal discharge, foul-tasting post-nasal drip, worsening cold symptoms or cold symptoms that last more than 7 days. (2)

Sinusitis occurs when mucus from the sinuses cannot drain normally to the back of the nose and throat. Usually this occurs when there is an obstruction such as thickening of the lining of the sinuses, a polyp or enlarged air cells within the inner folds of the nose. Allergies are a common cause of this thickening of the lining of the sinuses. Sinusitis is more likely to develop in patients with allergies.(3) Therefore a child with allergies who has worsening of her symptoms should be evaluated for Sinusitis.

If a child has Sinusitis and is not treated, Chronic Sinusitis can develop. Chronic Sinusitis is defined as a Sinus infection that lasts more than 30 days. The symptoms of Chronic Sinusitis may be more subtle. Symptoms of Chronic Sinusitis in children include nasal discharge, postnasal drip, nasal obstruction, cough, behavior changes and acting out.(3) Adults on the other hand may complain of chronic fatigue and general malaise at work. A study by Benninger found that 54% of patients diagnosed with Chronic Sinusitis also had Allergic rhinitis.(4)

Allergies or Hay fever can also cause nasal congestion. Allergy symptoms include allergic shiners, watery eyes, sneezing, an allergic crease (on the nose), sneezing, the allergic salute (upward wiping of the nose with the child’s hand) and itchy eyes. A child with allergies should not have a fever. Allergies can be described more as an annoyance than an acute illness. The difference between Allergies and a cold or Sinusitis is that allergy symptoms intensify after exposure to the offending item.

Tonsillar and Adenoid hypertrophy (enlarged tonsils and adenoids) are other conditions that can result in nasal symptoms. Enlarged tonsils and adenoids prevent the proper drainage of nasal secretions which can lead to infections. Signs of Tonsillar and Adenoid Hypertrophy include mouth breathing, difficulty swallowing food, snoring and failure to thrive.(5)

Gastroesophageal reflux (GER) does not only cause heartburn, but can also cause symptoms outside of the esophagus (food tube). These symptoms include chronic cough, Sinusitis, nasal congestion, sore throat, hoarseness, pharyngitis (throat infection), Otitis media (Middle ear infection), wheezing and Asthma. (6) The acidic gastric contents refluxed beyond the esophagus causes damage that leads to these problems. In addition, GER indirectly affects the common neural pathways between the lower esophagus and the respiratory tract that lead to respiratory symptoms.

Children with GER develop Sinus infections and ear infections more often than children without GER. If a child has chronic nasal congestion that cannot be attributed to another cause, GER should be ruled out.

I hope this information helps.

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

Hay Fever

Snoring

References:
(1)Mackey T. The best therapies for bacterial rhino sinusitis. The Clinical Advisor. 2006 July:59-64.
(2)Smart B. What you Need to Know about Sinusitis. Asthma Magazine. 2002. Sept/Oct:38.
(3)Huang S. Nasal Allergy and Sinus Infection. Consultant for Pediatricians. 2006.June:345-352.
(4)Benninger M. Rhinitis, Sinusitis, and their relationship to allergies. Am J Rhinol. 1992.6:37-43.
(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. 1990:855.
(6)Christensen M, Gold B. Clinical Management of Infants and Children with Gastroesophageal Reflux Disease: Disease Recognition and Therapeutic options. Presented at: ASHP Midyear Clinical Meeting;Dec 9, 2002:Atlanta.

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

Pediatric Advice For Parents

Infant Back Arching

Dear Lisa,

Infant born at 25.5 weeks (weight 2 lbs 1 oz). Now 7 months of age. Recently began arching back, holding head back and stiffening arms. Has a shunt, has had hernia repairs, has had surgery on muscle between stomach and esophagus (can't burp or spit up), has feeding button (now eats most formula from bottle). Acid reflux? Food Allergies? Other suggestions????

“Concerned Family”

Dear “Concerned Family”,

It sounds like you and your baby have been through a lot over the last 7 months. Certainly back arching can be a sign of Gastroesophageal reflux disease(GERD). Infants with Sandifer syndrome demonstrate these symptoms. Sandifer syndrome is a condition that is found in some infants with GERD. The symptoms include spasms of the head, neck as well as back arching in response to refluxed abdominal contents. (1,2) An infant with this condition arches her back and turns her head to the side in order to lengthen the esophagus, increase lower esophageal sphincter pressure and avoid aspiration. (1,3)

Infants who had anti-reflux surgery such as the one you described should not have symptoms of reflux. The purpose of this type of surgery, also known as Fundoplication, is to treat GERD symptoms. Of the several different Fundoplication techniques, the Nissen Fundoplication, is the one most commonly performed.(4) During this type of surgery the fundus or the top part of the stomach is wrapped 360 degrees around the base of the esophagus or food tube. After a child eats, the stomach distends and the increased pressure around the wrap should prevent reflux.(5)

The outcome of anti-reflux surgery is usually favorable, but the duration of efficacy or the length of time that the results last is limited. The need for repeat surgery is common. (6) There have been some reports of high rates of failure associated with this surgery. (7) In children who have had Fundoplication surgery, 3- 18.9% of them need re-operation. (8)

An evaluation by your Gastroenterologist and Surgeon that performed you child’s surgery will be able to tell you if the procedure is effectively controlling her GERD symptoms. Testing, such as 24 hour intraesophageal pH monitoring may need to be performed in order to determine if your daughter’s present symptoms are due to GER. A pH probe determines the percentage of total time that the esophagus is exposed to a pH lower than 4. This is the most valid measure of gastric acid reflux and is considered the gold standard in the diagnosis of GER.(9)

Reflux is not the only condition that can cause a child to have head and neck spasms and back arching. GERD symptoms and seizure activity are very similar in their presentation and one of these conditions can easily be mistaken for the other. (10) Seizure activity can present in many different ways. A partial focal seizure can present with unusual body movements. Simple partial seizures can present as something as discrete as hand twitching. (11) An absence seizure presents as a staring spell in which a child gazes into space and can be mistaken for daydreaming.

The symptoms of these types of seizures are much different from what most people consider to be a seizure. Most people are familiar with myoclonic generalized seizures which involve the rapid jerking of the whole body and its extremities. Something as subtle as back arching, abnormal positioning of the head and stiffening of the extremities could be signs of seizure activity in an infant and should be further investigated.

Other potential causes for this type of infant activity include cardiac events or dystonia. (11) A dystonia is a movement disorder with many causes. It presents as a sustained muscle contraction that may cause twisting or repetitive movements. (11) Dystonia can be caused by a side effect to a medication. Certain medications such as Phenothiazines and Metoclopramide (an anti-emetic drug) can cause dystonia. (1) Phenothiazine derivatives can be found in some cough medications.

Your daughter’s symptoms need to be evaluated by a Health Care Professional in order to determine the cause. You can take a video recording of the event so that your Pediatrician can visualize the symptoms that you are describing. A symptom diary should be kept noting the time, duration, relation to activity and eating, eliciting factors and surrounding environment. This information can aid your daughter’s Physician in determining the cause of her symptoms.

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

Gastroesophageal Reflux

I wish you and your daughter well.

References:
(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. 1990:353,344.
(2)Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapeutic Spotlight. 2005. August:4-13.
(3)Gorrotxategi P, Reguilon MJ, Arana J. Gastroesophageal reflux in association with the Sandifer syndrome. Eur J Pediatr Surg.1995.5:203-205.
(4)Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Children. Pediatric Annals. 2006.35(4):259-266.
(5)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:393.
(6)Waring JP, Fieler MJ, Hunter JG. Childhood Gastroesophageal reflux symptoms in adult patients. J Pediatr Gastroenterol Nutr. 2002.; 35:334-338.
(7)Hassall E. Wrap session: is the Nissen slipping? Can medical treatment replace surgery for severe Gastroesophageal reflux disease in children? Am J Gastroenterol 1995;90
(8):1212-1220. (8) North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of Gastroesophageal reflux in infants and children. J Pediatr Gastroenterol Nutr. 2001.32(suppl 2).
(9)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(Supple 2):S1-31.
(10) Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis, Missouri: Mosby –Yearbook, Inc. 1992:278.
(11) Wolf S, Engel McGoldrick P. Recognition and Management of Pediatric Seizures. Pediatric Annals. 2006. 35(5):332-344.

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

Pediatric Advice Website

Umbilical Hernia

Dear Lisa,

My two year old son has had a herniated belly button since birth. Although it not much bigger than anyone who has an "outie" belly button, it still does not look entirely normal and if you apply just a little bit of pressure, you hear a gurgling sound. The dr does not seem concerned about this in the least and has always said that he would probably outgrow it. Should I be concerned though or getting a second opinion?

“Second Opinion”

Dear “Second Opinion”,

An Umbilical Hernia occurs when there is incomplete closure of the umbilical ring within the abdominal cavity. (1) During fetal development, the intestines return to the abdominal cavity around the 11th week of fetal life. An Umbilical Hernia develops when the umbilical ring fails to close completely and the intestines slide in and out of the defect. This sliding of the intestines in and out of the opening results in a bulging of the belly button area. (1)

When a child has an umbilical hernia, it is normal for the belly button to make a gurgling or deflating sound when gentle pressure is applied to the area. The hernia can become more noticeable when there is increased intra-abdominal pressure as in the case of a child who cries a lot, strains to have a bowel movement, coughs or is constipated.(2) When these situations occur it is common to see the belly button protrude to the point that it sticks out of the top of the diaper.

Umbilical hernias are pretty much a benign condition where 90% of the cases resolve on their own without treatment. (1) In most cases the Umbilical Hernia goes away by the time a child is 2 years old. In African American children the umbilical hernia tends not to resolve until an older age, sometimes up until the age of 7. (2) If a child’s Umbilical Hernia is still present by 5 years old it is a good idea to see a Pediatric Surgeon for an evaluation. (1)

In the past it was a common practice for parents to bind the abdomen or tape a quarter over the belly button in the attempt to cause the Umbilical Hernia to heal. This is not recommended because it has never been documented that these remedies aid in the closure of the defect. (1) In addition, the application of tape and binders cause irritation and may lead to infection. (1)

It sounds like the Umbilical Hernia that your son has is small and barely noticeable. It probably is resolving on its own. I have taken care of plenty of children with an Umbilical Hernia and in the majority of the cases the Umbilical Hernia resolved on its own. On a few occasions I did need to refer a child to a surgeon, but these children also had a Supra-Umbilical Hernia or Ventral Hernia as well as an Umbilical Hernia.

A supra-umbilical hernia is a weakness in the abdominal wall above the belly button. A ventral hernia is a weakness in the abdominal wall.

So to answer your question, it doesn’t seem that a second opinion is necessary.

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

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

Pediatric Advice Website

Stooling in Pants

Dear Lisa,

We can not get our 4 1/2 yr old grandson to go to potty for any bowel movements. He will hide in a corner and go in his pants. He will get on his bed and go in his pants. He does not care where you are at when he goes in his pants. You can punish him and it is like he does not care. I will tell him how embarrassing it is and that does not bother him either. Can you please help and tell us what to do or try next? I have run out of ideas or suggestions from others. His sister is very embarrassed about the situation.

“Need help in Virginia”

Dear “Need Help In Virginia”,

In order for a child to be ready to potty train, there are a few developmental milestones that need to be reached. First a child needs the fine and gross motor skills to pull down their pants and sit on a potty. They also need the physical strength and coordination to remain on the potty and the abdominal strength to push a bowel movement out.(1) Secondly, a child requires the intellectual ability and attention span needed to be able to sense the need to go to the bathroom and understand what will happen if they don’t go on the potty. (1,2) A child also needs to reach the level of speech development that is required to communicate to adults that they need to go. (2)

Besides being physically and developmentally ready, children need to be psychologically ready to use the potty or toilet. Children need to be able to adjust to change, they need the desire to want to please their parent or caregiver, they need the desire to conform to what is expected and they need to overcome any fears that they may have related to toileting. (2)

I can understand your concern because your grandson is 4 ½ years old and still not potty trained. From your description it sounds like he does not have a desire to go in the potty and just goes to the bathroom when and where he wants to. This must be frustrating for you and his whole family.

The normal age for potty training ranges from 2 to 4 years old. It can take 6 months to train a child to go to the bathroom in the potty. (1) If a child is over 4 years and cannot achieve this goal in six moths, an evaluation and treatment by a health care professional is needed.

The first step in approaching this problem is to have your grandson evaluated by his Pediatrician. This evaluation should include a complete history and physical examination in order to rule out any physical causes for your grandson’s inability to potty train. There are some childhood health conditions, such as a tethered spinal cord that prevents a child from feeling the sensation to go. As as a result, a child with this problem has difficulty controlling his bowel movements. Other conditions such as a developmental disorder, Autism or Attention Deficit Disorder may also interfere with the process of potty training. (1) Children with medical conditions such as Cerebral palsy or Autism can benefit from the expertise of specialists. An Occupational Therapist or a Preschool Handicap Program may be needed to assist children with these conditions.

Once all physical causes for the inability to potty train are ruled out; family dynamics and psychological problems should be addressed. Control issues may be the source of the inability to potty train in some circumstances. (1) Control issues may develop in a child who is seeking attention because of a change in family dynamics such divorce, sibling rivalry or a new baby entering the home. (1) A child can use their refusal to potty train as a source of getting attention.

For families in this situation, special alone time with the child can help. Scheduled time alone with the child, reading a book, going for a walk or playing a game can offer positive ways for a child to get the attention that he is seeking. It is important to be consistent and schedule alone time on a daily basis. When scheduling alone time, limit setting may be necessary for children who struggle with this issue. An effective way to set limits is to use an egg timer. (1)

In some cases, difficulty potty training can be complicated by constipation, stool withholding or painful stools. (1) It is important to first establish a successful stooling pattern, before attempting to potty train. Dietary modifications or use of laxatives may be necessary in order to maintain a soft regular stool pattern that facilitates training. If this is an issue with your grandson it would be important to discuss this with his Pediatrician.

You did mention that punishing your grandson did not make a difference. Punishing a child for soiling his pants is not recommended. (1,2) Accidents are best approached in a matter of fact manner. This may be very difficult to do, especially in a case where a child takes such a long time to potty train and does not seem to listen. Praising your grandson for good behavior, such as sitting on the potty, telling you that he needs to go, being cooperative with changing can help boost his confidence level and give him the tools that he needs to know that he is capable.

For children who refuse to comply at all, room restriction may be an option. This approach is successful in children with established stool patterns including a soft bowel movement around the same time each day. First, the caregiver tells the child that he is expected to use the potty. Thirty minutes before the expected time of the bowel movement the child should be confined to one room with toys, but no television. The child must stay there until he poops in the potty. (1) Caregivers are encouraged to come and go in and out of the room.

Once the child uses the potty then he is free for the rest of the day. If the child has an accident, the caregiver should not punish the child or reprimand the child, but instead just clean up the mess in a matter of fact way. This approach takes two days on average before a child starts using the potty. (1)

Many of the preschoolers that I took care of refused to use the potty because they were dependent upon or attached to a Pull up or diaper. If this is the case you can open the diaper, stretch it out and place it inside the potty by clicking it under the removable rim. Your child can then sit on the potty and see the diaper inside. This way your child can have the control of going in the diaper, but the diaper is actually inside the potty.

Once a child starts to go on the potty on a regular basis, then the caregiver can cut a hole in the center of the diaper before putting it into the potty. When this is done, some of the stool will fall into the potty when the child goes to the bathroom. Each week cut a larger and larger hole in the diaper until you reach the point that there is only a small piece of the diaper in the potty. This approach helps children who have difficulty "letting go" of the diaper.

Changes in the family dynamics, stress, and history of sexual abuse are all additional potential reasons for a child not potty train. (1) If a child is approaching 5 years old and still will not potty train after all physical reasons are ruled out , a consultation with a Child Psychologist may be necessary.

I wish you success in your endeavor and your grandson the confidence and self control he needs to accomplish this very difficult task!

If you are interested in reading other stories on the Pediatric Advice Website addressing these issues:

Toilet Training

Withholding Stool

Constipation

References:
(1)Howard BJ. Toileting Problems of Young Children. Audio-Digest Pediatrics. 2000.46(02).
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:219-221.


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

Pediatric Advice Updated Daily