Chest Pain

Dear Lisa,

My son is 9 years old and has been complaining of pains in his chest. They are not continuous or everyday. They come and go and happen at different times of the day. He can be in the middle of an activity or doing something calm. He also has dark circles under his eyes and his coloring in his face has been a little pale lately. Is this something that could be serious or is it possibly growing pains?

“Son with Chest Pain”

Dear “Son with Chest Pain”,

Growing Pains are the pains that children experience in their arms and legs, not in the chest. Pains in the joints or the chest are due to other conditions. Growing pains usually occur in the calves or shins of both legs.(1) Children typically complain of pain in the evening or in the middle of the night. The story of a child who has Growing Pains goes like this; the child goes to sleep at night and suddenly awakes due to pain in the calf. After applying warm compresses or administering a pain medication the child goes back to sleep. By the next morning the child is absolutely fine with no complaint of pain, no limp and no rash. The child proceeds to run and jump on the leg all day with no noticeable problems.

On the other hand, pain in the chest can be due to a variety of reasons. Most people become alarmed when a child complains of Chest Pain, associating this symptom with a heart problem. In reality, cardiac defects are rarely the cause of chest pain in children. Only 4 to 6% of childhood complaints of chest pain are attributed to cardiovascular lesions.(2)

Acute Pericarditis is one of the potential cardiac causes for Chest Pain. Pericarditis occurs when the lining of the heart or the pericardium becomes inflamed. This inflammation is usually caused by an infection. The signs of Pericarditis include a stabbing, sharp chest pain that occurs when a patient lies down. The symptoms improve when the patient sits up.

Hypertrophic Obstructive Cardiomyopathy is a life threatening cardiac condition that occurs in children. adolescents and young adults. The symptoms include angina like chest pain, fatigue, shortness of breath, palpitations or passing out; usually occurring during exercise.(3) It is a familial condition and a known cause of sudden cardiac death.(3) Many times there is a history of a family member who had a sudden unexplained death.

Luckily, musculoskeletal conditions are the most common cause of Chest Pain in the pediatric population.(4) Muscles strains or injuries to the pectoral, shoulder or back muscles due to trauma or physical activity are the leading cause of Chest Pain in children. Costochondritis is a common childhood musculoskeletal disorder. It occurs when the cartilage between the ribs becomes inflammed. The point of inflammation occurs at the point where the sternum (breastbone) meets the ribs on a chid's anterior chest.

The symptoms of Costochondritis include a chronic sharp pain of the anterior chest wall that typically radiates to the back or abdomen. The pain can be worsened by deep breathing and physical activity. Application of pressure to the area where the ribs meet the sternum elicits chest pain in patients with Costochondritis.(5) The pain from Costochondritis can last for months. The children that tend to develop Costochondritis are those who participate in sports that involve swinging of the arms; such as tennis or swimming.

Conditions of the upper gastrointestinal tract such as gastritis, esophagitis or Gastroesophageal reflux can also present with chest pain. The pain from gastritis usually occurs behind the breastbone and is aggravated when the child leans forward. Children taking oral steroids or Non steroidal anti-inflammatory drugs such as Ibuprofen are at greater risk for developing gastritis.

Gastroesophageal Reflux Disease (GERD) is a common gastrointestinal disorder experienced by both children and adults. Signs and symptoms of GERD in an older child include heartburn, vomiting, difficulty swallowing, and chronic cough. GERD symptoms occur more frequently after meals and at night.(6) The older children that I cared for with GERD often complained of a bad taste in their mouth or a feeling like food was coming up their throat. It is important that GERD is diagnosed and treated because untreated GERD can lead to Esophagitis, throat disease and Barrett’s esophagus.(7)

Chest pain due to a respiratory origin is also a common finding in children. A respiratory infection can cause acute chest pain due to Pleurisy. Pleurisy occurs when the pleural membrane or the lining of the lungs becomes inflamed. Certain respiratory infections can cause this membrane to become inflamed. When the pleural membrane becomes inflamed it causes friction during breathing which can be quite painful. A patient with Pleurisy experiences such sharp pain that it causes him to catch his breath. Pleuritic pain can also refer to the abdomen and shoulder due to a common sensory nerve supply.(5)

Chest pain is also a common finding in children with Asthma.(5) Asthma is the most common chronic disorder in childhood. It affects approximately 5 million children in the United States.(8) Because the symptoms vary from child to child and different triggers affect different children, Asthma tends to be a challenge to diagnose. There is no one diagnostic test that determines whether a child has Asthma or not.(8) The diagnosis is made through a careful evaluation of a child’s clinical history as well as his family history.(8)

Airway inflammation is the hallmark of Asthma. This inflammation can remain “silent” and not cause any noticeable symptoms. The emergence of Asthma symptoms develops long after the inflammatory cascade causes changes in the airway.(8) By the time a child develops symptoms their disease is out of control. Therefore, many times the diagnosis of Asthma is more of a subjective decision rather than a measure of objective findings. That is why a detailed history of symptoms is necessary in order to make the diagnosis.

Children with Asthma can go undetected or undiagnosed for months or years before a diagnosis is made. Many Asthma related Emergency Department visits and hospitalizations can be attributed to the Doctor’s failure to recognize and correctly classify the severity of disease in a timely manner.(9) It takes an astute practitioner with extensive experience to identify Asthma in the early stages.

The most common symptoms of Asthma include recurring cough, wheeze, shortness of breath and chest tightness or pain. Symptoms that are elicited with triggers, symptoms that worsen at night and waking at night due to respiratory symptoms are key indicators for Asthma.(10) Other more subtle signs of Asthma include exercise intolerance, allergic shiners(dark circles under the eyes) and prolonged expiratory phase during breathing. From my experience I found that many children with Asthma triggered by exercise experienced chest pain as their presenting symptom.

A viral infection can also cause Chest Pain in children. Pleurodynia also known as “The devil’s grip” can cause intense chest pain. Coxsackievirus Group B is usually the offending organism that causes the condition. The chest pain from Pleurodynia occurs in spasms and is intensified by breathing and coughing. Other symptoms include fever, sore throat and diarrhea.(11)

Psychogenic Chest Pain accounts for 5 to 17% of the cases of Chest Pain in the pediatric population. (2) Psychogenic Chest Pain is usually seen in children over 12 years old and more often found in females.(12) This diagnosis is a diagnosis of exclusion and is a only a consideration when all other causes have been ruled out. Psychosocial or social pressures in a child’s life can contribute to Psychogenic Chest Pain. Stressors including a death in the family or divorce are potential causes of Psychogenic Chest Pain.

As you can see, the causes of Chest Pain in children are many. An accurate diagnosis can only be made through a complete history and physical examination performed by a health care professional. To aide in the diagnosis it would be a good idea to keep a symptom diary. The symptom diary should include the location of the pain, its affect on activity, the time of day, relation to food intake, environmental conditions and activities (ex. coloring with markers), weather, medication use and activity level. It would also be important to record the duration of symptoms, associated findings (for example a runny nose) and measures that improve the symptoms. A symptom diary can help you determine if there are triggers that elicit the Chest Pain.

Since your child is experiencing intermittent chest pain, sometimes associated with exercise, dark circles under the eyes and pale skin color a respiratory cause should be investigated. It would be unlikely that his symptoms are due to a respiratory infection or virus because you did not mention a recent illness or fever. Instead, Asthma should be considered because it is a very common childhood disorder and because his symptoms are commonly found in children with Asthma.

If there is a family history of Asthma, Allergies or Eczema, then Asthma would be a strong consideration. It would be a good idea to have your son evaluated by a practitioner who specializes in treating childhood Asthma. An in depth review of your child’s personal history of symptoms, such as Allergies and Eczema as well as a review of the family history regarding these conditions should be investigated. This is essential because the presence of Allergies and Eczema puts a child at risk for the development of Asthma. (13,14)

If your child is presently engaged in sports, has heartburn or has a relative who experienced an unexplained sudded death you should discuss this with your doctor. These findings may represent one of the other conditions discussed.

I wish your son well.

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

Growing Pains

Asthma Treatment

Asthma Triggers

Allergic Shiners

Gastroesophageal Reflux in Infancy

Gastroesophageal Reflux

References:
(1)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:566,572.
(2)Fyfe DA, Moodie DS.Chest pain in pediatric patients presenting to cardiac clinic. Clin Pediatr (Phila). 1984. 23:321-340.
(3) Walsh CA. Syncope and sudden death in the adolescent. Adolesc Med. 2001.(12)105-132.
(4)Kocis KC. Chest pain in pediatrics. Pediatr Clin North Am. 1999;46:189-203.
(5)Kundra M, Mahajan P. Pediatric Chest Pain: Key to the Diagnosis. Consultant for Pediatricians. 2006. August:460-466.
(6) Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. (35)4:259-266.
(7)Rudolph CD, Mazur, 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:S1-S31.
(8)Mahr T, Crisalida T, Hollingsworth J, Ortiz G, Senske B, Calvin M, Waldrop J. Attaining the Inside Track on Asthma Control. The Clinical Advisor. 2006. Dec:S 3-S14.
(9)Wolfenden LL, Diette GB, Krishnan JA,. Lower physician estimate of underlying asthma severity leads to under treatment. Arch Intern Med. 2003. 163:231-236.
(10)National Asthma Education And Prevention Program. Guidelines for the diagnosis and management of asthma: expert panel report 2. Bethesda, Md; US Department of Health and Human Services. Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute. 1997. NIH publication no. 97-4051.
(11)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:345-346.
(12) Selbst SM. Chest pain in children. Pediatrics. 1985. (75):1068-1070.
(13)Kumar R. The Wheezing Infant: Diagnosis and Treatment.Pediatric Annals. 2003. (32)1:30-36.
(14 ) Hogan M, Wilson N. Asthma in the School-Aged Child. Pediatric Annals. 2003. 32(1):20-25.

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

Pediatric Health Questions Answered

Omnicef Side Effects

Hi,

My 2yr old daughter was prescribed Omnicef for Strep throat. This is day five and yesterday evening we started noticing a significant change in behavior. She's screaming and crying not wanting to take a bath and not wanting to go to bed (both unusual). She appears okay during the day. Could this excessive irritability be due to the Omnicef?

“? Side effect to Omnicef "

Dear “? Side effect to Omnicef”,

Irritability is not a side effect listed in the Physician’s Desk Reference as an adverse reaction to Omnicef. Omnicef is an antibiotic that is commonly prescribed in the pediatric population and I personally have never heard this complaint from any of my patients. The side effects that may occur in the pediatric population (> or = 1 %)include diarrhea, rash and vomiting. Other less frequent side effects(Less than 1%) include abdominal pain, vaginal yeast infection, vaginitis, upset stomach, rash, nausea and abnormal stools.(1)

Brick red colored stools is a side effect that occurs when Omnicef is taken with foods rich in iron or with iron supplements. The iron in the food binds with the Omnicef to form a nonabsorbable complex in the gastrointestinal tract. This nonabsorbable complex causes the stool to turn brick red in color.(1) I have seen this side effect in children taking Omnicef. The brick colored stools return to their normal color after the antibiotic course is finished. In order to prevent this change of stool color from occurring, iron supplements should not be giving within two hours of receiving Omnicef. Iron supplements can be given 2 hours before the Omnicef dosage or two hours after the dosage.

A two year old child typically does not have the cognitive ability or communication skills to decipher and communicate pain, abdominal discomfort, vaginal itchiness or nausea effectively. If your daughter’s irritability continues, these potential side effect to Omnicef should be considered as a possible cause. Irritability and crying at night can also represent another problem such as an ear infection or a behavioral issue. Therefore an evaluation by your Doctor may be necessary in order to decipher the cause of her symptoms.

Many children receive extra loving care when they are sick. During an illness, routines change and special privileges may be granted. For example a child may be allowed to stay up later at night or sleep in their parent’s bed when they are sick. They also tend to get more individual attention from their parents when they are not feeling well. When a child’s condition improves it is normal for them to find displeasure and misbehave when old routines are re-introduced.

If your daughter had a change in her bedtime routine when she was ill, there is always the possibility that she may be acting out because she doesn’t want to go back to the old routine. For example if she was allowed to sleep in your bed when she was sick, it would be expected that she would become upset when she was put in her bed alone.

If you feel this is the case, explain to your daughter that she was allowed to stay up late or sleep in mommy’s bed when she was sick but now that she’s better, she has to sleep in her own bed again. Be assured that children understand hundreds of words before they actually speak and she will understand what you are trying to tell her. At the same time it would be a good idea to emphasize what she can do now that she is feeing better; for example go to the store or visit with friends.

Lastly, I would like to mention that a Strep infection can develop complications. In most cases, once a child receives Antibiotics the infection is eradicated and the child does not experience any complications or long term effects. Although there is a possibility that a child can develop complications whether she is treated with an Antibiotic or not.(2,3) These potential complications include Otitis Media(middle ear infection), Sinusitis, peritonsillar abscess, Tonsillitis, Cervical Adenitis, Glomerulonephritis, Scarlet fever, Arthritis and Bacteremia (infection in the blood).(2,3)

Therefore a child diagnosed with a Strep infection that fails to show a positive response to Antibiotic therapy or a child who develops new symptoms shortly after being diagnosed with Strep needs to be re-evaluated by a Physician. Concerning signs include a persistent fever, inability to swallow, swelling in the neck area, shortness of breath, change in urinary pattern or rash.

I hope your daughter is feeling better soon.

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

Strep Throat

Scarlatina

Scarlet Fever

Acute Otitis Media

Chronic Otitis Media

Cervical Adenitis

References:
(1) Physician’s Desk Reference. 2007. Montvale, NJ. Thomson PDR at Montvale.
(2)American Academy of Pediatrics. Group A Streptococcal infections. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:483-494.
(3)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1600-1602,1592,1686.

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

Pediatric Advice- Your Questions Answered

Parvovirus

Dear Lisa,

My son had Fifths disease about a month ago. He now has it again. Most of the children at the daycare have it or has had it. What can be done besides washing hands to get it out of the daycare? Is it likely for a child to get it more than once in that time period?

“Child with Fifth Disease”

Dear “Child with Fifth Disease”,

Fifth Disease also known as Erythema Infectious is caused by the virus Parvovirus B 19. The infection develops in stages. First an afflicted child develops a low grade fever, general malaise, muscle aches and headache.(1) Sometimes these symptoms are so mild that they go undetected. (1) Following this stage a symptom free period occurs which lasts 1 to 7 days. Next the characteristic “slapped cheek” rash develops on the face which is accompanied by a pale color noticed around the lips. The important thing to know is that once the rash develops the child is no longer contagious.

Following the appearance of red cheeks a body rash develops. This rash is diffuse, lacey, flat and pink in color. It appears on the torso, extremities and buttocks. The palms and soles are spared. The rash may become pruritic in some with fifteen percent of the children affected complaining of itching.(1)

During the third stage of the disease the rash appears to come and go. There are certain triggers associated with the reappearance of the rash. These triggers include exercise, emotional stress, hot tubs and sunlight.(2) This waxing and waning of the rash can go on for weeks and in some cases months. (2) Therefore a reoccurrence of the rash does not mean that a child developed Fifth Disease again, it just means that they are in the third stage of the disease which can be quite prolonged.

Young adults may develop a less common presentation called the “gloves-and socks” syndrome. This condition includes an itchy, eruption on the hands and feet that consists of small pink bumps. The rash causes some mild pain and swelling and is frequently followed by a body rash that consists of tiny broken blood vessels.(3)

In regards to your question about your son getting Fifth Disease again, Fifth Disease is a virus that children only get once. It is likely that the recurrence of the rash is the continuation of the original infection contracted one month ago. He probably is in the third stage of the disease, the time that the rash comes and goes.

Your other question about getting Fifth Disease out of your son’s daycare is a common question that parents ask. Typically outbreaks occur during the winter and spring months. Fifth Disease is a very difficult virus to contain. The transmission of the disease occurs before the eruption of the rash and therefore it is not determined that a child has Fifth disease until the contagious part of the disease has passed. Since many children have such mild symptoms during the first stage of the disease and because there is an asymptomatic period immediately before the development of the rash there is no way to know that a child is contagious until it is too late. In addition the virus is formed in such a way that it is resistant to heat, cold and detergents which are the typical conditions that kill most other viruses.(4)

The transmission of Fifth Disease occurs via respiratory droplets, which means the disease is spread when a child coughs, sneezes or comes into contact with another child’s nasal discharge. The infection can also be spread from exposure to an infected person’s blood or blood products and from a pregnant mother to her fetus.(5) The incubation period or the time it takes a person to become infected once exposed is 4 to 21 days.(6)

Although it may seem alarming because Fifth Disease is difficult to contain, this is not a significant concern because in the majority of cases, Fifth Disease is a mild, and self limiting condition.(1) The best way to prevent the spread of infection is to practice good hand washing at all times, even when children do not appear to be ill. It is also a good idea to teach children to cover their mouths and noses when they cough and sneeze and to properly dispose of soiled tissues.

It is important to note that Fifth’s Disease is not the only medical condition that causes a child’s cheeks to become red. I have had children who experienced recurrences of red cheeks accompanied by a body rash and it turned out that these children did not have Fifth Disease but had food allergies.

The condition “Popsicle Panniculitis” is another condition that can cause red cheeks in young children. This rash develops three days after a young child is exposed to cold from sucking on ice pops, the use of a cold pack or exposure to cold air. It appears as red, painless, swollen nodules or plaques on the cheeks. No treatment is necessary except avoidance of the cold and the rash will subside on its own.(7) Other potential causes of red cheeks in a child includes skin abscesses and Lupus erythematosus.(7)

The diagnosis of Fifth Disease is usually made through history and Physical Examination. If necessary a blood test for antibodies to Parvovirus B19 may be performed in order to confirm the diagnosis.(1) The development of a new rash in a child should be examined by a health care professional so that the correct diagnosis can be made and proper treatment recommended.

For more information about topics discussed, read other Pediatric Advice Stories:


Fifth Disease

Skin Abscesses

Food Allergies

References:
(1)Leung A, Robinson WM. What’s Your Diagnosis? Consultant for Pediatricians. 2006. June:366-370.(
2)Leach CT., Jenson HB. Erythema infectiosum (fifth disease). In: Jenson HB, Baltimore RS. Pediatric Infectious Disease. Principles and Practice. Philadelphia: WB Saunders Company;2002:325-330.
(3)Harrington J. Parvovirus B19 Infection. Consultant for Pediatricians. 2006. April:234-235.(4)Koch WC. Fifth(human parvovirus B 19) and sixth (Herpesvirus 6) diseases. Curr Opin Infect Dis. 2001.14:343-356.
(5)Frydenberg A, Starr M. Slapped cheek disease. How it affects children and pregnant women. Aust Fam Physician. 2003. 32:589-592.
(6)Weir E. Parvovirus B 19 infections: fifth disease and more. CMAJ. 2005. 172:743.
(7)Kamat D. “Popsicle” Panniculitis. Consultant for Pediatricians. 2006. Nov:729.

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

Pediatric Advice About Childhood Infectious Diseases

Salmonella

Dear Lisa,

My baby is due this April. My 15 yr old son has a ball python. I've read that reptiles carry Salmonella and that this can be deadly to a newborn and children up to age 5. Would you recommend I remove the pet from my household or are there things I can do to limit any exposure to the baby. Also, am I at risk during my pregnancy? We have had the snake for 4 years.

“Salmonella Concerns”

Dear “Salmonella Concerns”,

Yes, it is true that reptiles can become infected with and carry Salmonella. Other pets such as dogs and cats can also become carriers.(1) The interesting thing is that when animals are infected with Salmonella they usually are asymptomatic or have no visible symptoms. Therefore an owner would never know that their pet is harboring the germ.(1)

Salmonella is responsible for a broad spectrum of illnesses. Salmonella infection can cause Gastroenteritis, Enteric fever, Bacteremia(blood infection), Meningitis, Osteomyelitis(bone infection) and Abscesses. The way that the disease manifests itself depends upon the serotype or type of Salmonella exposure and the health condition and age of the person exposed.

Gastroenteritis is the most common condition caused by Salmonella. The symptoms of Gastroenteritis caused by Salmonella develop abruptly and include nausea, vomiting and crampy abdominal pain followed by loose watery stools. Diarrhea caused by Salmonella may contain mucus and visible blood. (1,2) Fever is a common symptom that is noted in 70% of patients.(1)

In normal healthy adults, the symptoms subside within 2 to 5 days. Those at risk for systemic disease or complications include children under 5 years old, the elderly, those with Sickle Cell Disease, patients taking antibiotics or steroids and those with compromised immune systems. (1,2) Infants in particular have a higher risk of developing Septicemia(overwhelming infection), Bacteremia(blood infection), Meningitis and Osteomyelitis (bone infection). Salmonella can be fatal in infants , especially in those under 3 months old, and in the elderly. (2)

The good thing is that there are measures that can be taken to prevent the transmission of the disease. Salmonella is transmitted via the fecal oral route. This means you can catch Salmonella from contact with an infected person’s stool. Microscopic amounts of stool can become caught underneath the fingernails or left on the hands from inadequate cleansing. The germ can be spread if an infected person handles food that other people eat.

Transmission can become an issue because Salmonella can be shed from a patient’s stool for weeks and sometimes months after the infection has resolved. Surprisingly 1% of patients continue to excrete Salmonella for more than one year after their acute infection!(2) The problem with such a long transmission period is that a patient can unknowingly spread the disease not realizing that they still harbor the germ.

Another mode of transmission is through undercooked food. Poultry, cattle and livestock are common reservoirs for Salmonella. Thoroughly cooking meat and eggs kills Salmonella and prevents people from becoming infected. The problem is that other items that come into contact with the raw meat or eggs during food preparation can become contaminated with the microorganism. Fruits and vegetables can also transmit the disease because once contaminated they are typically not cooked but eaten raw allowing the germ to infect the host.

Other sources of transmission include ingestion of contaminated water or unpasteurized milk and contact with contaminated medications, dyes and medical instruments. Contact with infected animals, especially pets is a common source of infection. Animals such as turtles, iguanas and other reptiles are known carriers of Salmonella. (2)

In order to prevent yourself from becoming infected during your pregnancy you should avoid handling your son’s snake, feeding it or cleaning its cage. It also would be a good idea to have your older son clean his own bedroom, washing his hands carefully afterwards. Whenever preparing food, careful cleansing of food surfaces and diligent hand washing is necessary in order to prevent the transmission of Salmonella. A person that is known to have a Salmonella infection should not handle or prepare food.(2)

From my experience, the infants that contracted Salmonella did so when their parents touched their pacifier or bottle with infected hands. In many of the cases, a caretaker touched an infant’s pacifier or bottle while they were preparing a meal made from chicken or eggs. Many of these parents reported that they put the pacifier in the baby’s mouth out of habit, forgetting to wash their hands first.

In order to keep a newborn baby from catching Salmonella it is necessary that each family member washes their hands before feeding the baby, touching the pacifier, touching the baby’s hands or cleaning the baby's belly button. When preparing meals remember to clean all cooking surfaces before putting the baby's food on them and to wash your hands before touching the baby or any baby items.

The addition of a new baby into the home will affect the dynamics of your whole family. This adjustment may be more difficult for some family members because of change in routine, change in family dynamics and shift of responsibilities. These changes can be difficult for a teenage sibling, especially if they affect his lifestyle. Removing your son’s pet from the home during this time may cause him a lot of grief.

It would be a good idea to sit down and talk with your son about where he stands. If the initial novelty of the snake has worn off and your son is no longer interested in caring for his pet it may be easier to find the snake a new home. I would not be surprised though, if your son is resistant to giving the snake away. Most people are unwilling to remove their pet from the home.(3) Many people view pets as part of the family and refuse to move a pet out of their bedroom, not to mention out of the home .(3)

There are a lot of positive aspects to pet ownership. Studies on the elderly have shown that interacting with animals causes a decrease in blood pressure.(4) Having a pet is a very good learning experience for a child too. Taking care of a pet teaches a child the value of life and the responsibility of taking care of someone other than themselves. Pet ownership has also been shown to have positive psychological effects. So there will be some benefits if the snake remains in the home.

Whether or not you keep the snake or not is your decision. You know your son the best, how mature and responsible he is and how likely it is that he will follow measures to prevent the spread of infection. If you decide to keep the snake it is important that your son understands the steps that he needs to take in order to keep your family free from infection.

You should explain to him that after he handles his ball python, feeds it or cleans its cage that he needs to thoroughly wash his hands with warm soapy water. Before handling the new baby’s food or pacifier he also needs to wash his hands. If your son lets the snake out of the cage and onto the floor it would be a good idea to keep the snake confined to his bedroom and to keep the new baby out of his bedroom when she learns to crawl.

Congratulations on your pregnancy. I wish you and your family well and you a happy and healthy pregnancy.

References:
(1)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:330.
(2)American Academy of Pediatrics. Salmonella 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; 1997:462-465.
(3)Phipatanakul, W. Environmental Indoor Allergens. Pediatric Annals. 2003. 32(1):40-48.
(4)Stephenson M. Spreading disease from pets to people. Infectious Diseases in Children. 2006. September:101-102.


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

Pediatric Advice About Infectious Diseases In Children

Pneumonia

Dear Lisa,

My 19 month old has a mucus filled cough followed by mucus filled vomiting she has no fever, no appetite, but she is very tired and groggy what should I do?

“Child with mucus filled Cough”

Dear “Child with mucus filled Cough”,

A child can develop mucus in her airway due to a respiratory infection. When a germ enters the airway the immune system responds by making antibodies and mucus in order to combat the germ. In some cases the mucus drips down the back of the throat and causes a post-nasal drip. This post nasal drip can cause a child to gag and vomit.

Mucus can also develop in the lower airways or in the lungs. Potential causes of mucus production in the lower airway in young child include Pneumonia, Bronchiolitis or Asthma. Signs of Pneumonia typically include a fever, fast breathing, lethargy(tiredness), shortness of breath, coughing, wheezing, decreased appetite, vomiting and abdominal pain. A child does not need to have all of these symptoms in order to be diagnosed with Pneumonia. Fever and fast breathing may be the only sign found in a young infant or toddler.(1)

Even though fever is usually present when a child has Pneumonia it does not have to be present. There are certain types of Pneumonia referred to as “Atypical Pneumonia” that present with minimal fever or no fever at all. (1) Even though Atypical Pneumonias are considered to be more prevalent in 5 to 10 year old children, preschool children are also at risk. A study performed by Michelow showed that preschool aged children experienced as many episodes of Atypical Pneumonia as older children.(2)

Bronchiolitis is one of the most common and serious viral infections that affects the lower respiratory tract in young children.(3) Almost 85% of cases are caused by RSV. Other potential pathogens include Parainfluenza Virus, Adenovirus, Influenza Virus and Rhinovirus. The symptoms of Bronchiolitis include a several day history of clear nasal discharge and nasal congestion followed by cough, fever, wheezing, retractions, poor feeding and in some cases respiratory distress.(4) Signs and symptoms of Bronchiolitis last for 10 to 14 days with the most intense symptoms occurring by the fifth day.(4)

Bronchiolitis is usually a mild and self limiting disorder, but in some cases it can become quite serious. It is the most common cause of hospitalization among infants. In the United States, 2 out of every 100,00 infants affected dies due to complications related to Bronchiolitis.(4) Those children at risk for developing severe disease include the very young, premature and those who are chronically ill.(5) All young children with symptoms consistent with Bronchiolitis should be evaluated and closely followed by a health care professional.

Asthma has many presentations, the most common in young children being chronic chough, nighttime cough, exercise intolerance, increased work of breathing, wheezing in a child with eczema and difficulty breathing.(6,7) Asthma is a chronic inflammatory disease that involves airflow limitation, bronchoconstriction, airway edema, mucus plug formation, airway hyperresponsiveness and airway wall remodeling. Excess mucus production, coughing up mucus and vomiting mucus are frequently found in children with Asthma.

Asthma is the most common chronic illness of childhood. It affects approximately 5 million children in the United States. Those at risk for developing Asthma include children with allergies and those with a family history of Asthma.(8) A Viral respiratory tract infection is one of the major triggers for an exacerbation of Asthma.(9) Therefore if a child with Asthma develops a respiratory infection, she should be evaluated by her Physician and have an action plan implemented in order to prevent deterioration of her health.

Since a mucusy cough can represent a wide range of disorders, a child presenting with this symptom needs to be evaluated by a Health Care Professional so that the correct diagnosis and treatment plan can be initiated. Young children are at a particular risk for developing complications from respiratory tract infections. Therefore, children under 3 years old with respiratory symptoms should be examined by a Physician or Nurse Practitioner.

Since your child is only 19 months old it would be important to have her seen by her Physician. Her decreased appetite and lethargy may be signs of worsening of her respiratory condition or they may represent a complication such as dehydration. Young children can easily become dehydrated when they are ill. Changes in diet and insensible water loss due to coughing and increased respiratory rate can quickly lead to dehydration in a young child. Sign of dehydration include dry tacky mucus membranes (inside of the mouth looks dry), poor skin turgor(non-elastic skin), decreased urine production, sunken fontanelle (soft spot), sunken eyeballs, reduction in amount of tears, increased heart rate, thirst, weight loss and listlessness.(10)

It is not a good idea to treat a young child suffering from respiratory symptoms with over-the-counter products. Over-the-counter products can cause side effects, fail to treat the cause of a cough and can mask symptoms of an underlying problem. There are many over-the-counter medications that are labeled to be used for cough. Many of these products are marketed as expectorants or a treatment for thinning mucusy secretions. Guaifenesin is a common component in many of these products.

At very high doses, Guaifenesin has mucokinetic effects and can thin respiratory secretions. The problem is at these high doses, significant side effects can occur. (11) In addition, controlled studies have shown that Guaifenesin has no benefit in the treatment of children with cough. It did not change volume or quantity of sputum, nor did it reduce cough frequency.(11)

The officials with the American College of Chest Physicians published Evidence–based Clinical Practice Guidelines regarding the treatment of a cough. These guidelines stressed that most over-the-counter syrups do not treat the underlying cause of the cough. The Guidelines’ authors do not recommend giving over-the-counter cough syrups to children under 14 years old.

Cough suppressants such as codeine and dextromethorphan can also cause significant side effects in children and are not recommended. They have the potential to cause breathing difficulties or respiratory arrest.(12) In addition no clinically evidence from controlled studies has documented their efficacy in the pediatric population.(13)

When a child has a mucusy cough the best thing that you can do is let the child cough and not give over-the-counter cough preparations. A cough is the body’s natural mechanism to protect and clear the airway. The force of a cough moves secretions in the respiratory tree upwards and thins the mucus. If a chid has excessive coughing, she should be evaluated by a Physician.

A natural way to help thin a child’s respiratory secretions is to increase the amount of fluids that your child drinks. This includes solids that melt to a liquid state at room temperature such as ice pops, Jell-O and sherbet. The application of saline nasal spray to the nasal passages can help liquefy and remove mucus from a child’s nose. Gargling with warm salt water can be performed in an older child. This can also aid in liquefying mucus that drips down the throat.

Concerning signs in a child with a respiratory symptoms include; difficulty breathing, pale or blue skin color, listlessness, irritability, accessory muscle use(the skin in between the ribs sucks inwards during breathing or the shoulders rise and fall), nasal flaring (the nostrils flare open with breathing), increased respiratory rate, clipped speech (the child cannot say the ABC’s without pausing to take breaths), back pain, chest pain, leaning forward and drooling or fever. These symptoms can represent worsening of a child’s condition or another serious health condition. If any of these symptoms occur when a child is suffering from symptoms of a respiratory infection, medical attention should be sought without delay.

I hope this information helps and that your daughter recovers quickly.

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

Nasal Congestion

Chronic Cough

Baby with Cold symptoms

Asthma Treatment

Asthma Triggers

Adenovirus

References:
(1)Nield L. Pneumonia: Update on Causes-and Treatment Options. Consultant for Pediatricians. 2005.Sept:365-370.
(2)Michelow IC, Olsen, Lozano J. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004; 113:701-707.
(3)Linzer JF, Guthrie CG. Managing a winter season risk: bronchiolitis in Children. Pediat Emerg Med Rep. 2003.8:13—24.
(4)Bradin SA. Croup and Bronchiolitis: Classic Childhood Maladies Still Pack a Punch. Consultant for Pediatricians. 2006. Jan:23-30.
(5)Gorelick MH, Singh SB. Respiratory emergencies. In; Selbst SM, Cronan K. Pediatric Emergency Medicine Secrets. Philadelphia, PA: Hanley & Belfus. 2001. 241-252.
(6)Stephenson M. Be aware of the myriad conditions that trigger chronic cough in children. Infectious Disease in Children. 2006. March:38.
(7)Castro-Rodriguez JA, Holberg GJ, Wright AL, Martinex FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med. 2000.162:1403-1406.
(8)Kumar R. The Wheezing Infant: Diagnosis and Treatment. Pediatric Annals. 2003. 32(1):30-36.
(9)Johnson NW. Viral Infections Increase Asthma Hospitalizations. Journal of Allergy and Clinical Immunology. 2006. 117:557-562.
(10)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:921.
(11)Franco ME. Evaluation of chronic cough in children. Presented at: Miami Children’s Hospital’s 41st Annual Postgraduate Course “Perspectives in Pediatrics. Feb 6-9 2006:Miami Beach, Fla.
(12)Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics. ACCP evidence based clinical practice guidelines. Chest. 2006.129:260S-283S.
(13)Bell E. Is codeine a useful medication in pediatrics? Infectious Diseases in Children. 2006. July:12.

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

Pediatric Advice For Parents with Sick Children

Chiari Malformation

Dear Lisa,

My 8 yr old daughter had brain surgery three yrs ago for a Chiari Malformation. She is now having the same symptoms but they have become more severe and persistent. My question is, can a Chiari malformation return? If not what could mimic the exact same symptoms of a Chiari?(severe headaches, fatigue, pain in neck radiating down arm, shock like feeling going down arm, depression, she can't sleep, VERY agitated, blurred vision, ringing in ears, constant blinking. The list goes on and on, but I know you are busy, I can't get her neurosurgeon or neurologist to listen. I really need help, and I don't know where to get it.

“Worried Sick”

Dear “Worried Sick”,

It sounds like you and your daughter have been through a lot over the last 8 years. As you already know, Chiari Malformation (also referred to as Arnold-Chiari Malformation) occurs when the part of a child’s brain called the posterior fossa is downwardly displaced towards the spinal cord. This downward displacement causes compression and elongation of the tissues and the cranial nerves which leads to the resulting signs and symptoms known to the disorder. Although children with Chiari Malformation are born with the condition, only about 1/3 of these children develop symptoms in infancy. (1)

The common symptoms include neck stiffness, neck pain, headache, nystagmus (involuntary periodic movement of the eyes from side to side or from up to down), difficulty swallowing, drooling, vomiting, inspiratory stridor, and in some cases apnea. (1,2) A poor gag and swallow reflex can also develop due to the compression of the cranial nerves. This often leads to aspiration of food and liquids during eating and recurrent Pneumonias. (1) In older children decreased strength in the upper extremities with increased muscle tone and exaggerated deep tendon reflexes may also be present. (1)

Chiari Malformation is diagnosed through imaging studies such as x-rays and/or an MRI of the brain. In cases of milder disease the symptoms may stabilize and the child outgrows the symptoms. In more severe cases, especially when apnea or recurrent pneumonia is involved, surgery may be necessary. The surgical procedure that is typically performed to treat Chiari malformation is a posterior fossa decompression. This decompression alleviates the pressure on the fourth ventricle and the affected cranial nerves which hopefully prevents worsening of symptoms.

Since your daughter is developing the same symptoms that she experienced before her surgery it would be important to have her re-evaluated. You mentioned that you informed your daughter’s Neurosurgeon and Neurologist about her symptoms, but they did not seem to listen. You did not mention if your daughter had an evaluation, a scan of her Brain or what the specialist’s impression of the findings was.

In some cases it may seem that a Doctor is not listening, but what they may be doing is monitoring symptoms to see if they progress. In other cases the Doctor may be deciding what treatment approach to take. Sometimes a child’s complicated condition goes beyond the expertise of a certain specialist and a second opinion is necessary.

I suggest that you write down all of your concerns and questions and schedule a consultation with your daughter’s specialists. At the consultation your Doctor should be able to tell you if your daughter's symptoms are due to her Chiari Malformation or due to another cause. Don’t be afraid to ask your Doctor what his impression is, what his plan is and what pain control measures can be instituted in order to alleviate your daughter’s discomfort. Pain medications may initially be withheld because they can mask symptoms and prevent an accurate diagnosis. If your daughter’s symptoms have been persistent and the disease course has been determined the institution of pain medication for comfort should be a viable option.

When a child has a chronic or complicated medical condition it is a good idea to seek a second opinion. A second opinion can help you gain additional insight into your daughter’s condition, offer you new alternatives or reassure you that you are already on the right course. Some people are afraid to get a second opinion because they do not want their Doctor to become insulted or because they are affraid that their Doctor will think that they do not trust him. A good Doctor will not take this personally and understand that you are trying to do the best that you can for your daughter.

Just like every other profession, there are some Doctors that have a stronger background, more expertise or more experience in a particular area of medicine as compared to others. By getting a second opinion you can explore all of your options and get a different perspective on your daughter’s condition.

When seeking a second opinion, it is a good idea to search out a Neurosurgeon associated with a major Children’s Hospital or associated with a major university in a large city. Your daughter’s pediatrician is a very good resource and should be able to refer you to a specialist that can answer your questions. A Nurse at your insurance company should also be able to direct you where to find a second opinion.

You will need to get a copy of your daughter’s operative report from the hospital where she had surgery and copies of all diagnostic testing as well as films from x-rays or MRI scans performed. The specialist that you see for a second opinion will need to review this information.

Many times very practical, useful and informative suggestions come from other parents experiencing the same situation. You can meet other parents with children diagnosed with Chiari Malformation by joining a support group. In order to find a support group you can contact a children’s rehabilitation hospital, children’s hospital or the Board of Health in your area.

Chiari Malformations are very commonly associated with spinal cord defects such as Spina Bifida. Spina Bifida is more common than Chiari Malformations and it may be easier to find a Spina Bifida support group close to your home. You can find information about Spina Bifida support groups on the Spina Bifida Association Website. Within the Spina Bifida Association and support groups you should be able to find other parents with children diagnosed with Chiari Malformation.

I hope this information helped and I wish you and your daughter well.

Spina Bifida Association

Spina Bifida Support Groups

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1789-1791.
(2)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:438.650-651.


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

Your Pediatric Health Questions Answered

Constipation

Dear Lisa,

My son is 12 months old and has had constipation problems since he was about six weeks despite the fact that he is a breastfed baby. His doctor is completely unconcerned and simply advised giving him juice with no further inquiries. Now my son is eating three complete meals a day along with breast milk and the food seems to come out quite a few days later. Now not only is he constipated but he is also beginning to pass stools that are hard, dry and black with a fine sandy texture surrounding them. I don’t believe it is anything I am feeding him but I am not sure. Am I overreacting or should I be worried?

“Worried about Constipation”,

Dear “Worried about Constipation”,

The term Constipation is often defined differently by parents and Physicians. (1) Some parents believe their child is constipated if a bowel movement does not occur in an expected timeframe. The frequency of bowel movements alone does not necessarily define constipation. Normal patterns can range from having several bowel movements per day to having one bowel movement every few days.(2)

The amount of time that stool takes to travel through the bowels and out the rectum is called the transit time. Every person’s body has a different colonic motility pattern which dictates their transit time. Some people’s transit time is slower than others. For people with slow transit time, it takes longer for the stool to travel through the intestinal tract. The longer it takes for the stool to travel through the digestive tract; more water is reabsorbed from the stool and put back into the body. Therefore if a child has a long transit time their bowel movements are expected to be infrequent and their stool is expected to be firm.

Colonic motility can be variable and influenced by other factors such as; sleep, meals, physical activity and emotional stress.(3) Therefore at times a child’s pattern can change dependent upon these variables. Children who have an abnormally slow transit time can develop Constipation. Symptoms of this type of Constipation include an infrequent urge to defecate, infrequent stools, bloating and abdominal discomfort.(4) Children with slow transit Constipation can benefit from the addition of fiber to their diet. Adding fiber to the diet increases stool weight and water content.

Actually, Constipation is defined as difficulty passing hard stools, pain with defecation and a decrease in the frequency of bowel movements. Streaks of red blood are also a common finding in children who are constipated because the passage of hard stools can cause a fissure or a small cut. This fissure bleeds and as a result streaks of red blood can be found on the outside of formed stool.(2)

Perhaps your Doctor seemed unconcerned about the infrequency of your son’s bowel movements because this could be normal for him and because he had no other symptoms. It is common for some children to have infrequent stools. As long as the stool comes out soft and there is no pain or straining it is not considered to be a problem. Now that your son is developing new symptoms such as hardness in texture and a black color this needs to be addressed.

In most cases, Constipation in childhood is acquired and due to changes in diet.(2) There are certain foods that can bind a child’s stool and other foods that may loosen a child’s stool. Every child is different and has a different response to the addition to a new type of food. For many children rice, soy and bananas are binding and can lead to hard stools. On the other hand fruits, fibrous vegetables, bran flakes and oatmeal can loosen a child’s stool. If your child’s stool consistency has changed since the introduction of solids you may want to keep a diary in order to determine if a certain type of food is changing the texture in his bowel movements.

In some cases Constipation can be due to a secondary cause. In other words a different condition can cause a child to develop Constipation. Constipation can be caused by a metabolic or endocrine disorder such as Hypothyroidism, due to a neurologic cause such as Muscular Dystrophy or because of a gastrointestinal disorder such as Celiac disease.(5) Other potential causes in childhood include central nervous system disorders, muscle disorders, mechanical obstruction or side effects to medication.(5)

Hirschsprung disease may be a consideration in a child who has had constipation since birth.(2) Hirschsprung disease is a condition that occurs due to the absence of ganglion cells in a child’s distal intestine.(6) This leads to ineffective colonic motility, constipation and obstruction. About 50 to 90% of cases are detected in the neonatal period.(6) Symptoms demonstrated in the newborn period include feeding intolerance, bilious vomiting and delayed passage of meconium.(7)

Typically 95% of full term infants pass meconium (first stool which is black and tarry in nature) within the first 24 hours of life. Fewer than 10% of children with Hirschsprung disease pass meconium within this timeframe.(6) Just because an infant has normal bowel movements during the neonatal period does not exclude the possibility of Hirschsprung disease. There certainly are a number of children who have a normal history of neonatal bowel movements who ultimately are found to have Hirschsprung disease.(8)

In some cases Hirschsprung disease is diagnosed at a later age.(8) In particular, breastfed infants with Hirschsprung disease have been found to be diagnosed later in the first year of life.(8) Other signs of Hirschsprung disease in an older child include; a history of intermittent abdominal distention and failure to have a bowel movement without the aid of an enema or laxative.(2) If this is the case it would be important to discuss this possibility with your Physician.

If your son is having straining or pain with his stooling, the stool consistency remains hard after dietary manipulation or he has black stools he should be evaluated by his Physician. If this is the case, it would be a good idea to bring a stool sample to the doctor’s office so that he can see the consistency and test it for blood. If it is determined that your son has Constipation this would be a good time to discuss dietary management and the possibility of secondary causes. In some cases a child with Constipation not responsive to dietary manipulation may need to be prescribed medication or referred to a Gastroenterologist for an evaluation.

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

Infant Constipation

Treatment for Constipation

Stool Color

Celiac Disease

Stool Withholding

References:
(1)Pare P, Ferrazzi S, Thompson WG, Irvine EJ, Rance L. An epidemiological survey of constipation in Canada; definitions, rates, demographics and predictors of health care seeking. Am J Gstroenterol. 2001.96:3130-3137.
(2)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:179-180.
(3)Rao SSC. Constipation evaluation and treatment. Gastroenterol Clin North Am. 2003.32:659-683.
(4)Lembo A, Camilleri M. Chronic constipation. N Engl J Med. 2003.349:1360-1368.
(5)Borum ML. Constipation; evaluation and management. Prim Care. 2001.28:577-590.
(6)Dasgupta R, Langer JC. Hirschsprung disease. Curr Probl Surg. 204;41:942-988.
(7)Kamat D. Hirschsprung Disease. Consultant for Pediatricians. 2006. March:190-191.
(8)Listernick R. A 4-month-old Girl with Bilious Emesis. Pediatric Annals. 2006. 35(7):470-477.


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

Pediatric Advice-Your Questions Answered

Migraine Headache

Dear Lisa,

I am a 19 year old nursing student and I need your help! Since I was about 5, I have suffered from some form of migraines. They have gotten worse as I have gotten older. I have worked with my pediatrician and two neurologists and over about 10 years, we diagnosed me with pseudotumor and dura-sinus thrombosis (b/c a blood clot was found in one of the veins in my brain). I have been put on an uncountable number of meds, and most didn't seem to help, or I had horrible reactions too. Currently I am taking a diuretic twice a day (500mg) and using the medicine called "Amerge" for when I do get a headache. I was doing really well for the past two or so years and then in this last six months I seem to have fallen again. I met with my neurologist last week and had another spinal tap done to see if my pressure was still high. It was 165, which as I was told, was low and normal, thus suggesting that the Diamox was working, and/or that I no longer had a problem with pseudotumor. I should probably say as well, that the psuedotumor diagnosis is a very odd one for me b/c I am not obese or in bad shape, but rather tall, thin and I try to stay active.

Anyways, for the past six months, I have experienced a horrible pulsing sound in my ears when I sleep and I feel like my head just throbs with each pulse. It doesn’t happen every night, but often. I woke up this morning with horrible pounding in my head, and I heard the "swooshing" sound as well. I began to get horribly nauseated as it got worse. It was 4am and I have a roommate and I couldn't just get up. The other thing is that my right eye begins to hurt terribly as well when this happens. I don't have double vision, or blurriness, it just hurts, aches, and throbs. Getting up and out of bed tends to help a little. But today the headache, nausea and eye sensitivity lasted most of the day and this is not unusual. I don't have a kink in my neck, and no other part of my body feels odd. I have done food diets and kept journals and have never found anything.

Sincerely,

“Nursing Student with killer pain”

Dear “Nursing Student with killer Pain”,

WOW! The one thing that I can say is, all of your experience with your own health conditions, medical specialists, diagnostic testing, coping with pain and navigating the health care system, you sure are going to be a great Nurse. I’m sure it has been extremely difficult dealing with your pain and medical problems from such a young age and find it very admirable that you have chosen a career dedicated to helping others. Your future patients will benefit from all of your life experiences.

Asking questions also makes a good Nurse and a well informed patient. When it comes to your health, there are never too many questions, especially when the situation is not clear. The first issue I would like to address is your diagnosis of Pseudotumor cerebri. I am sure you already know that Pseudotumor cerebri is a condition that is caused by increased intracranial pressure. This increased pressure can lead to cerebral edema (swelling) or subarachnoid fluid accumulation.(1) Typically the reason for the increased pressure is unknown.

The symptoms of Pseudotumor cerebri include a headache that occurs first thing in the morning or wakes a person at night, nighttime or early morning vomiting, visual field deficits and problems with lateral deviation of the eye caused by sixth cranial nerve palsy. The conditions that are associated with Pseudotumor Cerebri include; obesity, menstrual irregularities, Addison disease, pregnancy, Hypoparathyroidism, Iron Deficiency Anemia, middle ear disease, Vitamin A excess or deficiency, Steroid therapy, Oral Contraceptive use, diseases that obstruct the cerebral spinal fluid pathways and obstruction of the major venous sinuses.(1,2)

You will find that as you become more involved with the health care field that medicine is not an exact science. When it is determined that a certain type of person has a risk factor for a disease or that a disease is associated with other findings, this does not mean that every patient needs to have a certain characteristic or condition in order to be diagnosed. All this means is that through researching past cases, common factors were found. Many times the reason for the association is not known. So the fact that you are not obese does not change your diagnosis of Pseudotumor cerebri.

You did mention that you were diagnosed with a dura sinus thrombosis. This can lead to an obstuction of the major venous sinuses which happens to be an assoociated finding in patients with Pseudotumor cerebri. Chances are this finding contributed to your Pseudotumor cerebri diagnosis more than your weight or level of fitness.

The next thing that I would like to mention is that I am not sure I understand the outcome of the visit with your Neurologist last week. You mentioned that you had a spinal tap to see if your pressure was still high and you were told that your pressure was 165 and normal, suggesting that the Diamox was working and/or that you no longer had a problem with Pseudotumor. I am not a Neurologist, but from the sources that I have, the lumbar puncture of patients with Pseudotumor cerebri demonstrates elevated opening pressure, often more than 20 cm H20. (2) Increased intra-cranial pressure (ICP) is defined as a sustained elevation in pressure above 20mm of Hg/cm of H20. (3 ) So I am not sure that I understand the results of your lumbar puncture reading. Since a reading over 20mm of Hg/cm of H20 is considered elevated, the report that your reading of 165 is normal is confusing. Perhaps the number was miscommunicated to you. I suggest investigating this further by discussing the results and the interpretation of those results with your Doctor.

It is common for a patient and their doctor to attribute new symptoms to a past medical condition. For example, it may be assumed that joint pain is most likely Arthritis in a patient with a history of Rheumatoid Arthritis or headaches are due to a Migraine in a patient with a history of migraines. When symptoms have a different presentation, persist, are resistant to therapy or come without an explanation it is important to step back and look at the whole picture. Sometimes you need to start from the very beginning and evaluate all possible causes of a Headache.

The evaluation should start with a routine screen and physical examination that is typically performed the first time a patient complains of recurrent or chronic headaches.
An initial screening for headaches includes; a physical examination including Vital signs and blood pressure screening, an neurologic evaluation, cardiac evaluation, routine bloodwork screening evaluating liver and kidney function and thyroid levels, imaging studies ruling out an AVM malformation, lesion or mass, an ear, nose and throat examination to rule out sinus or middle ear disease, an ophthalmologic examination and an evaluation of the cervical spine. (4) In addition, all medications and herbal remedies used should be reviewed in order to determine if any interactions or common side effects could be responsible for symptoms.

Hypertension or High Blood Pressure is a potential cause of headaches that may be overlooked. (4) Symptoms of High Blood Pressure include headaches, more frequent nosebleeds than normal and dizzy spells. Although most people with High Blood Pressure have no symptoms at all. (5) Many patients with known High Blood Pressure have told me that they feel a hot sensation in their face or head or humming by their ear when their blood pressure is out of control.

More importantly, in your case, the prescription medication, “Amerge” belongs to the 5-HT1 agonist class and can potentially cause High Blood Pressure as a side effect. (6) In healthy volunteers, dose related increases in systemic blood pressure have been observed after administration of up to 20 mg of oral naratriptan (Amerge). Significant elevation in blood pressure , including hypertensive crisis has been reported on rare occasions in patients receiving 5-HT1 agonists with and without a history of hypertension. (6)

Since you are taking this medication and presently suffering from a reoccurrence of you headaches it would be a good idea to have your blood pressure monitored to make sure that you are not having an elevation in your blood pressure. I also think that it is important to have the pulsing and ‘swooshing” sound in your ear evaluated. Your Neurologist or an Otolaryngologist (ENT specialist) can perform this evaluation. When a patient complains of humming, swooshing or buzzing in only one ear, many times an MRI is ordered in order to determine the cause of the symptoms.

If it is determined that your evaluation is normal, it is likely that you will find that the headaches that you are having are due to a Migraine or a migraine variant such as a Cluster headache. A Cluster headache is a sharp very severe headache that usually localizes in or around one eye. This type of headache often begins 60 to 90 minutes after falling asleep and is commonly associated with tearing and nasal congestion on one side.(6) The cause of Cluster headaches is unknown but alcohol is a known precipitating factor. In some cases a Headache specialist is needed in order to decipher the type of migraine that a patient is having and determine the best course of treatment to relieve the pain.(7)

I hope this information was helpful and that you find resolution to your symptoms soon.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Cluster Headaches

Chronic Headaches

Migraine Triggers

References:
(1) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:640-641.
(2)Rubin D, Suecoff S, Knupp K. Headaches in Children. Pediatric Annals. 2006.35(5):345-353.(3)Neurosurgery on the Web. Thamburaj A. Intracranial pressure. Available at: http://www.thamburaj.com/intracranial_pressure.htm. Accessed Jan 2007.
(4) Linder S. Understanding the Comprehensive Pediatric Headache Examination. 2005.34(6):442-446.
(5)The Mayo Clinic. High Blood Pressure(Hypertension). Available at: http://www.mayoclinic.com/health/highbloodpressure//DS00100/. Accessed Jan 2007.
(6) Physician’s Desk Reference. 2004. Montvale, NJ. Thomson PDR at Montvale:1425.
(7)Alper B, Passarelli B. Cluster Headache. The Clinical Advisor. 2006. August:85-86.


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

Pediatric Advice About Common Health Problems

Infant Colic

Dear Lisa,

My 6 week old son is very fussy. He has changed formulas 3 times and now is onNutramigen. He is also on Axid for reflux. However he seems to be in pain. He will cry and scream for hours and won’t settle down until he has a bowel movement. Sometimes he can’t go and I have to use a thermometer with jelly to get him to go. He doesn’t like to lay flat on his back, isn't sleeping much, holds his breath when he gets going and seems to always be hungry. It breaks my heart when he’s like this. It's usually between the hours of 6pm and 3am, but also during the day sometimes. Any advice????

“SLB80”

Dear “SLB80”

It looks like you and your baby have had a rough time for the last 6 weeks. It also looks like you and your Physician have tried many avenues to help your son find some comfort. Nutramigen is one of the recommended formulas for children allergic to milk protein. (1) The switch to this formula should have addressed a possible milk sensitivity. Your son’s Gastroesophageal Reflux Disease (GERD) is also being addressed with the use of the medication Axid that he is taking.

Axid is an H2 receptor antagonist which works by blocking stomach acid secreted by histamine. H2 receptor antagonists are the first line treatment for children with GERD. H2 receptor antagonists typically need to be administered twice per day because the medication’s effectiveness runs out approximately 9 to 11 hours after the morning dose. Infants who are prescribed this type of medications only once per day tend to have a return of their symptoms in the evening hours when the medication is no longer working.

H2 antagonists also tend to gradually lose their efficacy with long-term administration.(2) Because of this children treated with H2 antagonists for a length of time can experience a return of their GER symptoms. Therefore it is common for children on H2 antagonists to be stepped up to the next treatment option, such as a Proton Pump Inhibitor (PPI) when GER symptoms occur.(3)

Proton pump inhibitors (PPIs) are superior to H2 receptor antagonists as acid suppressors.(4) Proton pump inhibitors prevent acid secretion stimulated by histamine as well as acetylcholine and gastrin.(5) In addition, the use of PPIs results in faster and higher rates of erosive esophagitis healing compared with H2 receptor antagonists.(4) Prevacid is one of the Proton pump Inhibitor that is approved in the pediatric population.(5) Even though it is recommended for children from 1-11 years old, it is prescribed by many Doctors and Nurse Practitioners to children less than 1 year old.(6)

Typical GER symptoms experienced by infants include vomiting, regurgitating, back arching, excessive hiccoughing and irritability. Some children with Silent Reflux will experience irritability with no obvious signs of vomiting.(3) You did not mention if your son’s GER symptoms improved with the institution of Axid or if he is presently experiencing GER symptoms. If this is the case, the approach to the treatment of his GERD may need to be re-evaluated.

In some cases medications need to be adjusted, non-medical treatments need to be initiated or further diagnostic testing needs to be performed. One of the non-medical treatmtnets for GER includes thickening the infant formula. Many doctors have moved away from the practice of thickening baby formula with rice cereal as a treatment for GER. It is true that it will not cure the disease, but it has been shown to decrease the amount of times per day that a baby spits up and has brought relief to many children.(3,7) You might want to discuss this option with your Doctor if your son is having vomiting with his GERD.

Another non-medical treatment is positioning. Babies with GER tend to experience less symptoms when they are elevated at a 30 degree angle.(3) Since your son has GER, it is not surprising that he has discomfort when he lies flat. You may want to purchase a bouncy seat that is made to maintain an infant in an elevated position. Placing a child in an infant car seat is usually not effective. Infant car seats cause the baby’s hips to flex which places pressure on the stomach and increases reflux. (5)

Babies with gas also have a lot of abdominal discomfort, abdominal pain and crying. Some infants entrap a lot of air with their vigorous sucking which causes air to be trapped in their stomach. In addition certain bottles allow more air to enter the baby’s stomach during a feeding than others. If your son is having a lot of burping you may want to consider adjusting your feeding technique. From my experience many parents have found success with the use of a Dr. Brown’s bottle which is designed to prevent air from entering the baby’s stomach.

Once all of these areas have been addressed and your baby’s Doctor determines that there is no other medical cause for your son’s crying, Colic should be considered. Colic usually begins in the first three weeks of life and typically lasts up until a child is three months old. In rare cases it may persist up until 6 month of age.

The symptoms include crying episodes accompanied by pulling the knees to the chest as if the baby is in pain. The crying episodes typically last 30 minutes to 2 hours and occur one to two times per day, usually concentrated in the evening hours. In between the crying spells the babies with colic are quite content and happy.

Taking care of a baby with colic can be extremely exhausting and can have a strong emotional impact on the whole family. It is very difficult to watch your baby cry, especially when measures taken to provide comfort do not seem to help. This stress can profoundly affect the primary caregiver who needs some time away from the baby.

When a baby has colic it is a good idea to have a friend or relative take care of the baby on a regular basis in order to give the major caretaker a break. In addition to parental breaks, there are some measures that may help soothe the baby’s symptoms. Parents may need to experiment with these interventions because each baby is different and different techniques work for different babies.

Some infants respond favorably to gentle pressure over the abdominal area. Walking with the infant held over your arm can provide the gentle pressure that is needed.(8) Other babies find relief if their position is changed frequently. Measures to distract the baby may work for some families. Music with a varied rhythm or a beating heartbeat in the background may stop the baby from crying.(8) Other babies find comfort from loud humming sounds such as the noise made by a clothes dryer, motor of a car or vacuum cleaner.

Swaddling an infant may also reduce the amount of crying and fussiness. The swaddled position replicates the position of comfort that neonates experienced in the womb. Swaddling promotes restful sleep, reduces scratching of the infant’s face and diminishes frequency, intensity and duration of crying episodes.(9) You can ask the Nurse in your Doctor’s office to show you how to swaddle your baby and practice on a doll or stuffed animal if necessary.

I hope this information helps because I understand how heart wrenching it can be to see your baby cry. Just be assured that many times it is normal for a baby to cry because it is their way of communicating. Also be assured that colic, and GER improve with age and this period will soon come to an end.

Signs that a crying baby needs medical attention include a baby with a fever, continuous crying, abdominal distention, bilious vomiting (foamy yellowish green vomit), projectile vomiting, lethargy, muscle weakness, a baby with improper head circumference growth, ineffective voiding and/or blood in the stool. These situations require medical attention and a further workup in order to determine the cause of the vomiting.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Swaddling

Infant Vomiting

Gastroesophageal Reflux

Infant Back Arching

Gassy Baby

References:
(1)Rudolph CD, Mazur L, Liptak GS. North American Society for Pediatric Gastroenterology and Nutrition Guidelines for evaluation and treatment of Gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition J Pediatr Gastroenterol Nutr 2001;32(Suppl 2 ):S1-31.
(2)Gillen D, McColl Ke. Problems related to acid rebound and tachyphylaxis. Best Pratct Res Clin Gastroenterol. 2001.15:487-95.
(3)Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006.35(4):259-266.
(4)Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapeutic Spotlight. 2005. August:4-13.
(5)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.
(6)Schwartz R, Guthrie K. GERD: the lessons my new grandchild taught me. Infectious Diseases in Children. 2006. April:14.
(7)Wenzi TG, Schneider S, Scheele F. Effects of the thickened feeding on Gastroesophageal reflux in infants. A placebo-controlled crossover study using intraluminal impedance. Pediatrics. 2003; 11:355-359.
(8)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1486-1487.
(9)Schwarz R, Guthrie K. Musings on infant swaddling. Infectious Diseases in Children. 2006. June:14.


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

Pediatric Advice For Parents with Infants

Vaginal Odor

Dear Lisa,

My daughter is almost 2 years old and today for the first time she had this really bad odor coming from her vagina. I tried looking it up online thinking its a yeast infection but there is no discharge and she gets a bath(she's not dirty or anything) What could this be? I can't seem to find an answer to make me feel better.

“Two year old with odor”,

Dear “Two year old with odor”,

Malodorous urine or foul smelling urine can be a sign of a Urinary Tract Infection in a young child. Therefore if the odor you are smelling is really an odor from your daughter’s urine, or her diaper filled with urine, a visit to the Doctor would be necessary in order to rule out a Urinary Tract Infection. Symptoms of a Urinary Tract infection in young children do not necessarily present the way that Urinary Tract Infections do in older children or adults. The typical urinary symptoms such as burning with urination or urinary frequency may not be present.

Instead infants and toddlers can develop non-specific symptoms such as a fever, vomiting, diarrhea, decrease appetite, weight loss, abdominal pain, pale grey skin color, lethargy, irritability or respiratory distress.(1) Older children are more likely to have the classic symptoms or other symptoms such as dribbling, incontinence, abdominal pain, decreased appetite, urinary urgency, blood in the urine or vomiting.

If the odor that your are smelling is from the vagina this may be normal. Many parents are surprised to find that girls as young as two can develop an odor in their private area the same way that adults do. Normal bathing should keep this odor under control. Although, a vaginal odor can be particularly noticeable in a child who still wears diapers.

Wearing a diaper traps moisture and provides a breeding ground for Candida albicans which is the microorganism responsible for yeast infections. Young girls can develop a yeast infection of the skin in the diaper area as well as in their vagina. Those children at risk for developing a Candia Yeast infection include children in diapers, children treated with antibiotics, children with Diabetes Mellitus and children treated with steroids. (2)

A child with a vaginal yeast infection does not display the same symptoms as an adult with this type of infection. The typical symptoms of a vaginal yeast infection in a child include vaginal discomfort, itching, redness, urinary frequency, or burning with urination. Sometimes children can be found rubbing thier private area on furniture. (3) From my experience, most young girls (including toddlers) with a vaginal yeast infection do not have a discharge coming from their vagina. Typically young girls do not develop an odor from a vaginal yeast infection.

The treatment for a vaginal yeast infection in a young child includes baking soda baths, exposing the area to air and the application of anti-fungal crèmes. Over-the counter antifungal crèmes such as Monistat or Lotrimin are used to treat yeast infections. In some cases a prescription antifungal crème may need to be prescribed.

Candida albicans is not the only cause of Vaginitis in a young girl. Vaginitis or the inflammation of the vaginal area can be caused by other infectious agents, irritation, or emotional stress.(4) Normal anatomical variations such as a high or microperforate hymen put some young girls more at risk for developing Vaginitis than others.(4)

Young girls with a high or microperforate hymen are more likely to trap urine or mucus in the area. The pooling of secretions in this area provides a good environment for microorganisms to grow. This cause should be considered in young girls who experience recurrent Vaginitis.

Irritation is a very common cause of Vaginitis in young girls. Items such as scented soap or lotions, bubble baths, tight fitting clothing, stockings and dyes in colored toilet paper or diapers can cause irritation and inflammation of the vaginal area that lead to symptoms. (4) Improper wiping of the female genital area after toileting is a common cause of vaginal irritation and subsequent Vaginitis.

Special care needs to be given to the cleansing of a young girl after toileting, always wiping from front to back, not back to front. Wiping from front to back prevents stool from being pushed into the vagina and contaminating the area. Sometimes a small piece of toilet paper or piece of stool can become trapped in the vaginal area which can cause irritation and in some cases an infection.(4)

As a part of normal development, toddlers and preschoolers learn about and explore their genital area through touching.(4) Frequent touching and playing with the genitals is another potential cause of Vaginitis in young girls. A tiny vaginal laceration may result if the child touches themsleves with sharp, untrimmed nails. The signs of a vaginal laceration include vaginal discomfort, burning with urination or bleeding.

In some cases a child’s natural exploring may lead to the insertion of a foreign body into the vagina. Items such a bead or a part from a small toy can become accidentally lodged in the area. (3) Symptoms of a foreign body in the vagina include vaginal discomfort, vaginal bleeding, a toddler who points to the area or an older child who says something is stuck.

Many times children will not tell a parent or even remember that they put something in one of their orifices. If a foreign body remains in the vagina for a length of time an infection can develop which can lead to odor and in some cases a discharge.

Symptoms of Vaginitis can mimic many disorders; therefore it is important to have a child who has vaginal symptoms evaluated by a Doctor or Nurse Practitioner. Urinary frequency and burning with urination can be caused by a Urinary Tract Infection. Redness and excessive itching of the vaginal area can be due to a vaginal strep infection. Pinworms, a common childhood infestation may also present with Vaginitis.(5)

If your daughter’s vaginal odor is relieved with bathing and only worsened after prolonged periods in her diaper this may be normal. If the odor is quite noticeable, not relieved by bathing or associated with fever, discharge or discomfort an evaluation by your Doctor or Nurse Practitioner is warranted. If you have noticed that your daughter has recently been touching and exploring her genital area and are not sure whether or not she placed a foreign body in her vagina, an evaluation would also be necessary.

I hope this answers your questions.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Burning with Urination

Candida Diaper Rash

Oral Candida Infection

Toddler Swallowed Paper Clips

Pinworms

Vaginal Strep

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. 1990:532.
(2)Goldstein SM. Advances in the treatment of superficial candida infections. Semin Dermatol. 1993;12:315-330.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:832-833.
(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1711-1714,209-210.
(5) Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:489.


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

Pediatric Advice About Childhood Illnesses

Seizures

Dear Lisa,

My little toddler has just recently had a seizure due to an elevated fever. He is 27 months old. Now I am beginning to wonder if he has epilepsy due to several reasons. Number one is...for several months he will just stare with a blank look in his eyes (as if he is really thinking about something) when we try to talk to him he acts as if we are not speaking to him at all. Then in a minute or so he will just begin to act like himself again. He also has just now started saying MaMa and DaDa..he is only able to say one or two more words...not very clearly though...however, he is extremely intelligent...as he knows exactly what you are saying to him and he has ways of letting you know what he wants...but he will not talk. Now that he has had this seizure due to a high fever from an ear infection...I am concerned that he may have been having seizures all along.. Please tell me if the symptoms I have described seem to be seizure related.....I love him so very much....

“Son with Staring Spells”

Dear “Son with Staring Spells’,

Epilepsy (also known as a seizure disorder) is one of the three most common neurologic disorders seen in the pediatric population.(1) Epilepsy is a chronic disorder of recurrent unprovoked seizures. A seizure is defined as a paradoxical nervous system event that is caused by an abnormal electrical discharge and associated with a change in usual functioning.(1} Seizures tend to occur more often in both the elderly and the very young and many Epileptic syndromes do present in childhood.

The typical manifestations of a seizure include twitching of the extremities, fluttering of the eyes, muscle rigidity or loss of muscle tone followed by a period of weakness. There are different types of seizures, some of them having a more subtle presentation. A simple partial seizure may present with something as mild as hand twitching and an Absence seizure can occur and appear as if a child is daydreaming.

There are triggers or conditions that can cause a seizure to occur. These triggers include; fever, injury, infection, sleep deprivation or use of elicit drugs.(1) The trigger itself can be quite serious and needs to be addressed as well as the seizure itself. It has been determined that one in eleven people will experience a seizure sometime in their lifetime.(2) Therefore, not everyone who has a seizure is considered to have Epilepsy. A diagnosis of Epilepsy is only made when a child has two or more unprovoked seizures or one unprovoked seizure with an abnormal EEG.(1)

Unprovoked means the seizure is not caused by a trigger. Therefore children who experience a seizure caused by a trigger are not considered to have Epilepsy. A seizure associated with a fever or a Febrile Seizure is considered a provoked seizure and is different from Epilepsy.

A Febrile Seizure is defined as a seizure that is associated with a fever in a child who is over 6 months old and free from a central nervous system infection or electrolyte imbalance. Febrile seizures more commonly occur in children between the ages of 6 months and 6 years old, with the average age of occurrence being 18 months old.

Children at risk for developing Febrile Seizures include those with a first or second degree relative with a history of Febrile Seizures, children who had a neonatal nursery stay for more than 30 days, children with a developmental delay and those attending daycare.(3) Although, it is possible for any child to develop a Febrile Seizure.

Witnessing a Febrile Seizure is a very scary experience, especially if it is your child having the seizure. Thirty three percent of children who have a Febrile Seizure will experience a second one and 10% will have three or more. (4) Children who experience their first Febrile Seizure before 18 months old are more likely to have recurrences.(1) Many doctors recommend control of future fevers with Tylenol every 4 hours or Ibuprofen every 6 hours, but there is limited evidence that these measures prevent a Febrile Seizure from occurring.(1)

When a child experiences a Febrile Seizure, this does not mean he will develop a seizure disorder later in life. You should be relieved to know that researchers on the Perinatal Collaborative Study noted that young children with febrile seizures do not go on to have chronic seizures.(5)

Even though your son’s Febrile Seizure does not constitute a seizure disorder such as Epilepsy, his staring spells are a concern. One type of generalized seizure, an Absence Seizure can present as a staring spell in children. The usual age of occurrence of Absence seizures is between 4 and 25 years old. During an Absence seizure a child experiences a brief loss of environmental awareness. Typically these staring spells only last a few seconds. Many times they are accompanied by eye fluttering or other manifestations such as turning of the head/eyes or humming.(6) Unlike other types of seizure activity, postictal symptoms such as weakness or confusion do not occur after an Absence Seizure.

In order to determine if these staring spells represent true seizure activity, an evaluation by a Pediatric Neurologist should be performed. A detailed description of the events is needed in order for the Doctor to diagnose a seizure disorder or determine if the episodes are due to another cause.(1) In addition to the evaluation, bloodwork and diagnostic testing including an EEG are typically part of the work-up.

In order to provide a thorough description of your son’s spells , it would be a good idea to keep a diary of the events. The diary should include the time of day, duration of the spell, any associated symptoms, your son’s activity before and after the episode, whether there is a change in color or breathing pattern and whether or not there are vocalizations during the event.(1) Other information such as your son’s sleep and family history will also need to be related to the doctor in order to make the presentation complete. It would be helpful if the doctor had a video recording of the event so that he can witness the episode firsthand.

Staring spells could also be a sign of a developmental delay. Having a developmental delay does not mean that a child is not intelligent. In some cases there may be a deficit in a specific area such as expressive language or hearing that may prevent a child from attaining his developmental milestones. One of the risk factors for a Febrile Seizure is a developmental delay and from the description of your son’s speech, it sounds like he may have a delay in his speech development.

Typically by the time a toddler is 25 months old he should be able to express up to 270 words with an average of 75 words spoken per hour during free play. At this age a child should use phrases in their speech by putting two words together such as, “Give me” or “milk please”. (7) Since your son is 27 months old and saying only 4 single words, this puts him in the category of a child who has a delay in speech development. It would be important to discuss this with your son’s Pediatrician.

Your Pediatrician can refer you to a Speech Therapist of Early Intervention Program in your area for an evaluation. Addressing this issue should be done at this time because early treatment is the key to promoting childhood development. Early Intervention Programs do have a cut off age which means your son may not be eligible for these services if you wait until he is older.

If your son is diagnosed with a speech delay it is also important to have other areas of childhood development evaluated. A comprehensive evaluation is necessary because in some cases a language delay in childhood can be a presenting symptom of another problem.(8) A child’s coordination, sensory skills, neurological status, perceptual-motor function, neurologic status and hearing are additional areas that should be assessed. An initial screening at the Pediatrician’s office is usually the first step and in some cases a referral to a Neurodevelopmental specialist may be necessary.

Your son is very luck to have a mother that is so concerned about him and loves him so much. By approaching these issues one day at a time you will be able to get all of the information that you need. I wish you and your son well.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Speech Delay

Infant with Back Arching

References:
(1)Wolf S McGoldrick P. Recognition and Management of Pediatric Seizures. Pediatric Annals.2006.35(5):332-344.
(2)Resnick TJ. Epilepsy 101: practical points for pediatricians. Presented at: Miami Children’s Hospital’s 41st Annual Pediatric Postgraduate Course: “Perspectives in Pediatric”:February 6-9,2006; Miami Beach, Fla.
(3)Camfield P, Camfield C, Gordon K. Antecedents and risk factors for febrile seizures. Febrile Seizures. In: Baram TZ, Shinnar S (eds) Febrile Seizure. Philadelphia, PA: Elsevier; 2002:27-35.
(4)Shinnar S. Pellock JM. Update on the epidemiology and prognosis of pediatric epilepsy. J Child Neurol. 2002;17(Suppl 1):S1-S14.
(5) Zacharyczuk C. New Data lead to better treatment for children with seizures. Infectious Diseases in Children. 2006. February:47.
(6) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:647.
(7)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:933-955.
(8)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:2074.


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

Advice For Parents About Childhood Health Conditions