Tuesday, February 27, 2007

How Much Formula?

Dear Lisa,

How much formula and how often should a 3 month, 13 pound baby drink? Thanks.

“How much formula?”

Dear “How much formula?”,

The amount of formula that an infant should take depends upon the weight of the child. A baby needs 50 calories per pound of body weight in a twenty-four hour period. (1)

Therefore a thirteen pound baby needs:

13 X 50 = 650 calories per day

Normal baby formula contains 20 calories per ounce. To figure out how many ounces a baby needs in one day, take the total calories required and divide by 20.

650 divided by 20 = 32.5 ounces of formula per day.

In general, most formula fed infants eat every 3 to 4 hours or 6 to 8 times per day. So in order to figure out how many ounces of formula are needed per feeding:

32.5 ounces divided by 6 = 5.4 ounces

32.5 ounces divided by 8 = 4 ounces

So your answer is:

A thirteen pound baby should drink 4 to 5 ½ ounces of formula per feeding.

This calculation does not apply to premature babies. If a baby is premature, the caloric requirements are different. In addition, premature babies many times are prescribed formulas that contain more then 20 calories per ounce.

It is a general belief that once a baby reaches 32 ounces per day, an increase in formula is not required. Instead, additional calories are given in the form of solid food fed to a baby by a spoon. A baby at three months old is too young to eat solid food. Solid food is typically introduced between the ages of 4 to 6 months old or when the infant doubles their birth weight. (2)

Besides reaching the age of 4 to 6 months, a child should be developmentally ready to accept the food. (2) An infant should have good head control and be able to sit up before he or she is allowed to eat solid food. (2) It is also important not to introduce solids before 4 months old because this may increase the risk of food allergies. A delay in the introduction of solid foods to an infant serves to reduce the risk of food allergies. (3)

Since your baby is already 13 pounds at 3 months old, it would be a good idea to discuss the proper time to introduce solids with your child's health care provider.

Congratulations on your new baby!

If you are interested in reading other Pediatric Advice stories discussing infant feeding issues:

Infant Feeding

Premature Infant Caloric Requirements

Nipple Confusion

Decreased Milk Production During Breastfeeding

Infant Colic

Gassy Baby

Introducing Cow’s Milk

Failure to Gain Weight

(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 303.
(2 )Grassia T. Pediatricians: Discuss healthy nutrition during well child checks. Infectious Diseases in Children. 2006. August: 54.
(3 )Bassett C. What to do when foods become allergens. The Clinical Advisor. 2005. Dec: 43-48.

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

Pediatric Advice About Infant Care

Monday, February 26, 2007

Fecal Impaction

Dear Lisa,

My daughter has recently gotten fecal impaction. We went 3 days with no bowel movement with the last one being one little ball. We tried karo syrup, glycerin suppository, magnesium citrate, and milk of mag with no results. We ended up in the ER with x-rays finding stool in the colon. They gave her an enema at the ER and got good results. She continued to c/o stomach pain throughout the next week and I called and took her to the Dr. numerous times that week. They kept insisting me to continue with the Miralax which she has been on for 1 year. I kept telling them it was doing nothing for her.

One week later with no BM I took her back with severe cramping and did a ct scan finding stool in the ascending and descending colon. They told me to do the Dulcolax. So we did the Dulcolax suppositories and on sun got one result. Mon morning she was able to go on her own and the Dr. also told me to give her another suppository. So I did and got another result on Mon. On Tues she went one time on her own and Dr. said, don't give another laxative. Wed. did not have one at all and Thurs did not have one. Fri had one with the pill form of Dulcolax and Sat(2-17-07)gave Dulcolax again with some results but not as good as they have been.

I went for a second opinion and this Dr. said to cut out the Dulcolax due to side effects are really bothersome to my daughter and said to try Senokot, mineral oil and to continue with my Miralax. So my concern is my daughter is constantly c/o leg aches, bad headaches, and just so fatigued. Is this a sign that the waste left in her is making her colon toxic? The DR. said she still has more in her can tell from pressing on stomach. How long can it stay in there before it starts making things toxic? Will she at some point just start having multiple BM's to get cleaned out all the way? B/c right now she is only having one a day or like now she has skipped 2 days. Should I let her skip or do I need to go back and do the suppository to get immediate results so that she is not getting further backed up? And what I don't understand either is that she stays hungry constantly and although she is having BM she is far from cleaned out with the look of her stomach. IT is so hard and so bulging. How can she possibly still want to continue to eat so much? Do you suggest taken her to a pediatric gastroenterologist also?

Thanks for any advice.

“Fecal Impaction”

Dear “Fecal Impaction”,

A fecal impaction occurs when a constipated child is not able to have a bowel movement. When a child develops constipation she experiences hard painful stools which are difficult to pass. This painful experience causes a child to hold back the stool because they fear it will hurt to have a bowel movement. As a result, a child becomes more constipated and the stool becomes larger and more difficult to pass.

The recommended treatment for fecal impaction is an enema, which is the treatment that your daughter received in the Emergency Room. (1) Once the initial problem is alleviated, and a bowel movement is produced it is imported to figure out the original cause of the constipation and fecal impaction. It is important to determine the cause so that the condition can be treated and the incidence of fecal impaction does not occur again.

Constipation in childhood is usually caused by the child’s diet. Excessive milk ingestion, insufficient amount of fluids and inadequate intake of bulk-forming foods are common causes of constipation in children. (1) Other potential causes include poor bowel habits, laxative misuse or underlying medical conditions. (1)

Medical conditions that may cause constipation include; Hypothyroidism, Celiac Disease, Hirschsprung Disease, muscle disorders, endocrine disorders such as Hypothyroidism or Diabetes mellitus, and medication side effects. (2) Medications that are commonly associated with constipation include; analgesics, anticholinergics, calcium channel blockers and stomach preparations containing Aluminum.

In some cases a child can develop constipation due to an anatomical defect such as rectal stenosis. Rectal stenosis is a condition that occurs when a child’s rectal openining is too tight or too small. Because the opening is so small it is very difficult to pass stools and as a result the child becomes constipated. Rectal stenosis can be confirmed by digital examination by a health care professional. (1)

Pelvic Floor Dyssynergia is another potential cause of constipation in children. This occurs when a child fails to learn to properly coordinate the muscle contractions necessary to pass a stool. When a child experiences Pelvic Floor Dyssynergia, the anal sphincter does not contract properly or in some cases, involuntary spasms occur during a bowel movement. This abnormal contraction prevents the stool from being expelled from the body. Signs of Pelvic Floor Dyssynergia include hard stools, fecal impaction, feelings of anal blockage, severe straining, and the need for digital maneuvers. (3)

Regardless of the cause of the constipation, the first step in treating the condition includes taking measures to promote adequate bowel movements. There needs to be an initial “clean out" period where the fecal material is removed from the colon. (4) This clean out period includes dietary alterations, behavior modification and the administration of laxatives under the supervision of a health care professional. Behavior modifications include having a child sit on the toilet for 10 minutes three times per day.

During this cleaning out process, a child should have a bowel movement on a daily basis until the stool is soft and no longer difficult to pass. If the stools become hard, difficult to pass or cause a lot of straining your doctor should be notified so that an adjustment can be made to the regimen. Since your daughter has an extensive history of constipation that has led to fecal impaction it would be important to not let her go too many days without having a bowel movement. Preferably, she should have a soft bowel movement on a daily basis until her system is cleaned out.

The purpose of laxatives is to soften the stool which allows it to pass more freely. Laxatives are not considered the cure for constipation, but a necessary measure to ensure the proper elimination of stool until the cause of the constipation is determined. It is important to address the underlying cause of your daughter’s symptoms, otherwise the symptoms will most likely return after the laxative is discontinued.

Miralax is one of the laxatives that is commonly used in the pediatric population. From my experience with children treated with Miralax, it works very well at loosening the stool. Typically within a couple of days of administering Miralax the stools should develop a softer consistency. Studies have shown that there is a statistically significant increase in bowel movement frequency observed when patients take Miralax as compared to a placebo. One study demonstrated that on average, patients receiving placebo had 2.7 bowel movements per week, while patients receiving Miralax had 4.5 bowl movements per week. (5)

You mentioned that your daughter was on Miralax for a year and that it was doing nothing for her. I’m not sure if you mean that it never loosened her stools or if the “need” for the Miralax persisted. The purpose of a laxatives is to loosen the stool so they will pass, not cure the cause of the constipation. If the underlying reason for the constipation was never addressed, it would be expected that your daughter’s constipation would return after discontinuing the Miralax. In general, if a child needs a laxative for a over three months, a work up is indicated in order to determine the cause of the constipation.

If your daughter is experiencing abdominal discomfort and pain with her bowel movements, it may helpful to have her to sit in a bath tub filled with warm water. The water should cover her abdomen and she should be allowed to play in the tub while she is monitored by an adult. This can serve as a “natural” enema because during her play in the tub she will relax and water will enter her rectum. This is a non-threatening and non-invasive way of getting water into her rectum, which will soften the stool and help it pass more readily. This approach is much more desirable than giving frequent enemas. Frequent enemas may be psychologically unsuitable and can cause electrolyte imbalances. (4)

Since your daughter has a long standing problem an evaluation by a Pediatric Gastroenterologist is a very reasonable next step. A Pediatric Gastroenterologist can perform a history and Physical examination on your child and order diagnostic testing in order to determine the cause of your daughter’s constipation. A Gastroenterologist can also recommend a treatment plan that addresses her present problem passing stools.

Pertaining to your question about your daughter’s food intake; all children requires a certain amount of calories per day based on their weight. A child needs to ingest the recommended amount of calories in a twenty-four hour period in order to achieve proper growth and development. The same amount of calories is needed whether or not a child has a bowel movement on that particular day. The fact that your daughter is hungry and wants to eat is normal.

It is true that constipation causes some children to experience a decrease in appetite. The abdominal distention and increased intra-abdominal pressure that results from being constipated can exacerbate Gastroesophageal reflux symptoms such as heartburn and regurgitation. These GER symptoms can cause a child to lose their appetite and suffer from insufficient weight grain. Other GER symptoms include vomiting, heartburn, difficulty swallowing, chronic cough, recurrent pneumonia, sore throat, hoarseness, wheezing, bad breath, sinusitis, dental erosions, feeding problems, poor weight gain and weight loss. (6,7,8) In particular children over 2 years old with GERD most often have symptoms related to heartburn as well as abdominal pain, vomiting and cough. (8,9)

The intestines are divided into two sections; the small intestine and the large intestine. The small intestine connects to the stomach and on average measures 21 feet long. It is in the small intestine that most of the absorption of water and nutrients takes place. The large intestine is connected to the small intestine and on average measures 5 feet long. The large intestine is also responsible for the absorption of water and nutrients. Additional purposes of the large intestine include the manufacturing of certain vitamins and the formation of stool. (10) It is the role of the intestines to form and hold stool, therefore presence of stool in the intestines is normal.

The reason why health care professionals are concerned about constipation is not because of toxicity, but because it is a problem that can worsen if not addressed. The longer the stool remains in the intestines, the more water and nutrients are absorbed from the stool into the body. When a lot of water is absorbed from the stool in the large intestines, the stool becomes hard and difficult to pass. This can just worsen the situation. Therefore the goal is to have a constipated child experience a soft bowel movement on a regular basis.

I would not worry that your child will become “toxic” if she doesn’t have a bowel movement. It is more important that the consistency of her stool is soft so she does not experience pain during a bowel movement or hold the stool in. Non-specific symptoms such as leg aches, headaches and fatigue, are common to many conditions and are not necessarily related to constipation. Even thought these specific symptoms may not be caused by constipation, chronic constipation can have a very significant impact on a patient’s overall health. A short term questionnaire given to patients demonstrated that physical functioning, vitality, social functioning, mental health, perception of health and pain scores were worse for patients that suffered from constipation. (11)

I hope your daughter finds relief from her symptoms soon.

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


Constipation Treatment

Stool Withholding

Celiac Disease

Gastroesophageal Reflux

Gastroesophageal Reflux in Infancy

Nutritional Requirements

(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1490-1492.
(2)Borum ML. Constipation: evaluation and management. Prim Care. 2001.28:577-590.
(3) Lembo A. Camilleri M, Chronic Constipation. N England J Med. 2003:349:1360-1368.
(4)Chronic Constipation in Children. Consultant for Peditricians. 2003. Apr:152-155.
(5)Brandt LJ, Prather CM, Quigley EM, Schiller LR, Schoenfeld P, Talley NJ. Systemic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005. 100(Suppl 1)S5-S21.
(6) Waring JP, Feiler MJ, Junter JG. Childhood Gastroesophageal reflux symptoms in adult patients. J Pediatr Gastroenterl Nutr. 2002; 35:334-348.
(7) Christensen M, Gold B. Clinical Management of Infants and Children with Gastroesophageal Reflux Disease: Disease Recognition and Therapeutic Options. Presented at: The Exhibitor’s Theatre Session at the 2002 ASHP Midyear Clinical Meeting, the Georgia World Congress Center; Dec 9, 2002:Atlanta.
(8)Hassall E. Decisions in diagnosing and managing chronic Gastroesophageal reflux disease in children. J Pediatr. 2005;146:S3-S12.
(9)Suwandhi E, Ton M, Schwarz M. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006;35(4):259-266.
(10)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:610-622.
(11)Irvine EJ, Ferrazzi S, Pare P, Thompson WG, Rance L. Health-related quality of life in functional GI disorders: focus on constipation and resource utilization. Am Journal Gastroenterology. 2002. 97:1986-1993.

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

Pediatric Health Advice

Tuesday, February 20, 2007

Chicken Pox

Dear Lisa,

Can u have chicken pox more than once? i had it as a child but have broken out in sore blistery spots, also my nan has chicken pox which i found out yesterday.

“Chicken Pox Twice?”

Dear “Chicken Pox Twice?”,

Varicella Zoster virus is a herpes virus that causes both Chicken Pox and Shingles. Chicken Pox occurs in 90% of U.S. children before they are 10 years old. (1) Shingles usually occurs in the adult population.

The symptoms of the Chicken Pox include a one to three day prodrome in which the exposed person experiences a fever, respiratory symptoms and a headache. Following this three day period the classic Chicken Pox rash develops. At first the rash appears as red flat lesions which then erupt into dew dropped shaped fluid filled sacs on top of a red base.(1)

The rash is distributed throughout the entire body including the torso, extremities, face, scalp and in some cases the mucosal surfaces(inside the mouth).(1) Chicken Pox lesions can cause intense pruritis (itchiness) and lead a patient to have uncontrollable scratching. Once scratched, the lesions form a scab and once healed may leave scarring. New crops of lesions erupt each day, leaving a patient with a rash consisting of lesions at all different stages.

Once a person contracts Chicken Pox they usually do not get it again. Although, it is possible that an individual can develop Chicken Pox more than once. Studies have shown that the second case of Chicken Pox may be as severe as the first.(2) In particular, children with HIV infection can develop chronic or recurrent Chicken Pox with new lesions appearing for months. (3)

Many people are under the impression that they contracted Chicken Pox twice but in reality one of the episodes represented a different skin condition that looked like the Chicken Pox. Skin conditions that may be mistaken for Chicken Pox include; Coxsackie, Enterocytopathic human orphan, Impetigo, Papular urticaria, Scabies, drug eruption, Contact Dermatitis or Folliculitis.(1)

After a child develops Chicken Pox, the Varicella virus remains dormant or in a resting state in the dorsal root ganglia. The virus can then be reactivated later in life when a person is under stress. This reactivation of the Varicella virus causes Shingles.

When a person develops Shingles they first notice pain, pruritis(itchiness) or numbness on an area of their skin. Soon after this an eruption of grouped vesicles form which remain limited to that area. Typically the rash develops in a band like pattern concentrated in that one area and does not cross the midline of the body. (4) Common places to find the Shingles include the waist, torso or chest.

In rarer cases Shingles can affect the trigeminal nerve which can involve the eye and lead to blindness.(4) Therefore the presence of the Shingles on the face or around the eye warrants immediate medical attention and the expertise of an Ophthalmologist. Immunocompromised patients may develop a generalized rash which spreads throughout their body. (3)

Shingles is expected to occur in 20% of health adults and in 50% of immunocompromised patients.(4) It is most common in people older than fifty and in certain children. Children at risk for developing Shingles include those who contracted Chicken Pox before the age of one, those exposed to the Varicella virus in utero, immunocompromised children, children with Systemic Lupus erythematosus and children suffering from Acute Lymphocytic Leukemia or other malignancies.(5) Individuals who are vaccinated for Varicella are less likely to develop Shingles as compared to individuals who were not vaccinated and contracted live Chicken Pox.(6)

If your rash started with symptoms such as numbness, pain or itchiness and is localized to one area of your body, your condition may actually be a reactivation of the Varicella Virus or Shingles. The only way to determine the cause of your rash is to have it evaluated by a health care professional. In the mean time it would be prudent to cover the rash, avoid skin to skin contact with other people and stay away from immunocompromised individuals and children who are not immunized.

It is important to remember that other conditions can look like Chicken Pox, therefore it is essential that you seek medical attention in order to get a proper diagnosis. This way you will know the best way to treat your rash and prevent the spread of infection to others.

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

Chicken Pox Vaccine

Chicken Pox Immunity



Norwegian Scabies

Contact Dermatitis

(1)Pang M. Spot the Rash. Infectious Diseases in Children. 2006. March:90.
(2)Hall S, Maupin T, Seward J. Second varicella infections: Are they more common than previously thought: Pedaitrics.2002.
(3) American Academy of Pediatrics. Varicella-Zoster 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; 1997:573-577.
(4)Krathen R, Hsu S. Vesicular lesions in an elderly woman with pneumonia. The Clinical Advisor. 2006. July:86,93.
(5)Treadwell P. Spot the Rash. Infectious Diseases in Children. 2006. September:104.
(6)Sharrar RG, LaRussa P, Galea SA. The post marketing safety profile of varicella . Vaccine. 2001.19:915-923.

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

Pediatric Advice About Infectious Diseases

Monday, February 19, 2007

Persistent Fever

Dear Lisa,

I've read over a few of your previous answers, but am still concerned. I have a 6 yr. old son who has a temperature. When it started it reached up to 104.4. It's highest point now is about 103 to 102.5. It's been 6 days and I'm really starting to worry. I took him in on day 3 and they said he had no strep but was sick. Dr. advised should last 3-5 days. He's got a stuffy nose, cough and mild nausea. Won't eat, and drinks very little. He doesn't act sick most of the time, wants to play and such. I can't afford to take him back to the dr. and am unsure of what to do next.


“Concerned Mother”

Dear “Concerned Mother”,

Taking care of a child with a fever is probably one of the hardest things that a mother has to do. Watching your child experience such discomfort, not knowing the cause and worrying about complications is very stressful. I know, because I have been in the same situation with my own child. Luckily, the majority of fevers in children are caused by a virus, which means; fluids, rest, time and loving care is all that is needed for a child to get better. In time the child’s body fights the infection and the fever goes away.

There are some situations and signs that should cause a parent to be concerned and seek medical attention. Any child under 3 months old with a fever of 100.4 rectally or higher needs to be evaluated by a Physician. Children at this age are more susceptible to serious infections such as Meningitis or Bacteremia. In addition, fever many times is the only indicator that an infant has a serious infection.(1)

A fever accompanied by a stiff neck, headache, sore throat, rash, painful urination, inability to eat, joint pain, problems breathing or abdominal pain should also be evaluated. (1) Children with a chronic medical conditions such as Diabetes, Sickle Cell Anemia, Immune Deficiency or Asthma need to be seen by a Physician because an illness can cause complications and worsening of the their underlying condition.(1) An evaluation by a health care professional is also indicated in a child with a fever that persists beyond a 5 day period. Even if a child was seen early in the course of his illness, as in the case of your son, a re-evaluation is necessary.

One of the reasons a re-evaluation is necessary is because a child with a virus may develop a secondary bacterial infection. When a child develops a virus his body mounts an immune response and works hard to fight the infection. It is during this time of stress that a child is more susceptible to developing a bacterial infection. That is why it is common for infections such as Sinusitis and Pneumonia to occur after a child is diagnosed with a cold or a virus.

A persistent fever is one of the signs of a bacterial infection.(1) A bacterial infection can settle anywhere in the body, including the respiratory tract, sinuses, urinary tract, skin, blood or the bones. Without the benefit of an evaluation by a health care professional, there is no way for a parent to know if their child has a bacterial infection. In some cases a fever may be the only sign that a bacterial infection is present.

Surely, there are some viruses such as the Influenza Virus or Epstein-Barr Virus (Mononucleosis) that can cause a fever to last beyond 5 days.(2,3) Only a thorough history and physical examination performed by a Physician or Nurse Practitioner can determine if a bacterial infection exists. Therefore the only way to find out if further intervention is neeeded is to bring a child back to the Doctor’s office for an evaluation.

During a follow up examination further testing may be performed in order to determine the cause of a persistent fever. The specific type of testing ordered depends upon the age of the child, his immunization status, social situation, contact with sick people and the findings on his Physical Examination. Bloodwork, urine testing and a chest x-ray are tests that may be performed.

Each Physician has his or her own opinion regarding when a follow up is necessary and which testing needs to be performed on a child with a persistent fever. Since your son has a fever for 6 days now, I suggest that you telephone your Physician and let him know that you cannot afford to return to the office but are concerned about his persistent fever. Your physician should be able to guide you regarding the next step. He is the one that examined your son and is familiar with his condition. He also is aware of the viruses and infections that are prevalent in your community at this time. He may be able to tell you that “Influenza” for example is going around your community and causing a prolonged fever in children.

It is important to stress your financial situation to your Physician because he may be able to offer you options that could help. Some Physicians may be willing to set up a payment plan or defer payments when a parent financially cannot afford healthcare. Your physician can also help you cut down on the cost of health care by offering free medication samples when they are necessary or recommending generic prescription medications instead of brand for a less expensive price.

You may also want to consider calling your insurance broker, Personnel Department that handles your health insurance or Health Department in your town in order to get information about lowering your health care costs. Your local Health Department should be able to give you information about free health clinics in your area.

The US Department of Health and Human Services can provide you with information about low cost health coverage for your family. This agency can give you information about state run programs that provide health insurance to children who do not have insurance. There are financial requirements for the programs offered, but you may still qualify even if you work.

It is also important that you address your child’s fever because the longer he is sick the more days he will miss from school. A longer illness also puts him at risk for complications such as dehydration and also gives him more opportunities to spread the infection to others. Worrying about his fever is also not good for your health, therefore I suggest addressing the situation for both of your sakes.

For Information about Low Cost Health Insurance for Children:

U.S. Department of Health and Human Services Website

NJ FamilyCare Insurance

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

High Fever

Fever, Rash & Joint Pain

Scarlet Fever

Fever and Vomiting

Tylenol Dosage


Tracking Flu Activity

(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: 429-434.
(2)Nield L, Kamat D. “Flu” Season: Here We Go Again.. Consultant for Pediatricians. 2005. Oct:411-416.
(3)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1688-1689.

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

Pediatric Advice For Parents with Sick Children

Thursday, February 15, 2007

Pressure in Vagina

Dear Lisa,

My 10 year old daughter for years has complained of a "bubble" or vaginal pressure that annoys her greatly, however without pain. She has had ultra sounds of the kidney, bladder and abdomen, an MRI, and vaginoscopy and cystoscopy, all of which were normal. She does have a history of chronic UTI's and constipation and is on a laxative and antibiotic now for those. Any ideas of what could be causing her this pressure, that would not appear on any of these exams? We are very frustrated and desperate for any more ideas to explore.

Thanks so much!

“Bubble in Vagina”

Dear “Bubble in Vagina”,

It must be so frustrating to go on for years listening to your daughter complain and not know the reason. It sounds like she has had an extensive work-up to determine the cause. It is also very concerning that she has chronic Urinary Tract Infections for no known reason.

For some children, chronic constipation can cause Urinary Tract infections. The large, hard stools that are present in the abdomen of a constipated child can impede the normal flow of urine through the urinary tract. This can cause the urine to pool or be pushed upwards back into the kidney. This pooling of urine and retrograde movement can put a child at risk for developing a Urinary Tract Infection. Constipation and large, hard stools can also lead to bloating and abdominal discomfort which may be the cause of the pressure that your daughter is feeling in her vaginal area.

The treatment in this case is to address the constipation. Dietary management and laxatives should loosen and clear out the bowels and prevent symptoms from occurring. You did mention that your daughter is on a laxative, but did not mention if it is working or not. If constipation is still an issue, this problem should be addressed first because many times once the constipation resolves the other symptoms go away too. If your daughter’s vaginal symptoms persist even after her constipation has resolved then a different cause should be investigated.

If constipation was the cause of your daughter’s Urinary Tract Infections, then the infections should also be alleviated with the resolution of her constipation. If your daughter still develops Urinary Tract Infections even after the constipation has resolved, then there may be a different reason for her recurrent infections.

Most practitioners agree that young children with a Urinary Tract Infection need a diagnostic work-up to determine the cause. This work-up typically includes a Renal Ultrasound and a Voiding Cystourethrogram(VCUG). (1,2) A Renal Ultrasound can determine if there is an obstruction in the urinary tract, renal stones, or lower tract abnormalities. This test also assesses the size and contour of the kidneys. (1) Since your daughter’s ultrasound was normal these conditions should have been ruled out.

You did not mention if your daughter had a Voiding Cystourethrogram (VCUG) performed, unless the cystoscopy you mentioned was a VCUG. The purpose of the VCUG is to evaluate the lower urinary tract and determine if there are any anatomical abnormalities such as Vesicoureteral Reflux. (3)

The advantage of having a Voiding Cystourethrogram performed is two-fold. Not only can it determine if a child has an anatomical anomaly of the urinary tract, it can assess the walls of the vagina. During a Voiding Cystourethrogram, dye is injected into the urinary tract. This injected dye tends to collect in the vaginal vault. If there is an abnormal opening between the vagina and rectum such as a Rectovaginal fistula this dye can seep through the opening and cause dye to appear in the rectum.

A Rectovaginal fistula is an abnormal communication between the rectum and the vagina. During a bowel movement, pieces of stool can pass through this abnormal opening allowing the vagina to be contaminated. Microorganisms from the stool can travel into the urethra, up into the urinary tract and cause an infection. Therefore children with Rectovaginal fistulas can have stool come out of their vagina and also can develop recurrent Urinary Tract Infections. If a Rectovaginal fistula is suspected a test called a retrograde Urethrocystogram is performed in order to determine if the abnormality exists. (1)

The appearance of a bubble or protrusion upon examination of a child’s vagina can be due to an Imperforate hymen. The hymen is a layer a tissue that surrounds the vaginal opening of a child. It usually ruptures during the perinatal period. If the hymen fails to rupture an Imperforate hymen develops.

An Imperforate hymen is a rare finding, occurring once in every 1,000 to 2,000 females. (4) When it does occur, it tends to go undetected until a female reaches early adolescence. (5) The typical symptoms include abdominal pain, constipation, low back pain, urinary retention, painful urination or frequent urination. (4)

In some cases an Imperforate hymen is not diagnosed until a young girl is old enough to have her period. When a girl with an Imperforate hymen menstruates, menstrual blood accumulates behind the closed hymen and gives it a blue, bulging appearance. (5) Other conditions that may present with similar symptoms include vaginal atresia, transverse vaginal septum, hymenal cyst, hymenal skin tag, or labial adhesions.

Since your daughter’s complaints include “feeling” a bubble and not “seeing” a bubble an Imperforate hymen is not likely the cause of her symptoms. In addition the vaginoscopy that she had performed should have ruled out an abnormality of the hymen and the external genital structures.

Since your daughter is still complaining about pressure in her vaginal area it might be a good idea to have her evaluated by a Pediatric Gynecologist, unless you have already done this when she had her vaginoscopy. A Pediatric Gynecologist has the expertise to diagnose and treat genital abnormalities in children. A Pediatric Gynecologist can also identify normal variations that may be responsible for your daughter’s complaints. It is important that a genital evaluation be performed by an expert in the area because genital abnormalities are quite difficult to diagnose.

Studies have shown that Family practitioners, Pediatricians and Surgeons generally do not excel in this area. Two studies using surveys of Family Practitioners, Pediatricians and Surgeons demonstrated physician difficulty in correctly labeling and identifying basic genital structures on a photograph of a prepubertal child’s genitalia. (6,7) The inability to correctly label basic anatomy on a photograph questions their ability to correctly interpret and diagnose clinical findings.

The vagina tends to be a very sensitive area which frequently causes young girls to complain. Some girls have normal anatomical variations that may cause more complaints than others. These normal variations can lead to different sensations and complaints. For example a high or microperforate hymen may trap drops of urine or mucus and lead to vaginal symptoms. (1)

Another common condition that I found in many of my female patients was Vaginal Adhesions. Vaginal Adhesions occur when tissue in the vaginal area known as the Labia minora sticks together. This causes the vaginal opening to become partially covered and in some cases a pocket to be formed which can trap urine, air or mucus. Vaginal Adhesions also can cause various vaginal complaints.

For girls with vaginal complaints it is a good idea to avoid activities that may contribute to vaginal irritation. Items and activities that can cause vaginal irritation include bubble baths, perfumed soaps, dyes found in colored underwear or colored toilet paper, tight fitting clothes, sitting in tight fitting jeans for prolonged periods and wearing stockings. (1)

I hope this information helps and I hope your daughter finds relief from her discomfort soon.

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


Urinary Tract Infections

Vaginal Odor

(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1526,1470, 1710-1715.
(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. 1990:534.
(3)Moore J. Oral and IV Treatment similar to urinary tract infections. Infectious Diseases in Children. 2006. Dec. 64.
(4)Wall EM, Stone B, Klein BL. Imperforate hymen: a not-so-hidden diagnosis. Am J Emerg Med. 2003.21:249-250.
(5)McAlhany A, Popovich D. Girl, 13, With Swollen Uterus and Pelvic Pain. Clinician Reviews. 2006. 16(10):53-58.
(6)Ladson S, Johnson CF, Doty RE. Do physicians recognize sexual abuse: Am J Dis Child. 1987. 141(4):411-415.
(7)Lentsch K, Johnson C. Do physicians have adequate knowledge of child sexual abuse: The results of two surveys of practicing physicians. 1986 and 1996. Child Maltreat. 2000;5(1)72-78.

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

Pediatric Advice -Your Questions Answered

Wednesday, February 14, 2007

Enlarged Lymph Nodes

Dear Lisa,

My 2 year old son has had enlarged lymph nodes on his neck for over 6 months now. He has been to 3 different pediatricians who say they have no concerns as its not growing and he has had a normal blood test and a normal physical exam. For 3 months now, he has been following up each month for a re-check. They measure it and check his liver and spleen. The doctor just keeps telling us that it's most likely nothing and that it might not go away for quite sometime, he even noted it may take years for it to go back to a normal size. It still worries me every day. Why does this happen to some kids and mean nothing? At what point do we go to a specialist for further testing? We live close to a very respectful children's hospital, why would they not be sending us there? Is there a point that we should see a specialist even if there is no change?

Thank you,

“Anxious and Worried Mom”

Dear "Anxious and Worried Mom",

Each time a child develops un upper respiratory infection or virus the body‘s immune system is activated. The lymphatic system is the part of the immune system that works to fight infections. The immune system consists of a special network of vessels and lymph nodes that are located throughout the body. Some of these lymph nodes are located close to the surface and can be visualized by the human eye while others are located so deep in the body that they never can be seen or felt. The cervical lymph nodes or lymph nodes located in the neck area are ones that are located close to the surface and can be seen and felt.

Children’s cervical lymph nodes enlarge with each upper respiratory tract infection that they contract. Since children are normally expected to develop 5 to 10 upper respiratory infections or viruses per year it is common for the lymph nodes in their neck area to appear enlarged for a long period of time. This is especially prevalent during the winter months when most of the upper respiratory tract infections occur.

Some viruses cause very obvious symptoms such as a fever or a sore throat. Other viruses can cause mild or non-specific symptoms such as irritability or tiredness. When this is the case, a parent may not even know that their child is ill. Therefore a child’s cervical lymph nodes may be swollen due to an infection that a parent does not recall.

Enlarged cervical lymph nodes in children are referred to as “Shotty nodes”. (1) This is a very common finding in the pediatric population and is considered normal. Shotty nodes are typically less than 2 centimeters in diameter, mobile, and not painful. As long as a child with Shotty nodes is evaluated and followed by a health care professional there should not be any cause for alarm.

Lymph nodes that are larger than 2 cm, painful, red or non-mobile are not considered to be normal. These symptoms require medical attention. In addition, enlarged lymph nodes associated with fever, pain, limited motion, weight loss, chronic cough, decreased appetite, rash, difficulty swallowing , abnormal movement of the tongue or joint pain are also a cause for concern. Children with enlarged lymph nodes associated with these symptoms need an evaluation in order to rule out another condition.

Without knowing the location or size of the lumps in you son's neck, it is impossible to determine if his condition is normal or not. Only a health care professional who physically examines your child and knows his medical and family history can make this determination. Since your son was evaluated by three separate Physicians and they all reported that his condition is normal it is unlikely that his condition represents a more serious condition. You can also be assured because his bloodwork was normal and he is not experiencing any other symptoms.

In regards to your question about seeing a specialist; usually the Primary Care Physician refers a patient to a specialist if he feels that it is necessary. Since you saw three Pediatricians and they all felt that your son’s condition is normal, I would be inclined to think that a specialist is not required.

Conditions that would lead me to think that your son may need further attention include the presence of the concerning symptoms mentioned above, swelling below the jaw line or bumps found in an area not consistent with the location of a lymph node. It is important to remember that not every bump or area of swelling in the neck is due to a lymph node. Swelling below the jaw line may be a sign of the Mumps. A mass in the center of the neck, near the Adam’s apple may represent a problem with the thyroid gland. A small round hard nodule located in the upper neck area that moves when a child swallows may be indicative of a Thyroglossal duct cyst. Thyroglossal duct cysts happen to be the most common cause of midline neck mass in children. (3)

If your son’s bumps are not consistent with the characteristics of normal lymph nodes, if they are located in an area not typical of the location of lymph nodes, or if you are still worried you may consider seeing a Pediatric Ear, Nose and Throat specialist or Otolaryngologist. This type of doctor will be able tell you if your son's bumps are normal lymph nodes and confirm your Pediatrician’s previous findings.

I wish you and your son well.

If you are interested in reading other Pediatric Advice Stories about this subject:

Lump in the Neck

Enlarged Lymph Nodes

Lump in the Groin

Inguinal Lymph Nodes


(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:475.
(2)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:588.
(3)Dedivitis RA, Camargo DI, Peixoto GL. Thyroglossal duct; a review of 55 cases. J Am Coll Surg. 2002. 194:274-277.

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

Pediatric Advice For Parents

Monday, February 12, 2007

Only Drinks Milk

Dear Lisa,

My 3 year old has chronic constipation along with stool withholding on top of that he refuses to eat food he lives off milk. What can I do? Respectfully,

“Mrs. M”

Dear “Mrs. M”,

Your son’s constipation is very likely related to his diet. Children need fiber in their diet in order to maintain a normal stool pattern and prevent constipation. Foods such as fruits, vegetables and grains add roughage to the diet. Excessive amounts of milk can also cause a child to become constipated. (1)

Milk alone does not provide the appropriate amount of nutrients necessary for a child’s growth and development. In particular, cow’s milk is a poor source of iron, containing only 0.5mg to 1.5 mg iron per liter.(2) In addition, drinking excessive amounts of cow’s milk can lead to blood loss through the intestines. Children over 6 months old who drink more than 1 quart of cow’s milk per day are at risk for developing Iron Deficiency Anemia.(2)

When a child is constipated he experiences straining and pain when ta bowel movement is passed. Children remember and fear this pain and as a result attempt to hold in their stool to avoid it. When a child holds in his stool, water in the stool is pulled out into the body, leaving a harder, more difficult to pass bowel movement. The longer the child holds in the stool, the harder the bowel movement becomes and a vicious cycle begins. Stool withholding can develop into a chronic problem and lead to complications.

Besides the nutritional value of eating food, young children also need to eat food in order to promote speech development. Biting, chewing and moving food around in the mouth helps develop the muscles and coordination that are necessary for speech. Drinking alone does not help develop the muscles in the mouth, jaw and throat that are responsible for the production of clear speech.

The many benefits of eating solid food should outweigh any concerns you may have about your son’s behavior when you attempt to give him solid foods. It is very normal for children to confront any change in their routine with frustration and acting out. Therefore, his refusal to eat and his acting out behavior should not persuade you to give in to him. Transitioning your son to a diet consisting of solid food is necessary at this time.

At first, the transistion may be difficult and emotionally challenging, but you should be reassured that most children adjust to change in approximately 2 weeks time. During this two week transition period it is important to stay firm in your decision and not give in to your son's pleading or crying. This may be very difficult to do because this behavior does have the potential to wear a mother down. Just remember that the body has a natural instinct, need and desire to eat. When your child is hungry he will eat something.

It should be helpful to know that it is healthier for your child to eat food rather than continue with his present diet consisting only of cow’s milk. When a child drinks milk continually throughout the day, he does not develop hunger or the desire to eat solid food. Therefore it is necessary to take away the milk. If he is drinking from a bottle, it is a good idea to just throw all of his bottles away so that you will not be tempted to give them back to him. You can give him sips of water in the mean time and frequently offer different types of solid food. Your son will initially protest, but when he gets hungry he will eat.

I have some practical suggestions that I hope will help this transition go a little smoother. One suggestion is to have your son stay at an Aunt’s or Grandparent’s house for a couple of days. Have his aunt or Grandma tell your son that there is no more milk and instead, offer other types of solid food. They should offer him foods with different temperatures, textures , shapes and and flavors. Mostly likely he will protest less when he is staying with relatives. Once it is determined which foods he eats at his relative’s house, then you will know what type of solids to offer him when he returns home.

Another suggestion is to have your son visit a friend or neighbor’s with older children and have your son watch them eat. Children learn from each other and many times they like to copy the actions of other kids. It is more likely that your son will eat food if he sees other children eating it.

You can also bring your son with you to the market and ask him to pick out something that he wants to eat. You may be surprised what he picks out. There may be a type of food that he saw an adult eat that he would like to try. Lastly, and probably most importantly, have your son sit down with the rest of the family for meals. Watching other family members eat sets a good example for your son. Parents that eat healthy food with a big smile on their face give their child the message that eating is good. Children learn eating behaviors from their parents, and what better way to teach them than to eat a big plate of fruits and vegetables.

I wish you luck.

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


Treating Constipation

Stool Withholding

Bottle Weaning

Picky Eater


Childhood Nutritional Requirements

(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. 1990:179.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1406

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

Pediatric Advice About Childhood Growth and Development

Thursday, February 08, 2007

High Fever

Dear Lisa,

My Child has high fever (102 to 103) can't bring it down.

“Worried mom”

Dear “Worried mom”,

The presence of a fever probably causes more parental anxiety than any other symptom experienced by a child. A fever is actually a good sign, because it shows that a child’s body is fighting an infection that has invaded his body. It is normal for a person’s body temperature to fluctuate throughout the span of a day. This diurnal variation causes the body to reach its highest temperature between 5 and 7 p.m. in the evening and the lowest temperature early in the morning before rising. (1) Because of this, most fevers are first noticed in the evening hours when the Doctor’s office happens to be closed. This probably is another reason why a febrile child causes a parent so much anxiety.

Generally speaking, if a child develops a fever in the middle of the night most health care professionals will tell you to give him an antipyretic (fever reducing medication) and call back in the morning. This is a reasonable approach to a fever in a child over 3 months old because it is likely that the fever will go down during the daytime hours due to normal physiologic responses.

There are certain situations when a child’s fever should cause a parent to be concerned and seek medical attention. All infants, younger than 3 months old with a rectal temperature reading 100.4 degrees Fahrenheit or higher need an evaluation by a health care professional. This is necessary because a child’s immune system is not fully developed at this young age.(1) A young infant will not be able to fight an infection the way that an older child or adult would. In many cases, a fever in an infant may be the only sign of a serious infection such as a Urinary Tract Infection, Bacteremia (blood infection) or Meningitis.(1) Therefore it is urgent that a young infant with a fever be seen by a health care professional without delay.

Other concerning signs include a fever accompanied by; a stiff neck, severe headache, abdominal pain, vomiting, rash, seizure activity or difficulty breathing. These signs may represent a serious condition and require medical attention. Children with chronic medical conditions such as Sickle Cell Anemia, Diabetes, Neutropenia, Immune Deficiency, Cystic Fibrosis, Cerebral Palsy, Cancer or children without a spleen should also be addressed differently. A fever can compromise an underlying chronic medical condition or may be a sign of a complication. Therefore children with chronic medical conditions should have an action plan created by their Doctor so that a parent knows exactly how to address a fever before it occurs.

Children free from chronic medical conditions or any immune deficiencies should be able to tolerate a fever without any harm to their body. A fever is the body’s regulated response to an infection. Because it is a regulated response, the body’s own defense mechanisms should not allow the core body temperature to reach a level that can be hazardous to the child. It is rare for a child’s fever to reach 107 degrees Fahrenheit or 41.7 degrees Centigrade.(1)

An exception can occur when a child develops Heat Exhaustion due to exposure to extreme heat. Conditions that put a child at risk for developing heat exhaustion include confining a child in a closed car or allowing a child to exercise when they are dehydrated or have a fever.(2) When a child develops heat exhaustion, their body’s natural mechanisms to dispel heat are thwarted.

Normal healthy children can tolerate changes in temperature and a higher core body temperature more than most parents expect. Because of their immature sweat mechanisms children tend to have higher temperatures overall. For example, it is not uncommon for children 18 months old and younger to have a rectal temperature reading of 100 degrees Fahrenheit under normal circumstances.(3) This temperature does not represent an infection and is considered to be normal. Therefore a temperature of 102 in a child this age is not particularly alarming. I am not saying that the fever does not need to be addressed; it just means that it is not an emergency situation. It is feasible to monitor and treat temperatures at this level at home until it is possible for a child to be examined by a Physician.

Many parents ask, “At what temperature should I be concerned?” Any fever associated with an ill-appearing child should cause concern. An otherwise healthy child with no other symptoms experiencing a fever can be managed at home until an evaluation by a health care practitioner can be performed. Children with persistent fevers that last beyond 5 days, regardless of the child’s age or appearance should be evaluated by a Physician or Nurse Practitioner in order to rule out a bacterial infection.

Many parents also ask, “At what temperature should my child be taken to the Hospital or Emergency Room?” This question depends upon a lot of variables. If a child has other symptoms along with a fever such as signs of dehydration, difficulty breathing, is not able to eat or drink, has pain, has a rash, is lethargic or is inconsolable an evaluation by a health care professional is necessary. Your Doctor should be able to direct you regarding how to access care. If you do not have a Doctor or cannot get in touch with your Doctor, then an Emergency Room Visit is the quickest way to have an evaluation by a health care professional when these concerning signs are present.

A temperature itself is not the only indicator that determines how serious a child’s condition is. A child can be quite ill and require an Emergency Room visit even if his temperature is not elevated. The height of the temperature does not necessarily reflect the seriousness of an illness either. A persistent low fever can be the sign of a serious condition such as a chronic infection, collagen vascular disease or tumor.(4) On the other hand, a child can develop a very high fever due to a virus, such as Roseola, which is typically benign and self limiting.

In general, a fever over 104 degrees Fahrenheit should cause some concern and warrants an evaluation in order to determine if a bacterial infection is the culprit. Fevers at this level should be followed closely by a Health Care Professional. A fever as high as 106 degrees Fahrenheit or 41 degrees Centigrade requires urgent medical attention.(4) A visit to the Emergency Room would be warranted in this situation.

The treatment for a fever includes giving anti-pyretics, tepid baths, administering cool fluids and dressing a child appropriately. Ibuprofen is typically recommended for children 6 months old or older with a fever greater than 102 degrees Fahrenheit. Before administering Ibuprofen it is wise to consult with your Doctor to make sure the medication in not contra-indicated in your child. For example, children with PKU should not take over-the-counter products such as Ibuprofen because some formulations may contain aspartame which can worsen the child’s condition.(5)

Acetaminophen is also commonly recommended for children with fever. The overall effect of this medication is dependent upon the dosage used. The Acetaminophen dosage recommendation ranges from 10 to 15 mg of medication per kilogram of child’s weight to be given every 4 to 6 hours.(6) Even though many parents believe that Acetaminophen is not as good as Ibuprofen in reducing fevers; studies have shown that Acetaminophen dosed at the higher end of the dosage scale, 15 mg per kg of child’s weight, is equally effective as Ibuprofen.(6)

When administering Acetaminophen be sure to give the correct dosage because an over dosage can lead to serious complications such as liver damage.(7) In addition, children with G6PD deficiency should not receive Tylenol or any products containing Acetaminophen. (8)

Around the clock treatment with anti-pyretics is not recommended when treating a child’s fever unless your Doctor instructs you to do so. This practice can mask symptoms and interfere with the diagnosis of the cause of the fever. A persistent fever needs to be re-evaluated by a Physician or Nurse Practitioner so that a proper diagnosis can be made. It is a good idea to wait the appropriate time between dosages and administer an anti-pyretic only after the temperature is taken and recorded.

Tepid baths can help reduce a child’s temperature approximately one degree. Unfortunately the effect is usually short lived and the procedure needs to be repeated every 2 hours.(3) When giving a tepid bath, make sure that the temperature of the water is not too cold and the bathing does not cause your child to shiver. Shivering increases a child’s metabolism and causes the fever to rise even higher.(3) In some cases it may be more feasible to gently wipe your child down with a moistened cloth instead of putting his whole body in the tub.

A child with a fever should be dressed in loose fitting cotton clothing. Using layers of light cotton blankets as opposed to a heavy wool blanket is also recommended. Clothing and blankets made from heavy fabrics such as fleece causes heat to become trapped under the material. This can cause an elevation in the child’s temperature. Sipping cool liquids during a fever also aids in reducing the temperature. The added benefit to increasing fluid intake is that it also helps prevent the child from becoming dehydrated due to insensible water loss.

Many parents feel that the minute that a child gets a fever that they need to treat it. Not every fever needs to be treated. If a sleeping child develops a fever it is okay to let him sleep if he is over 3 months of age and free from any other symptoms or chronic medical conditions. In this case scenario it is okay to monitor the temperature and only treat it if the child wakes and is uncomfortable. The fever itself helps fight the infection and as long as the child is comfortable there is no urgency in treating it.

As a parent, if you feel uncomfortable with the way your child appears or with the height of your child’s fever, it is important that you communicate your feelings with your child’s Doctor who can give you further guidance.

If your are interested in reading other Pediatric Advice Stories abvout topics discussed:

Getting a Temperature Reading

Tylenol Dosage

Heat Exhaustion

Exposure to Cold Air

(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. 1990:429-433.
(2)Unusual case of heat stroke in a young boy. The Clinical Advisor. 2006. March:50-58.
(3)Bellack J, Bamford P. Nursing Assessment, A Multidimensional Approach. 1984. Belmont California:283-286.
(4)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 557-561.
(5)Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis, Missouri: Mosby –Yearbook, Inc. 1992:435.
(6)Bell E. Take another look at acetaminophen, ibuprofen or both for managing fever. Infectious Diseases in Children. 2006. April:12.
(7)Physician’s Desk Reference for Nonprescription Drugs, Dietary Supplements, and Herbs. 2007. Montvale, NJ. Thomson PDR at Montvale:679,686.
(8)Greene M. The Harriet Lane Handbook. St. Louis, Miss

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

Pediatric Advice For Parents

Wednesday, February 07, 2007

Ingrown Toenails

Dear Lisa,

My daughter is 20 months old. Few months ago I noticed that her toe nails on her big toes look ingrown. During her routine exam I mentioned it to her doctor. She said that there is nothing to worry about, just put some Vaseline around the baby’s nails and let them grow. I’ve been doing so. However, it doesn’t seem to help. The toe nails grow out, but then break off very close to the skin, which makes it even worse. Is there anything else I could use? I myself have that problem, but it developed when I was in my late teens, and now it doesn’t bother me at all. I worry that her toe nails will get even worse. I really appreciate your advice.

Thank you.

“Ingrown Toenails”

Dear “Ingrown Toenails”,

Ingrown Toenails occur when the nail curves while it grows and embeds into the skin at the corner of the nail. The big toe tends to be the toe that is prone to this problem. It seems that you are concerned that your daughter developed this condition at such a young age, but actually Ingrown Toenails are not uncommon in young children at all. Children can develop Ingrown Toenails during their first year of life.

Some health care professionals believe that restrictive clothing such as tight fitting feetie pajamas or tight socks contribute to the problem. (1) In order to prevent and treat Ingrown Toenails parents should avoid dressing their children in tight fitting footwear. Dressing children in pajamas without attached feet many times rectifies the problem.

The condition usually resolves if a child's nails are cared for properly. (1) Proper nail care includes trimming the nail straight across with a clean clipper or pair of scissors. It is not recommended to cut the nails on a diagonal on the outer edges. Applying gentle pressure on the nail margin after a child comes out of the bath also may help. If this is done on a regular basis, this will eventually lift the nail plate above the adjoining skin.(1)

Ingrown Toenails can become infected therefore it is important to monitor your child’s toe nail for signs and symptoms of an infection. Signs of infection include swelling, redness, induration, warmth and pain. It is important to remember that young children are not be able to communicate pain. Instead they may become irritable, walk with a limp or refuse to let their parents put shoes on their feet.

Pus is another sign of an infected Ingrown Toenail. If gentle pressure is applied to an infected Ingrown Toenail, pus may seep out of the corner where the nail meets the skin. If colored pus is noted with this maneuver, the child should be evaluated by a health care professional.

The treatment for an infection of an Ingrown Toenail includes soaking the toe in warm salt water, applying warm compresses and applying an antibiotic ointment. Warm compresses should be applied for 15 minutes, three to four times per day. In some cases, on oral antibiotic may be needed in order to eradicate the infection. If your child has an Ingrown Toenail and develops signs of an infection an evaluation by a health care professional is necessary.

Typically these non-invasive measures are all that is needed to resolve the problem. It is very rare that a young child requires more aggressive treatment. (1) If chronic or recurrent problems occur an evaluation by a Podiatrist may be needed, but in most childhood cases, this is not necessary.

(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. 1990:32.

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

Pediatric Advice For Parents with Infants

Tuesday, February 06, 2007

Problems Breathing

Dear Lisa,

My son is 2 years old. Since he was born he had problems breathing, he is "always" sick and every time I take him to the doctor and it’s always a flu and it will go away soon. A flu goes away 1 week the most 2 but my son has had a flu I would say most of his short life. I really think there's more to this flu but how can I make the doctor understand?


Dear “Yayo”,

On average most children develop 7 Colds or Viruses per year during the first few years of life.(1) A child in daycare is expected to develop more episodes than average. Most of these Colds and Viruses tend to occur during the winter months. Viral or Cold symptoms including a runny nose or cough can last 10 to 14 days with each episode. Therefore it can appear that a young child is "constantly sick" during the winter months when in reality they are experiencing symptoms of recurring Colds and Viruses.

On the other hand, symptoms that do not go away in between episodes may be due to a different cause. You are correct, a "flu" or Cold should resolve in 1 to 2 weeks. When respiratory symptoms linger beyond the 3 to 4 week mark a further investigation is warranted. Unlike adults, children do not need to have a cough for 8 weeks before it is considered to be chronic. In a child a daily cough that persists for more than 4 weeks is considered to be chronic. (2) Any child with a chronic cough needs to be evaluated in order to determine its cause. (3)

There are many childhood respiratory conditions that cause a chronic cough, with Asthma being high on the list. Other conditions that commonly cause a chronic cough in the pediatric population include Sinusitis, Gastroesophageal reflux and Allergies. In particular the most common cause for chronic cough in the 18 month to 6 year old age group is Sinusitis. Asthma is the second most common cause in this age group.(3)

There are some infectious agents that invade the respiratory system that can cause a mild onset and persistent respiratory symptoms. These infectious agents include Mycoplasma (“Walking Pneumonia”), Bordetella pertussis (Whooping Cough), Cytomegalovirus, Ureaplasma, Urealyticum, Chlamydia trachomatis and Mycobacterium tuberculosis (TB).(3) A child with persistent respiratory symptoms should be evaluated for these infections.

Rare causes of chronic respiratory symptoms include Vascular anomalies, Tracheomalacia, Subglottic Stenosis (the air tube it too small), Bronchogenic cyst, Cystic Fibrosis, Immune deficiency, Immotile Cilia Syndrome and Foreign Body Aspiration. (3) Foreign bodies can become lodged in a child's airway for a length of time without the parent ever knowing it. Chronic cough can be the presenting symptom if the diagnosis was missed. (2)

Lastly, but not the least important, children exposed to second hand cigarette smoke can also develop a chronic cough and respiratory symptoms. Cigarette smoke exposure increases a child’s risk of developing Otitis Media(Middle ear infection), triggers Asthma and increases an infant’s risk for Sudden Infant Death Syndrome(SIDS).(4,5)

If you feel that your child’s respiratory symptoms are chronic in nature and not the result of recurrent acute infections, an evaluation to help determine the cause is necessary. In order to make your Doctor understand the chronicity of your son’s symptoms and how they affect his daily activities, you may need to write down the information and read it to him. For example, instead of bringing in your child into the doctor’s office saying, “He has a runny nose and cough”, it would be more effective to say:

“My son has a continuous runny nose for 28 days with no relief from his symptoms. He has a daily cough which causes him to gag, choke and vomit. He coughs every night which wakes up him and the whole household. The cough has been going on for 6 weeks straight. Whenever he runs around the house he becomes short of breath and winded.”

In other words, give your doctor a very specific description of his symptoms, including how they affect his life. In some cases, it may be helpful to keep a diary so that you can relay an accurate description of his day to day symptoms. If you use this approach and you still feel that your concerns are not being addressed you may want to seek a second opinion with a Pediatric Pulmonologist.

A Pediatric Pulmonologist is a Doctor who specializes in pediatric respiratory conditions and will be able to determine the cause of your son’s symptoms. The work-up for chronic respiratory symptoms or a Chronic Cough includes information about your child’s medical history and family history as well as a physical examination and diagnostic testing.

Pediatric respiratory specialists recommend that all children with a chronic cough receive a Chest x-ray as part of the work up.(2) A Chest x-ray will be able to identify any pulmonary, cardiac or thoracic abnormalites that warrant a further investigation. Spirometry is another important test performed on children. It determines a child's lung function and helps with the diagnosis of Asthma. Traditional Pulmonary Function testing is difficult to obtain in children under five years old because of their lack of cooperation and the unavailability of machinery appropriate for this age group.

Testing for Tuberculosis is recommended for children who live in or travel to countries where Tuberculosis is endemic.(2) For example, Tuberculosis is the second most common cause of chronic cough in 1 to 12 year old children who live in India.(5) Therefore it is very important to report the types of travel your child is involved with. Tuberculosis testing is also recommended in children who have been exposed to high risk adults. High risk adults include those born in countries in which Tuberculosis is endemic, residents of correctional facilities, shelters, or nursing homes, illicit drug users, persons infected with HIV, health care workers, and the homeless.

In addition, a child with chronic respiratory symptoms may need to be tested for Allergies, an Immune deficiency or Cystic Fibrosis. In some cases a Barium Swallow may be recommended if a Vascular anomaly is suspected.

I hope this information helps and you get to the bottom of your son’s respiratory symptoms real soon.

If you would like further information about topics discussed, read other Pediatric Advice Stories:

Baby with Cold Symptoms

Chronic Cough


Asthma Treatment

Asthma Triggers


Allergy Treatment

Gastroesophageal Reflux in Infancy

Gastroesophageal Reflux


Sudden Infant Death Syndrome

Foreign Body Aspiration

The Surgeon Generals Report on
the Effects of Second Hand Cigarette Smoke

(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:707-708.
(2)Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics. ACCP evidence-based clinical practice guidelines. Chest. 2006. 129:260S-283S.
(3)Nield L, Kamat D. How to Handle Chronic Cough in Kids: A Practical Approach to the Workup. Consultant for Pediatricians. 2003. Sept:315-321.
(4)Alper B, Fox G. Acute Otitis Media. The Clinical Advisor. 2005. April:78-85.
(5)The United States Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Available at: www.surgeongeneral.gov/library/secondhandsmoke/. Accessed Jan 2007.
(6)Mogre VS, Mogre SS, Saoji R. Evaluation of chronic cough in children: clinical and diagnostic spectrum and outcome of specific therapy. Indian Pediatr. 2002.39:63-69.

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

Pediatric Advice For Parents with Sick Kids

Monday, February 05, 2007

Breath Holding Spells

Dear Lisa,

I have a 2-yr old that frequently holds her breath when she cries. My son used to do the same, but he grew out of it before turning 1. I'm worried that she is still doing this. She doesn't do it every time she cries, but she does it enough to have me worried. She's even passed out due to holding her breath. What can I do?

“Worried Mom in New Jersey”,

Dear “Worried Mom in New Jersey”,

Breath Holding spells are very frightening to watch. As you already know, a child who holds her breath first starts to cry or becomes angry and then appears to hold her breath. In a few seconds the child may turn pale or blue in color and then go limp.(1)

When witnessing a Breath Holding spell, some parents fear that their child may be having a seizure because in some cases the child develops tonic clonic movements similar to a seizure. The difference between a seizure and a Breathing Holding spell is that a child with a Breath Holding spell cries first, holds her breath, turns pale or blue in color and then develops jerking movements. When a child has a seizure, she has seizure activity or jerking of the extremities first and then develops a change in color to pale or blue during or right after the seizure.(1) When a child has a seizure there usually is no obvious precipitating event. A child who holds her breath commonly does this during a tantrum.

Breath Holding spells occur in 5% of children between 6 months and 6 years old.(1) The treatment for Breath Holding is to ignore the behavior. Sometimes the most difficult advice a parent can receive is the instruction to “do nothing”. It would be much easier to just give a child a medication to make her stop this behavior, but unfortunately there is no medicine that stops a child from holding her breath. It should reassure you to know that there are no serious long term effects or damage done due to Breath Holding spells.(1)

Actually, passing out is the best thing that can physiologically happen to a child’s body during a Breath Holding spell. When a child passes out, the body’s natural reflexes keep the child breathing. This ensures that the required amount of oxygen reaches the brain.(2) If a child sees that a parent becomes upset and does whatever that the child wants to prevent the Breath Holding spell, she will continue to carry out this behavior in order to get attention.

The best way to avoid a Breath Holding spell is to avoid situations that lead to a tantrum. If your child tends to have tantrums at the store, leave her at a relative’s or friend’s home when shopping. If this is not an option try other alternatives to keep her occupied at the store. For example, hide a toy or a book in the closet for a few weeks. Then bring it out at the store for her to play with. The introduction of the new toy will entertain her long enough for you to get your job done.

If your daughter tends to have a tantrum or hold her breath when she’s over tired, try to prevent situations where she misses a nap. Just remember that you are older and wiser than she is and you can manipulate the environment to avoid situations that you know will precipitate a tantrum. You also have the ability to keep her environment safe in case she has a Breath Holding Spell and goes limp. Measures such as keeping her away from stairs, covering the sharp corners of furniture and removing hard objects from the area will assure that she will not become injured when she passes out.

There is no reason to be worried that your daughter is still having Breath Holding Spells at the age of two. This is a common age for them to occur. Breath Holding spells tend to be prevalent during the toddler years. You are fortunate that your son outgrew the episodes by the time he was one year old because for many parents this is not the case. All children do outgrow Breath Holding spells by grade school.(1) It should be reassuring to know that this phase in your daughter’s life will come to an end.

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


(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: 66-67.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:213.

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

Pediatric Advice About Childhood Behavior

Thursday, February 01, 2007

Second Opinion

Dear Lisa,



Dear “TITA”,

It depends on the test that your daughter had. For example, if your daughter had a Chest x-ray the best place to get a second opinion would be with a Pediatric Pulmonologist. If the test was an Echocardiogram or EKG, the best place to get a second opinion would be with a Pediatric Cardiologist. If your daughter had an MRI of the brain, the best place to get a second opinion would be with a Pediatric Neurologist or with a Pediatric Neurosurgeon, depending upon what the doctor was looking for. If the test performed on your daughter was an Ultrasound of the kidney, the best place to get a second opinion would be with a Pediatric Nephrologist.

Pediatric Specialists receive concentrated training that includes the ability to interpret testing pertaining to their particular area. Your Primary Care Physician should be able to direct you to the appropriate specialist depending upon the type of test that your daughter had.

When searching for a Doctor for a second opinion, it is a good idea to ask if he or she is board certified in his or her area of expertise. In addition, you would need to bring the present test results as well as past test results with you to the consultation. If an imaging scan was done such as an x-ray, CAT scan or MRI, a copy of the films would need to be shown to the new Doctor for a second opinion.

A test is only one piece of the entire clinical picture. An impression of the results from a test should only be made in conjunction with a complete history and physical examination. Therefore, it would be important to bring your daughter with you to the consultation so that she can also be examined.

I wish you luck.

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

Pediatric Advice Website