Saturday, March 24, 2007

Coughing Infant

Dear Lisa,

My 6-month old baby is teething, but for the last, she had a running nose. This morning when she woke up, she had a very bad cough. We don't have a medical aid, but she has to see a doctor. Can you please give me some advice?

God bless.

“Worried Mom”

Dear “Worried Mom”,

Babies that are teething tend to have a runny nose and drool a lot. Other signs of teething include waking at night, bulging gums, bleeding gums, fussiness, irritability, putting objects or fists in the mouth, biting and gnawing.(1) These symptoms seem to intensify a few days before a tooth actually erupts. Babies may also experience diarrhea, a diaper rash, low grade fever and cough right before they “break a tooth”.

It is normal for a baby that is teething to cough a few times per day. Coughing is a natural protective mechanism that clears the secretions from the baby’s airway. If the frequency of the cough is more than a few times per day or if the quality of the cough is deep or harsh, it may be due to another condition.

Constantly putting hands and teething rings in the mouth increases an infant’s exposure to germs that cause Upper Respiratory Infections. It is common for a baby to develop a virus or an Upper Respiratory Tract infection while teething. Therefore, the development of a cough in a teething infant can be a sign of a respiratory infection. Signs of an Upper Respiratory Tract infection include; nasal discharge, sneezing, fussiness, decreased appetite and cough.(2)

Many times it is difficult to differentiate a baby who is teething from one with an Upper Respiratory Tract infection. Therefore it is a good idea to have a baby with a cough or signs of a respiratory infection evaluated by a health care professional. In addition, infants are at risk for developing complications from an upper respiratory infection. These complications may include Otitis Media (Middle Ear Infection), Bronchiolitis or Pneumonia.

Otitis Media is the infection of the middle ear cavity. It is commonly referred to as a Middle Ear Infection. A Middle Ear infection is a common childhood ailment which accounts for 20% of all visits to the doctor during the first five years of life.(3) The symptoms include earache, sensation of “blockage” of ears, rubbing or pulling ears, hearing loss, fever, irritability, upper respiratory symptoms, vomiting or diarrhea.(3)

Bronchiolitis is one of the most common and serious viral infection that affects the lower respiratory tract in young children.(4) Almost 85% of cases are caused by the RSV virus. 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.(5) Signs and symptoms of Bronchiolitis last for 10 to 14 days with the most intense symptoms occurring by the fifth day.(5)

Bronchiolitis is usually a mild and self limiting disorder, but in some cases it can become quite serious. It happens to be the most common cause of hospitalization among infants. 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.

Signs of Pneumonia in an infant include fever, fast breathing and irritability. (6) In some cases an Atypical Pneumonia may occur which presents with different symptoms. Signs of Atypical Pneumonia include; cough, fast breathing or wheezing. A fever is typically not present in a child with Atypical Pneumonia. (6)

The diagnosis of Pneumonia is made from a physical examination, bloodwork and X-rays. Many times X-ray results will "lag behind" the clinical presentation of Pneumonia. In other words, an initial X-ray will show normal results, but a follow-up X-ray performed at a later date demonstrates signs of Pneumonia. (6) Sputum analysis is routinely not performed on children because of the difficulty of obtaining a suitable specimen. (6)

It is a good sign that your daughter is not experiencing difficulty with feeding, irritability, fast breathing or fever. It is important to watch for these signs because they can represent a condition more serious than teething. Concerning signs include a baby who will not drink, fever over 100 degrees Fahrenheit, increased respiratory rate, increased work of breathing, nasal flaring, retractions (chest wall sucks in between the ribs with breathing), wheezing, pale or blue color and a baby that cannot be consoled. If your baby is experiencing any of these symptoms an evaluation by a Physician should be performed without delay.

I hope your baby is feeling better soon.

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


Baby with Cold Symptoms

Otitis Media

Treatment for Cough

Chronic Cough



(1)Grassia T. Talking teething: Start god oral hygiene early. Infectious Diseases in Children. 2006. August:44.
(2) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 707-708.
(3)Alper B, Fox G. Acute Otitis Media. The Clinical Advisor. 2005. April:78-86.
(4)Linzer JF, Guthrie CG. Managing a winter season risk: bronchiolitis in Children. Pediat Emerg Med Rep. 2003.8:13—24.
(5)Bradin SA. Croup and Bronchiolitis: Classic Childhood Maladies Still Pack a Punch. Consultant for Pediatricians. 2006. Jan:23-30.
(6)Nield L, Mahajan P, Kamat D. Pneumonia: Update on Causes-and Treatment Options. Consultant for Pediatricians. 2005. Sept:365-370.

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

Pediatric Advice For Parents

Thursday, March 22, 2007

Noisy Breathing

Dear Lisa,

My 6-week-old's chest is noisy when he breathes. His nose is not running, he doesn't have a fever, he doesn't have a rash, his appetite is not affected, but he is irritable. What could be wrong with him?


Dear “Buttaflies”,

The chest wall of an infant is very thin and pliable as compared to the chest wall of an adult. Because of this it is very easy to see the muscles in the chest move and hear rumbling from inside of the chest. Babies are also obligate nose breathers which means they breathe only through their nose, not their mouth. They continue to be nose breathers for the entire first year of life. Since all of an infant’s breathing is through his nose, the slightest congestion or mucus tends to make a lot of noise.

Young infants can be very noisy breathers when their nasal passages are congested. The sounds of upper airway congestion can transmit to the lower airway and sound like they are coming from the chest instead. A newborn can develop nasal congestion due to irritants in the environment or due to the build up of secretions from an Upper Respiratory Tract Infection. Signs of an Upper Respiratory Tract infection include nasal discharge, sneezing, fussiness, decreased appetite and an occasional mild cough.(1)

One of the most common causes of obstruction of the airway and resulting noisy breathing in a child is Adenoidal Tonsillar Hypertrophy or enlarged tonsils and adenoids. Tonsil and adenoid tissue can enlarge from recurrent infection, allergy and from non-specific stimuli. (2) Signs of enlarged tonsils and adenoids include snoring, snorting, obstructive sleep apnea and recurrent ear infections.(2) Enlarged tonsils and Adenoids are diagnosed by neck x-ray or by nasopharyngoscopy performed by an Otolaryngologist. (2)

As a child grows the diameter of his airway naturally enlarges. The increased size of the airway can better accommodate the tonsillar and adenoid tissue. In many cases the symptoms of enlarged tonsils and adenoids disappear as a child grows older.

Laryngomalacia is another common pediatric condition that causes noisy breathing during infancy. The symptoms include Stridor or a “high” pitched inspiratory wheeze that begins at birth or shortly after birth. Laryngomalacia is caused by a softening of the cartilage in the upper airway. When a child has Laryngomalacia his upper airway temporarily collapses during inspiration. The airway then opens again during expiration or when the baby exhales.

The breathing of a child with Laryngomalacia is the loudest when he is feeding or quietly relaxing. Viral infections tend to exacerbate the symptoms of Laryngomalacia. The loud breathing usually diminishes during sleep or when the child is crying.(2) As a child grows the cartilage all over the body, including the cartilage in the airway hardens. Because of this, as a child ages the symptoms of Laryngomalacia decreases. In most cases Laryngomalacia resolves on its own by the time the child is one year old.(2)

The presence of a Hemangioma in the airway is another potential cause of Stridor in the newborn period. A Hemangioma in the subglottic space is one of the most common types of airway lesions found in the pediatric population.(2) Children with stridor who also have a Hemangioma on their skin have an increased chance of having a Hemangioma in the airway.(2)

The facts that your baby does not have a fever, has a good appetite and is not in respiratory distress are all good signs. The noisy breathing that you hear may be due to normal newborn congestion or due to an Upper Respiratory Infection or the "Common Cold". An evaluation by your Pediatrician can guide you regarding the proper diagnosis and treatment. If your child’s symptoms continue to concern you a consultation with a Pediatric Pulmonologist can ease your worries by diagnosing the condition that is causing his noisy breathing.

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

Baby with Stuffy Nose

Newborn Congestion

Treating Baby’s Cold Symptoms

Newborn Breathing Problem

Obstructive Sleep Apnea

(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 707-708.
(2)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:424-425.

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

Pediatric Advice For Moms with Newborns

Tuesday, March 20, 2007

Strep Infection

Hello Lisa,

I just happened to come across your site and am so glad I did. My question is that I have a 3 year old daughter who since early this morning has vomited four times in four hours and her morning stool had streaks of blood and when I wiped her there was pinkish red blood on the paper. I'm not sure if this would help but two days ago she broke out in what almost looked like acne on her chin and neck. I counted 13 little bumps. I'm not sure if they could be related but just in case I wanted to mention it. I tend to over react so your opinion would be greatly appreciated.

Thank you in advance.

“Pimples on the chin”

Dear "Pimples on the chin",

Pimples around the mouth in a young child and vomiting can both be signs of a group A beta hemolytic Streptococcus infection or Strep throat. Other signs of Strep throat include fever, painful throat, decreased appetite, drooling, stomach ache, bad breath, headache, runny nose, swollen lymph nodes in the neck, nausea, and abdominal pain. (1,2) Although Strep Pharyngitis is usually associated with fever, some children with Strep have little or no fever at all.(1)

Symptoms that are specific for a Strep infection include pettechiae or red spots on the soft palate and a fine sandpapery like rash on the torso. (1,2) A new type of skin rash associated with Strep pharyngitis has been documented in the literature. It has been described as a painful, itchy, burning rash on the palms of the hands, soles of the feet, buttocks and knees. Once the infection resolves the skin in the area of the rash tends to peel. This new presentation of Strep is thought to be caused by a toxin-mediated immune response. (3)

Young children are known to put their hands in their mouth and touch their buttocks or vagina. This activity puts a child with Strep throat at risk for also developing Rectal Strep (Perianal Streptococcal Dermatitis) and Vaginal Strep. (4) Signs of Rectal Strep include rectal pain with defecation, rectal itching, redness, and rectal bleeding.(4) When a child infected with Rectal Strep scratches her rectal area the skin becomes irritated and bleeding may occur. Signs of Vaginal Strep include itching and redness of the vaginal area. Discomfort with urination is also commonly found.

Blood in the stool can be a sign of a gastro-intestinal infection, especially if diarrhea accompanies the symptoms. An example of a gastro-intestinal infection that causes blood to appear in the stool is Salmonella. When a child experiences blood in her stool it is necessary to determine its cause. It is a good idea to bring the suspicious stool sample to the Doctor’s office with your daughter for the evaluation. There is a test called a Guaiac or Hemoccult that can be performed on a stool specimen to determine if the red color is truly blood.

Blood in the stool may also occur when a child is constipated. The hardness and large size of the stool can cause a tiny cut or laceration when the stool is passed. This tiny laceration can bleed when a child has a bowel movement. A child with a history of constipation who develops vomiting at the same time should be evaluated by a Physician in order to rule out an intestinal obstruction. Other signs of an intestinal obstruction include abdominal pain and abdominal distention.

It is difficult to assess symptoms in the pediatric population because young children do not have the ability to effectively verbalize and describe what they are feeling. To make matters more complicated, a child’s symptoms can be very general or subtle in nature. For example, a change in temperament or sleep pattern is sometimes the only noticeable sign that a child is ill. A young child with a sore throat is not likely to tell her mother that her throat hurts. Instead she may have a decrease in appetite or refuse to eat or drink all together. Health Professionals who have experience with children are aware of the difficulties in assessing a child’s condition. Therefore, you should not be concerned that you are overreacting when it comes to your child's health.

Without physically examining your child I am not able to definitively tell you what is causing your daughter's symptoms. Only the Physician who performs a physical examination on your child and knows her family and medical history can determine the cause of her symptoms and make a diagnosis. I do feel that your daughter’s symptoms warrant an examination by her Physician . Since her symptoms include vomiting, blood in the stool and pimples around her mouth, a Strep infection should be a consideration.

I hope you find the answers that you are looking for real soon.

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

Strep Pharyngitis

Scarlet Fever


Breastfeeding with Strep

Infant Exposed to Strep

Pimples around the mouth


Blood in Stool


Fecal Impaction


(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: 496-498.
(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; 1997:483-485.
(3)Photoclinic. Atypical Rash Associated With Streptococcal Pharyngitis. Consultant for Pediatricians. 2005. Sept:390-391.
(4)Perianal Streptococcal Pharyngitis. Consultant for Pediatricians. 2005. Oct:441.

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

Pediatric Advice About Infectious Diseases

Friday, March 16, 2007

Severe Asthma

Dear Lisa,

My 8 year old son suffers from severe asthma. We have problems every week to two weeks. It seems that it is getting worse. We are currently taking Singulair, Advair diskus, and Maxair. We also do updraft treatments. Do you have any suggestions? I am worried that it might be something else. We have a family history of COPD, Asthma, alpha 1 antitrypsin def. and lung cancer.

Any thing would greatly be appreciated. Thanks.


Dear “Mom4kids”,

Your son is lucky to have a mom that is so concerned about him and interested in finding ways to improve his condition. Unfortunately, Asthma is a chronic medical condition consisting of periods of exacerbations. It requires frequent medical evaluations, follow up care and in many cases daily medication and treatments.

When a child’s Asthma symptoms occur more than twice per week, the condition is considered to be out of control. The first step in gaining control of your son’s Asthma is to determine and eliminate the triggers that may be exacerbating his condition. Potential Asthma triggers include Allergies, infections, irritants, weather, medications, exercise, hormone fluctuations and emotional stress. (1) The most likely triggers for an eight year old child include Allergies, irritants and emotional stress.

It is important to rule out Allergies as a contributng factor in your son’s condition. If your son is constantly being exposed to products that he is allergic to, his Asthma will continue to remain out of control. Irritants in his environment should also be considered. Irritants known to trigger Asthma include cigarette smoke, wood burning stoves, diesel fuel, air pollution, household cleaning products, air fresheners, powder, perfume and scented candles.

Has there been a change in the environment which may be responsible for the exacerbation of your son’s symptoms? Does he have a new friend that he has been playing with who owns a pet? Does his condition worsen when he sleeps on the sofa or over a relative’s house? Are there cat or dog hairs on his coat or hat? Does he have a new coat or blanket made with down feathers? Is there construction going on in your home or at school? Have you changed the position of the bed in his bedroom? Is the bed now located under a heating vent with the air blowing dust and re-circulated irritants into his face all night while he is sleeping? Is he under stress at school due to a change in work load? These are some of the questions that you need to ask yourself in order to determine if there is something in his environment that is triggering his Asthma.

It may be helpful to keep a diary and write down the environmental conditions, exposures, his activities, the weather, his state of health and any over-the-counter medications that he may be taking. You should record information from the day before his symptoms begin. In some cases there may be a late phase response where symtpoms do not develop until up to 12 hours after an exposure. That is why it is important to record what he was doing the night before his symptoms begin. A consultation with a Nurse Practitioner at an Asthma Specialist’s office can guide you in determining your son’s triggers. There may be certain measures that you can take to control his environment, eliminate triggers and ultimately control his symptoms.

It is important that you have your son evaluated by an Asthma Specialist. Pulmonary Function Testing is a necessary part of the work up which will evaluate his lung function and determine the effectiveness of his medication regime. A complete evaluation should also include the evaluation for underlying conditions that that may be contributing to your son's Asthma. An infection with Sinusitis, Allergies, Gastroesophageal Reflux, Vocal Cord Dysfunction and side effects from medications can all contribute to the worsening of a child’s Asthma.(2)

An evaluation by an Allergist and allergy testing are recommended in order to determine if Allergies are playing a part in your son’s condition. Allergies and Asthma frequently come hand and hand. Allergen exposure happens to be a major trigger of symptoms in 80% to 90% of children with Asthma.(3) If a child is determined to have Allergies; measures taken to control the child’s allergies will also help control the child’s Asthma.

An association between the presence of Gastroesophageal Reflux Disease (GERD) and Asthma in the pediatric population has been noted. GERD is thought to contribute to ongoing Asthma symptoms and may be substantially involved in the underlying pathogenesis of Asthma.(4) Studies have shown that 50 to 63% of children with Asthma also have underlying GERD. Signs of Gastroesophageal Reflux in an older child include heartburn and difficulty swallowing. (5) Other symptoms may include abdominal pain, vomiting, coughing at night, belching and a sour taste in the mouth.(6)

In some cases Gastroesophageal Reflux can be silent, which means there may not be any vomiting or obvious symptoms. The symptoms could present as a cough or worsening of a child’s underlying Asthma. A significant amount of Asthmatic children with unstable disease have silent GERD.(6) A consultation with an Asthma Specialist or Gastroenterologist will be able to tell you if your son’s Asthma is affected by Gastroesophageal Reflux Disease and treat him accordingly.

Vocal Cord Dysfunction (VCD) is another condition that is associated with Asthma. VCD often occurs in patients with Asthma.(7) When a child suffers from VCD they experience a paradoxical movement of their vocal cords which leads to stridor, wheezing, voice changes and cough.(7) A child experiencing an episode of Vocal Cord Dysfunction appears to have difficulty breathing but continues to maintain normal oxygen levels in their body. VCD can be triggered by exercise and stress. An evaluation by an Asthma specialist during an acute episode can diagnose the problem. The treatment for VCD includes speech therapy performed by a speech therapist who has experience with the condition.

Medications that can trigger Asthma include Non-steroidal anti-inflammatory drugs(NSAIDs) and Beta-blockers. Examples of NSAIDs include Motrin, Advil and Aleve. These over-the-counter products are commonly given to children, many times without consulting a Physician. It is important for parents of children with Asthma to know that this drug class can trigger Asthma and should not be given unless under the direction and observation of your Physician. Asthmatic patients can have worsening of their condition when taking these medications and not realize the association.

There has been recent research linking the administration of Acetaminophen with prevalence of Asthma. The proposed mechanism includes the acetaminophen-induced glutathione depletion theory. Glutathione is found in its largest amount in the respiratory tract. It serves as an anti-oxidant and removes molecules that cause airway inflammation.(8) Results from clinical studies suggest that Acetaminophen can exacerbate Asthma.(9)

In regards to your comments about your family history of COPD, alpha 1-Antitrypsin deficiency and lung cancer; of the three, alpha-1-antitrypsin disorder is a potential cause for chronic respiratory symptoms in childhood. COPD is a chronic lung condition that occurs in the adult population and lung cancer is typically found in adults after years of exposure to carcinogens. Children may develop lung cancer if they have cancer in another part of their body that metastasizes to the lungs.

Alpha-1-Antitrypsin Deficiency is a condition that causes liver or lung disease. Jaundice within the first 3 months of life is usually the presenting sign.(10) The diagnosis is made through quantifying levels of Alpha-1-antitrypsin levels in the blood. Since there is a family history of Alpha-1-Antitrypsin Deficiency you may want to discuss having testing done to rule out this condition with your Doctor.

Other conditions that may cause chronic respiratory symptoms in childhood include Foreign Body Aspiration, Cystic Fibrosis, Pertussis, Tuberculosis and IgA deficiency.(6) Cystic Fibrosis is a chronic disorder that is typically found in Caucasians. It is usually associated with difficulties gaining weight, sinus disease and GI symptoms. When a child suffers from an IgA deficiency they experience an increased susceptibility to respiratory infections. IgA is responsible for fighting respiratory infections such as Sinusitis and Pneumonia. Children with a history of recurrent Sinusitis or Pneumonia should be tested for an IgA deficiency.

I hope this information helps and your son finds control of his Asthma symptoms soon.

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

Asthma Triggers

Asthma Treatment

Early Warning Signs of Asthma

Chronic Cough

Allergy Symptoms

Hayfever Treatments

Food Allergies

Pet Allergy



Gastroesophageal Reflux

GER in Infancy

(1)Mahr T, Crisalida T, Holingsworth J, Ortiz G, Senske Heier B, Briscoe Waldrop J. Attaining the Inside Track on Asthma Control. The Clinical Advisor. 2006. Dec:S2-14.
(2)The Allergy Report. Allergic Disorders: Promoting Best Practice. Available at: Accessed March 2007.
(3)Phipatanakul W. Environmental Factors and Childhood Asthma. Pediatric Annals. 2006. 35(9):647-656.
(4)Gold BD. Review article: epidemiology and management of gastro-esophageal reflux in children. Ailment Pharmacol Ther. 2004. 19(supple 1):22-27.
(5)Hogan M, Wilson N. Asthma in the School-Aged Child. Pediatric Annals. 2003. 32(1):20-25.(6)Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006. 35(4):259-266.
(7)Kaplan A. All that wheezes is not pediatric asthma. The Clinical Advisor. 2007. Jan:31-39.
(8)Eneli I. Acetaminophen and Asthma: Any Connection? Consultant for Pediatricians. 2006. May:281-282.
(9)Eneli, Sadri K, Camargo C Jr, Barr RG. Acetaminophen and the risk of asthma: the epidemiologic and pathophysiologic evidence. Chest. 2005.127:604-612.
(10)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia,PA:W.B.Saunders Company. 1990:408-409.

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

Pediatric Advice For Parents with Sick Children

Thursday, March 15, 2007

First Tooth

Hi Lisa,

I am writing to you to ask you if it is normal for a one month old baby to have teeth coming in? It hasn't broken in yet but I just wanted to know if that is normal.

Well Thank you.


Dear “momsbadgirl”,

The onset of teething varies from child to child. The duration of teething and amount of pain experienced is also different for each child. The average age for the first tooth eruption is between 6 and 8 months old. (1) This does not mean that it is not normal for a child to “break a tooth” as early as one month old or as late as a year old. The onset of teething often follows heredity patterns. Therefore, if the mother or father was an early teether, then the child may follow the same pattern.(1)

In general, an “early teether” experiences her first tooth eruption at 4 months old. A “late teether” may not develop her first tooth until after she turns one year old.(1) The lower central incisors (bottom middle teeth) are usually the first teeth to come in, followed by the four upper incisors. Next the first four molars usually erupt. The second molars typically do not erupt until after the age of two. Between the ages of 2 and 3 years old a child is expected to have 20 teeth.

Signs of teething typically begin a month or more before the tooth actually erupts. The signs of teething include; drooling, waking at night, bulging gums, bleeding gums, fussiness, irritability, putting objects or fists in the mouth, biting and gnawing.(1) Just before a tooth is about to erupt other symptoms may develop such as a diaper rash, diarrhea, low grade fever and cough. (1)
Some people are under the impression that a high fever is a sign of teething. There is no research or data that supports this notion.(1)

A high fever in a baby that is teething is more likely due to an infection such as a virus. Children who are teething frequently develop viruses.(1) The frequent mouthing of various items such as their hands or teething rings may be responsible for transmitting the germs to the child that cause the infection.

So you do not have to be concerned if your child “breaks a tooth” at one month old. The only challenge of an early teether is keeping the teeth clean. It can be quite difficult to open a young infant's mouth and maneuver your fingers in order to properly clean the teeth. Once the first tooth erupts, it is recommended that it should be cleaned on a daily basis.

The way to clean a young infant’s teeth is to wet a clean wash cloth or piece of gauze and gently rub the teeth each night before bedtime. (1) Using a soft bristle toothbrush and water is another alternative. The American Academy of Pediatric Dentistry does not recommend using toothpaste with fluoride until a child is 2 or 3 years old.

On many occasions parents have informed me that they believed their infant was teething because they saw something white on their child’s gums. In many of these cases a coating of milk or a plaque of oral thrush were mistaken for a tooth. So I would not be surprised if the white you are seeing is something else besides teething. If you are not sure, an examination by your Doctor or Nurse Practitioner will be able to tell you if your child is teething or not.

It is a challenge for many parents to figure out if their child is teething. One major clue is, in many cases teething is accompanied by other symptoms such as drooling or waking at night. Therefore looking for other signs of teething may be helpful. It is true that some children can "break a tooth" and show little or no symptoms at all.(1) From my experience, “early teethers” tend to have additional symptoms such as drooling, gnawing or irritability.

I hope this information helps. I wish you good luck with your new baby.

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

Infant Drooling

Caring for Infant's Teeth

Oral Thrush

(1)Grassia T. Talking teething: Start god oral hygiene early. Infectious Diseases in Children. 2006. August:44.

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

Pediatric Advice About Infant Care

Tuesday, March 13, 2007

Not Urinating

Dear Lisa,

My baby daughter has not urinated in about a week what can be the cause of this?

“Baby not Urinating”

Dear “Baby not Urinating”,

If your baby has not urinated in a week she would be extremely ill. Infants and children are expected to urinate approximately 6 times in a twenty-four hour period. Urine is produced hourly at the rate of 1 ml of urine per kilogram of weight per hour.(1) Therefore if your infant weighs 22 pounds or 10 kg she should urinate 10 ml which is equivalent to two teaspoons per hour. This is such a small amount of urine that it can easily go unnoticed.

It is expected that an infant will urinate every 1 ½ hours. Children that are potty trained have the ability to hold in their urine for a few hours and will urinate at intervals throughout the day. Many times parents believe that their child is not urinating because the amount of urine that a child passes is so small that it is difficult to detect in the diaper. This is particularly true for children who wear disposable diapers. Disposable diapers are so absorbent that it is sometimes impossible to tell if a child urinated. To make matters worse, children often urinate at the same time that they have a bowel movement. When this occurs it is too difficult to decipher what part of the dirty diaper is stool and what part is urine.

If you are not sure if your child is urinating, you should rip apart the inside part of the diaper and expose the gel like beads that are beneath the surface. These beads will feel wet and smell like urine if your child urinated. If the inside of the diaper is dry, you should recheck the diaper in 1 ½ hours.

If it is too difficult to determine whether or not the beads are wet, you should bring your baby and the diaper to your Doctor’s office for an evaluation. They will be able to tell if your baby has urinated by weighing her diaper on an infant scale. You should also bring a dry diaper from the same package so that the weight of the two diapers can be compared. If the diaper that your child is wearing weighs more than a brand new diaper, then you will know that your child has urinated.

The conditions that cause a child not to urinate include dehydration, urinary obstruction, renal failure and medication side effects.(1) Other signs of dehydration include dry mucus membranes, a sunken fontanelle (soft spot), decreased tear production during crying, sunken eyeballs, weight loss, increased heart rate, non-elastic skin turgor, weak cry, high pitched cry, muscle weakness, irritability or lethargy.(1) The principle manifestation of Acute Renal Failure is oliguria or anuria. Oliguria is the medical term for scant urine output and anuria is the term for no urine output. Additional signs of Acute Renal Failure include edema(swelling), drowsiness, and fast breathing (1)

The severe reduction or absence of urination in an infant or child is a sign of a serious problem. Any child experiencing decreased or absent urination needs to be evaluated by a health care professional without delay in order to determine and treat the cause.

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

Detecting Urine Output

Particles in Urine

Burning with Urination


(1) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 928-932, 1538.

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

Pediatric Advice on the Web

Monday, March 12, 2007

Pneumococcal Vaccine

Dear Lisa,

My daughter is 21 months old. She still didn't get her last (4th) Pneumococcal Conjugate vaccine. Her doctor keeps telling me that it's O.K., that there is no rush with this one. Is that so?

Here is when my daughter had her previous PCV shots:

#1- when she was 2 months old
#2- when she was 4.5 months old
#3- when she was 12 months old

Should I worry that so much time already passed and the vaccine is still not done?

Should I tell the doctor to give the 4th shot at our next appointment?

“Pneumococcal Conjugate Vaccine”

Dear “Pneumococcal Conjugate Vaccine”,

When a child receives a vaccination her body mounts an immune response. The immune response results in the formation of antibodies or special white blood cells that fight a particular organism. If a child is exposed to that particular organism at a later date, she will be better equipped to fight the infection because the antibodies that are needed are already made and available.

When a child receives a vaccine at a young age, the immune response is not as effective as the immune response of an older child or an adult. Less antibodies are formed and the child is not as well equipped to fight the infection when exposed to it. Therefore, multiple vaccines are given to young infants in order to achieve antibody levels that are sufficient to combat the organism if it is encountered.

The companies that manufacture vaccines perform studies to determine the body’s immune response to vaccines given at specific ages. From this information, a vaccine schedule is recommended so that children will receive the greatest benefit from a vaccine. Following the vaccine schedule gives the child the opportunity to fight infections based on scientific research results.

If a vaccine schedule is not followed, a “catch up” schedule is recommended. The total number of actual injections given according to a “catch up” schedule may be different from the amount of injections given to a child who follows the recommended schedule. For many vaccines, fewer injections are needed if the vaccinations are given at an older age. The down side of this approach is that the young infant is not protected against the disease when they are most susceptible.

The recommended schedule for Prevnar or the Pneumococcal Conjugate Vaccine is three doses at approximately 2 month intervals, followed by a fourth dose at 12 to 15 months old. (1) The recommended dosing interval is 4 to 8 weeks. The fourth dose should be administered at least 2 months after the 3rd dose. (1)

The recommended schedule is as follows:

First Dose: 2 months
Second Dose: 4 months
Third Dose: 6 months
Fourth Dose: 12 – 15 months

The "catch up" schedule for Prevnar can be confusing. When a child misses a vaccination, the total recommended amount of injections changes. For example, if a child did not receive their first Prevnar immunization until they were 2 years old, then only one dose is recommended. (1) If a Child receives the first Prevnar vaccination between 7 and 11 months old, then only a total of 3 doses are recommended.

The schedule that you provided shows that your child missed the 3rd dose or the 6 month vaccination. According to the “catch up” schedule, Dose #3, when administered 8 weeks after dosage #2 is considered the “final” dose if it is given to a child that is greater than or equal to 12 months old. (2) Dose number 4 is only necessary for children aged 12 months to 5 years old who received 3 doses before the age of 12 months. Since your daughter is 21 months old and her 3rd dose was given at 12 months old, that dose would be considered her final dose. In her case, the 4th dose is not necessary.

So you do not have to worry that time has passed and you do not need to insist that the fourth dose be given now. At your daughter’s next scheduled visit, her Doctor should tell you if he recommends the fourth dose or not.

(1)Physician’s Desk Reference. 2004. Montvale, NJ. Thomson PDR at Montvale:3471-3479.
(2)RedBook Online. Recommended Immunization Schedule for Children and Adolescents who start late or who are More than 1 month behind, 2007. Available at: Accessed March 2007.

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

Pediatric Advice About Keeping Children Healthy

Thursday, March 08, 2007

Blue Lips

Dear Lisa,

My son has just had tonsillitis and upset stomach (prescribed a/b) he has been suffering from occasional blue lips but gp's not taking seriously as they haven't seen it and said can't do anything until see what I mean. Lasts 5 or so mins at a time happens 3+ times a day and at night. Please help.

“Son has Blue Lips”,

Dear “Son has Blue Lips”,

Cyanosis is the medical term for the bluish discoloration of the skin. During normal circulation, the oxygen in a child’s blood passes to the tissues. When this passage of oxygen occurs, the blood turns a darker red or bluish color. If there is not enough oxygen in a child’s blood, the bluish color of the blood becomes more pronounced and as a result the skin also appears blue. Therefore Cyanosis is a symptom that should be taken seriously. It can represent an underlying problem with a child’s blood, heart or lungs.

Not every case of Cyanosis represents a serious problem. In some cases, Cyanois can occur as a normal response to various stimuli. For example, if a child is very anxious or exposed to a very cold environment, the amount of blood flow to the arms and legs decreases and slows. (1) This can result in a bluish discoloration of the nail beds. (1) I have seen children with no underlying medical problems experience high temperatures and skin color changes. When a young child’s fever is high their abdomen and back can feel very hot to touch while their arms and legs feel cool. In some of these children the hands and feet may also appear to be bluish in color.

Skin color is also affected by the scattering of light as it is reflected back through the superficial layers of the skin. This scattering of light can make the skin color appear blue and less red. (1) From my experience, this scattering of light tends to make a child’s skin to appear bluish in color when they are sitting in a blue colored room or wearing blue clothes.

Methemoglobinemia is another potential cause of bluish discolored skin in children. Congenital Methemoglobinemia is a condition that a child is born with that involves an abnormality in the processing of iron in the blood. Acquired Methemoglobinemia can occur when a child ingests certain oxidants. Nitrates and nitrites derived from fertilizer and disinfectants in well water and foods are major causes of Acquired Methemoglobinemia. (2). The treatment for Methemoglobinemia includes the administration of Intravenous Methylene blue which reverses the condition by converting Fe +3 to Fe +2. (2)

Very young patients or patients with glucose-6-phosphate deficiencies are more susceptible to Methemoglobinemia. Patients taking drugs associated with drug-induced-Methemoglobinemia such as sulfonamides, acetaminophen (Tylenol), Phenobarbital, phenytoin, acetanilid, aniline dyes, benzocaine, chloroquine, dapsone, naphthalene, nitrates, nitrites, nitrofurantoin, nitroglycerin, nitroprusside, pamaquine, para-aminosalicylic acid, phenacetin , primaquine, quinine and emla crème are also at risk for developing Methemoglobinemia.(3) If you are not sure if the medication that your child is receiving is included in this group you can contact your Pharmacist and read the medication labels to him. He should be able to tell you if the medication that your child is taking contains any of these products.

If your son’s symptoms are new and have only recently developed with this llness, you may want to consider one of the foods or medications that he is taking as a potential cause. You report that your general practitioner is not taking your son’s symptoms seriously since he hasn’t witnessed it; I suggest taking a video recording of the event and bring it into the office.

Since your son’s symptoms are occurring frequently it would be a good idea to keep a diary of the episodes. You should note the room temperature, the relation to activity or other symptoms, any food or medication that your child is taking and the time and duration of the events. This information can help your Doctor determine the cause of your son’s symptoms. If there is a specific time of day that the episodes occur, you may want to make a doctor’s appointment at that particular time of day. You can wait in the waiting area until your son turns blue so that your Doctor can witness the event.

There are tests that can be performed to determine the cause of a child’s blue skin. These tests include a special type of blood sample called an arterial blood gas or a non-invasive test called Pulse Oximetry. These tests performed on a child during a "blue" spell can help your Doctor diagnose the problem.

You seem concerned because your Doctor is not taking your son's symptoms seriously. If your attempts to display your son's symptoms to his Doctor are not successful, it may benefit you to get a second opionion with a Physician who is willing to believe you.

I hope you get to the bottom of your son’s cyanotic spells soon.

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


Breath Holding Spells

Pulse Oximetry

(1)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:140.
(2)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:507.
(3)Physician’s Desk Reference. 2004. Montvale, NJ. Thomson PDR at Montvale:606-607.

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

Pediatric Advice Updated Daily

Monday, March 05, 2007

Learning Disability

Dear Lisa,

My son is in 1st grade. It was recommended that we hold him back in Kindergarten. We didn't. He was out two weeks after having his tonsils out. We have about 2 1/2 months of school left. During a recent IEP meeting (yes, disabilities are involved), the Principal announced that he will probably be recommended for hold back this year (he is currently failing reading and spelling).

Homework is such a struggle and none of us seems to be in the same page. Can we let homework go until the Fall?


“Dear “Mom of 1st Grader”,

Homework is a struggle for many children, whether there is a learning disability involved or not. Problems with homework are only intensified when a child suffers from a health condition such as a learning disability or Attention Deficit Disorder (ADD). Homework takes concentration, discipline, attention and patience. Some children naturally develop these attributes with age and maturity while others need special help. It can be quite frustrating for both the parent and the child when the process does not come naturally.

Be assured that you are not alone, many parents and children struggle with learning. Approximately 20% of school-aged children have academic performance problems.(1) Since your child is in the IEP, a leaning evaluation must have been performed and the type of learning disability should have been identified. Your son's school should provide him with the tools that he needs to help him with his struggles. In some cases a child may need in classroom support with an aide or other modalities. In other cases, additional tutoring outside of school may be recommended.

If you have not been informed regarding which type of learning disability that your child has, or you do not see an improvement with the interventions implemented, it may benefit your son to have a second opinion. If this is the case, a consultation with a Developmental Pediatrician or Neurodevelopmental specialist can provide you with the guidance that you need. Your Pediatrician can direct you regarding how to find a Developmental Pediatrician, or you can locate one at your local Children’s Hospital.

I can understand your point of view regarding your son’s homework. If your son is going to repeat 1st grade anyway, why suffer through two and a half more months of homework? On the other hand, the more review he receives this year, the smoother next year will go. I suggest asking his teacher how long each assignment is expected to take and then have your son only spend that amount of time on his assignments. On average, most 1st grade teachers will agree that the total homework time should not exceed a total of 45 minutes.

If your son’s teacher tells you that math homework is expected to take 15 minutes to complete then you can make an agreement with her based on this information. It would be reasonable to agree to have your son spend only 15 minutes on Math and finish as much as he can without any penalty for not finishing.

Choosing the time and place that homework is done is half the battle. If homework occurs late in the evening, children may be too tired or hungry to perform successfully. They can become distracted by the household activities such as dinner time and clean up. This is not a good time to do homework, especially if your child has a learning disability. A child with a learning disability requires an organized and structured environment. (2) For example, have your son do his homework in his bedroom or in the dining room, away from the other household noise and distractions. Provide a spacious area with all of the proper equipment available and organized.(2)

When approaching homework, start with a subject that comes easiest for your child. This can prevent him from becoming too frustrated and disappointed in the beginning of the homework period. It will also be helpful to have your son go to the bathroom and eat a snack before starting his homework. This will prevent interruptions that can set him off track.

Another important tool in helping homework time run smoothly is the egg timer. An egg timer can be used to time each part of your son’s homework assignment. If math homework is expected to take 15 minutes, put the timer on for fifteen minutes. Inform him that he is not to get up before the bell goes off. Once the bell rings your son is finished with his math. You can offer incentives, such as 15 minutes playing his favorite video game, if he finishes within the allotted time. It is also a good idea to space out the homework by giving him a 10 minute break between assignments.

Whether or not your son finishes all of his homework and gets every answer correct is not important. As long as he attempts his homework and does the best that he can, he will learn the skills that he needs to discipline himself for next year.

Having a child with a learning disability can be very physically and emotionally draining on a parent. It can also cause a child to experience a lot of stress, feelings of hopelessness and low self esteem. Children with learning disabilities may believe that they cannot learn, that school tasks are too difficult and not worth the effort. (2) As a parent, you are in the position to encourage your child and provide a positive attitude about learning. It is also very important to foster self-esteem and point out areas that your child is successful. Therefore giving your son frequent praise will not only give him encouragement but can help improve his self esteem.

It is important to remember that children do not only learn at school or from doing homework. They also learn from talking, listening, reading with their parents, telling stories and playing games.(2) A good way to reinforce lessons is to have your son play games with cards using numbers and sequences. Playing board games that involve waiting for your turn, counting, reading, matching and finishing the task will also help your son with learning and prepare him for next year. Playing Charades using spelling words or incorporating words and letters into artwork are other fun ways to reinforce school work. Playing games can help your son learn in a relaxed environment and take away the pressure to produce.

I hope these pointers help homework time go a little smoother for the both of you.

For Information About Learning Disabilities contact the following Agencies and Organizations:

Directory of Facilities and Services for the Learning Disabilities, 16th ed. Novato, CA: Academic Therapy; 1998.
Phone 1-800-422-7249 (outside California) or (415)883-3314 (in California)

Learning Disabilities Association of America (LDA)
4156 Library Road, Pittsburgh, PA 15234
Phone: (412)341-1515 or 1(888)300-6710
Email:, Web site:

National Center for Learning Disabilities
381 Park Avenue South, Suite 1401
New York, New York 10016
Phone: (212)545-7510 or 1(888)575-7373
Web site:

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

Homework Tips

Attention Deficit Disorder

Problems Focusing

(1)Kelly D, Aylward G. Identifying School Performance Problems in the Pediatric Office. Pediatric Annals. 2005. 34(4):289-298.
(2)Lambros k, Leslie L. Mangement of the Child with a Learning Disorder. Pediatric Annals. 2005. 34(4):275-287.

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

Pediatric Advice on The Web

Friday, March 02, 2007

Newborn Breathing Problem

Dear Lisa,

My nephew baby, 7bls 4 oz, was born three days ago has had trouble breathing through his nose. They have used meds to take swelling if any from inside of the nose. The oxygen levels are at 95% to 97%...Is this ok? They have a monitor and alarm on him at this point.

They are at a small Hospital in rural Arkansas. Would you suggest going to a children’s hospital at this point?


Dear “Sassygilr”,

If a newborn has problems breathing through the nose, he should be checked for Choanal Atresia, also knonw as Choanal Stenosis. Choanal Atresia occurs when the nasal passage is too narrow or obstructed. The narrowing or obstruction can occur in one or both nasal passages. Either a membranous or bony septum between the nose and the throat is responsible for the obstruction.

When Choanal Atresia is present on one side, the symptoms can be very mild and may not surface until the baby develops his first cold. Signs of unilateral (one-sided) Choanal Atresia include the absence of air moving in and out of the nostril and nasal discharge from the involved side. These signs tend to become more pronounced during a respiratory infection.(1)

If Choanal Atresia is present on both sides, the child can suffer from respiratory distress. The severity of respiratory distress depends upon the degree of obstruction. Signs of bilateral Choanal Atresia include difficulty breathing after the initial cry at birth. The baby may turn blue and develop retractions. The baby also develops sucking in motions of the lips. The distress can be relieved by opening the child’s mouth (1)

If there is a concern that an infant has Choanal Atresia, the Doctor uses a firm catheter and passes it through each nostril, one at a time. If there is difficulty with this maneuver Choanal Atresia is suspected. The diagnosis can be confirmed by direct Nasopharyngoscope or Bronchoscope performed by an Otolaryngologist. In some cases the diagnosis may also be confirmed through a special type of x-ray.

The presence of nasal congestion in the newborn period that interferes with breathing can also be due to other conditions such as Gastroesophageal Reflux or a respiratory infection such as RSV or Sinusitis. The Doctor in charge of the case is responsible for determining the cause of your nephew's symptoms and providing interventions that are necessary to alleviate the problem.

Hemoglobin O2 saturation or pulse oximetry(a number given in a percentage) represents the total oxygen-binding sites on the hemoglobin that are bound with oxygen.(1). Generally speaking, a pulse oximetry reading between 95 and 97% is normal. How this one number relates to your nephew’s overall condition can only be interpreted by the Physician who is caring for him.

A pulse oximetry reading in and of itself is only one measure, one piece of a very large puzzle. Other factors need to be taken into consideration when interpreting a child’s respiratory condition which includes other diagnostic tests, findings from the physical examination and the need for artificial breathing devices or supplemental oxygen. In other words, the O2 saturation reading on a child breathing room air as compared to an O2 saturation reading on a child who is receiving oxygen represents two very different things, even if the number is the same.

Whether or not your nephew needs to be transferred to a Children’s hospital or a higher level Special Care Nursery can best be determined by the Doctor in charge of his case. This generally is a decision made by the Neonatal Intensive Care Physician. If your nephew’s parents do not see any improvement in their child’s condition, are unhappy with the care or are seeking a second opinion they do have the right to be transferred to a different hospital. If this is the case, they should discuss this with their Doctor because this is a decision that should be made in conjunction with the Physician in charge of the case and with the child’s Pediatrician.

It is a very difficult to be in the position of an Aunt, because you are concerned about your nephew’s health, but at the same time, you do not legally have the right to review his medical records, discuss his condition with his Doctor or make decisions about his care. Only his parents have that right. It is very stressful for parents to have a sick newborn. There is a lot of information to absorb and a lot of decisions to be made. In some cases, the opinions of others makes the situation more confusing. Many times parents need time and privacy to make these decisions on their own.

If your nephew’s parents asked your opinion about his medical condition, then it is very admirable of you to seek out the information that they need. In this case, the information that you give them can be very helpful. If they did not ask your opinion about their child’s medical condition then the best thing that you can do is ask them what you can do to help their life run a little smoother.

Congratulations on the birth of your Nephew and I hope that his health issues resolve quickly so that he can go home soon.

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

Newborn Congestion

Baby with a Stuffy Nose

Baby with Cold Symptoms

Gastroesophageal Reflux in infancy

(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1265, 1177.

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

Pediatric Advice For Parents with Newborns