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lyme rash photo

The classic bullseye rash of Lyme

Just like last year, experts are predicting more Lyme disease. While it used to be a pesky disease only in our midatlantic/Lyme Connecticut area of the world, Lyme continues to appear across the northeast and has been reported on the west coast of the United States. According to the American Academy of Pediatric’s Redbook,  about fifty percent of reported Lyme disease is during June and July.  We’ve already had children come  to our office with tick bites concerns, so here’s an update:

Lyme disease is spread to people by blacklegged ticks. Take heart- even in areas where a high percentage of blacklegged ticks carry the bacteria that causes Lyme disease, the risk of getting Lyme from any one infected tick is low. Most of the little critters DON’T carry Lyme disease… but there are an awful lot of ticks out there. Blacklegged ticks are tiny and easy to miss on ourselves and our kids. In the spring, the ticks are in a baby stage (nymph) and can be as small as a poppy seed or sesame seed. In order to spread disease, the tick has to be attached and feeding on human blood for more than 36 hours, and engorged.

In areas in the United States where Lyme disease is prevalent (New England and Mid-Atlantic states, upper Midwest states such as Minnesota and Wisconsin, and California), parents should be vigilant about searching their children’s bodies daily for ticks and for the rash of early Lyme disease. Tick bites, and therefore the rash as well, especially like to show up on the head, in belt lines, groins, and armpits, but can occur anywhere. When my kids were young, I showered them daily in summer time not just to wash off pool water, sunscreen, and dirt, but also for the opportunity to check them for ticks and rashes. Now that they are older I call through the bathroom door periodically when they shower: “Remember to check for ticks!” Read our post on how to remove ticks from your kids.

“I thought that Lyme is spread by deer ticks and deer are all over my yard.”  Nope, it’s not just Bambi that the ticks love. Actually, there are two main types of blacklegged ticks, Ioxdes Scapularis and Ioxdes Pacificus, which both carry Lyme and feed not only on deer, but on small animals such as mice.  (Fun fact: Ioxdes Scapularis is known as a deer tick or a bear tick.)

Most kids get the classic rash of Lyme disease at the site of a tick bite. The rash most commonly occurs by 1-2 weeks after the tick bite and is round, flat, and red or pink. It can have some central clearing. The rash typically does not itch or hurt. The key is that the rash expands to more than 5 cm, and can become quite large as seen in the above photo.  This finding is helpful because if you think you are seeing a rash of Lyme disease on your child, you can safely wait a few days before bringing your child to the pediatrician because the rash will continue to grow. The Lyme disease rash does not come and then fade in the same day, and the small (a few millimeters) red bump that forms at the tick site within a day of removing a tick is not the Lyme disease rash. Knowing that a rash has been enlarging over a few days helps us diagnose the disease. Some kids have fever, headache, or muscle aches at the same time that the rash appears.

If your child has early localized Lyme disease (just the enlarging red round rash), the diagnosis is made by having a doctor examine your child. Your child does not need blood work because it takes several weeks for a person’s body to make antibodies to the disease, and blood work checks for for antibodies against Lyme disease, not actual disease germs. In other words, the test can be negative (normal) when a child does in fact have early localized Lyme disease.

Other symptoms of early Lyme disease may accompany the rash or can occur even in the absence of the rash. This stage is called Early Disseminated disease.   Within about one month from the time of the tick bite, some children with Lyme develop a rash that appears in multiple body sites all at once, not just at the site of the tick bite. Each circular lesion of rash looks like the rash described above,  but usually is smaller. Additional symptoms include fever, body aches, headaches, and fatigue without other viral symptoms such as sore throat, runny nose, and cough. Some kids get one-sided facial weakness. Blood testing at this point is more likely to be positive. 

The treatment of early Lyme disease is straightforward. The child takes 2-3 weeks of an antibiotic that is known to treat Lyme disease effectively such as amoxicillin or doxycycline. Your pediatrician needs to see the rash and evaluate other symptoms to make the diagnosis. Treatment prevents later complications of the disease. Treated children fortunately do not get “chronic Lyme disease.” Once treatment is started, the rash fades over several days and other symptoms, if present, resolve. Sometimes at the beginning of treatment the child experiences chills, aches, or fever for a day or two. This reaction is normal but you should contact your child’s doctor if it persists for longer.

Later stages of Lyme disease  may be treated with  the same oral antibiotic as for early Lyme but for 4 weeks instead of 2-3 weeks. The most common symptom of late stage Lyme disease is arthritis (red, swollen, mildly painful joint) of a large joint such as a knee, hip, or shoulder. Some kids just develop joint swelling without pain and the arthritis can come and go.

For some manifestations, IV antibiotics are used. The longest course of treatment is 4 weeks for any stage. Again, children do not develop “chronic Lyme” disease. If symptoms persist despite adequate treatment, sometimes one more course of antibiotics is prescribed, but if symptoms continue, the diagnosis should be questioned. No advantage is shown by longer treatments. Some adults have lingering symptoms of fatigue and aches years after treatment for Lyme disease. While the cause of the symptoms is not understood, we do know that prolonged courses of antibiotics do not affect symptoms.

For kids eight years old or older, if a blacklegged tick has been attached for well over 36 hours and is clearly engorged, and if you live in an area of high rates of Lyme disease-carrying ticks, your pediatrician may in some instances choose to prescribe a one time dose of the antibiotic doxycycline to prevent Lyme disease. The study that this strategy was based on and a few other criteria that are considered in this situation are described here. Your pediatrician can discuss the pros and cons of this treatment.

Bug checks and insect repellent. Protect kids with DEET containing insect repellents. The Centers for Disease Control recommends 10 to 30 percent DEET- higher percent stays on longer. Spray on clothing and exposed areas and do not apply to babies under two months of age. Grab your kids and preform daily bug checks- in particular look in crevices where ticks like to hide such as the groin, armpits, between the toes and check the hair. Ticks can be tough to spot. Dr. Lai once had a elementary school patient who had a blacklegged tick in the middle of his forehead. The mother noticed it at breakfast, tried to brush it off,  thought it was a scab and sent the boy to school. Later that day the teacher called saying, “I think your son has a bug on his face.”

Misinformation about this disease abounds, and self proclaimed “Lyme disease experts” play into people’s fears. While pediatricians who practice in Lyme disease endemic areas are usually well versed in Lyme disease, if you feel that you need another opinion about your child’s Lyme disease, the “expert” that you should consult would be a pediatric infectious disease specialist.

For a more detailed discussion of Lyme disease, look to the Center for Disease Control website: www.cdc.gov.

Julie Kardos, MD and Naline Lai, MD

©2017, 2016, 2009 Two Peds in a Pod®

 

 

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Mother and Child

Today we bring you a fierce depiction of maternal love, written by poet Catherine Pierce PhD- who is Dr. Kardos’s sister-in-law.
We hope your Mother’s Day is full of flowers and free of tornados.
–Drs. Lai and Kardos

The Mother Warns the Tornado
I know I’ve had more than I deserve.
These lungs that rise and fall without effort,
the husband who sets free house lizards,
this red-doored ranch, my mother on the phone,
the fact that I can eat anything—gouda, popcorn,
massaman curry—without worry. Sometimes
I feel like I’ve been overlooked. Checks
and balances, and I wait for the tally to be evened.
But I am a greedy son of a bitch, and there
I know we are kin. Tornado, this is my child.
Tornado, I won’t say I built him, but I am
his shelter. For months I buoyed him
in the ocean, on the highway; on crowded streets
I learned to walk with my elbows out.
And now he is here, and he is new, and he
is a small moon, an open face, a heart.
Tornado, I want more. Nothing is enough.
Nothing ever is. I will heed the warning
protocol, I will cover him with my body, I will
wait with mattress and flashlight,
but know this: If you come down here—
if you splinter your way through our pines,
if you suck the roof off this red-doored ranch,
if you reach out a smoky arm for my child—
I will turn hacksaw. I will turn grenade.
I will invent for you a throat and choke you.
I will find your stupid wicked whirling
head and cut it off. Do not test me.
If you come down here, I will teach you about
greed and hunger. I will slice you into palm-

sized gusts. Then I will feed you to yourself.

Catherine Pierce
From The Tornado is the World (Saturnalia Books, 2016)

An associate professor and co-director of the creative writing program at Mississippi State, Dr. Pierce has authored three books of poems and won the Mississippi Institute of Arts and Letters Poetry Prize. She is a mom of two young boys.
 
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stye photo

What’s causing this child’s eyelid swelling?

“When the moon hits your eye like a big pizza pie…”
Actually, that’s not amore, but that’s a stye on this child’s upper eyelid.

A stye (medical term = hordeolum) pops up seemingly overnight, although sometimes the child feels some tenderness at the eyelashes a day or two before it appears. Styes are tiny infections of eyelid glands that are self-limited and easily treated with warm wet compresses. We instruct patients to apply a clean, warm, wet cloth to the stye for 5-10 minutes four times per day.

Styes tend to improve after a few days but can take up to two weeks to completely resolve.
Persistent styes may actually be chalazions. Chalazions, the result of a dysfunctional eyelid gland, are firm and are not tender. They tend to “point” toward the inside of the eyelid rather than outward.

Insect bites may also masquerade as styes. However, insect bites are itchy rather than painful.

 

stye

stye: the view from the inside

Reasons to call your child’s doctor:
-the entire eyelid is red, painful, and swollen
-pain is felt inside the eye itself
-child is sensitive to light
-child has vision changes
-the inside white part of your child’s eye becomes red
-stye lasts more than two weeks despite treatment with warm compresses

 

Julie Kardos, MD and Naline Lai, MD
©2013, updated 2017  Two Peds in a Pod®

With special thanks to Dean Martin

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ringwormAlthough it’s called ringworm, this rash isn’t caused by a worm.  In fact, it barely looks like a worm. Otherwise known as tinea corporis, the patch of ringworm is usually a flesh or light-pink colored, slightly scaly oval with raised, red edges.

Caused by a fungus, sometimes the patch is itchy. The same organism also causes athlete’s foot (tinea pedis), jock itch (tinea cruris),  and scalp infections (tinea capitis).

Ringworm falls into the mostly-harmless-but-annoying category of skin rashes (cover it up and no one will notice). Your child’s doctor will diagnose the rash by examining your child’s skin. To treat the rash, apply antifungal medication until the rash is gone for at least 48 hours (about two to three weeks duration). Clotrimazole (for example, brand name Lotrimin) is over-the-counter and is applied twice daily. You will find it in the anti-athlete’s foot section.

On the scalp, ringworm causes hair loss where the rash occurs.  Treatment is not so straight forward. Ringworm on the scalp requires a prescription oral antifungal medication for several weeks. The fungus on the scalp lives not only on the skin, but also in hair follicles. So, topical antifungals fail to reach the infection.

Ringworm spreads through direct contact. Wrestling teams are often plagued with this infection. Cats may carry ringworm. If your family cat has signs of feline ring worm such as patches of hair loss, take him to the vet for diagnosis.

If your child’s “ringworm” fails to improve after a week of applying antifungal medication, have your child’s doctor examine (or re-examine) the rash. Other diagnoses we keep in mind include eczema and granuloma annulare. If the rash continues to enlarge we consider Lyme disease.

Kids are allowed to attend school and daycare with ringworm once treatment is started. Wrestlers are advised to cover the rash for the first three days of treatment.

The sooner you start to treat ringworm, the more quickly it resolves. Just remember, “the early bird catches the…” oh, never mind.

Naline Lai, MD and Julie Kardos, MD
©2017 Two Peds in a Pod®, updated from 2012

 

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flu cartoon

“Now what kind of soup did the doctor recommend? Was that tomato soup? Mushroom barley?”

Happy New Year and welcome to Flu Season 2017! Parents ask us every day how they can tell if their child has the flu or just a common cold. Here’s how:

Colds, even really yucky ones, start out gradually. Think back to your last cold: first your throat felt scratchy or sore, then the next day your nose got stuffy or then started running profusely, then you developed a cough. Sometimes during a cold you get a fever for a few days. Sometimes you get hoarse and lose your voice. Kids are the same way. In addition, they often feel tired because of interrupted sleep from cough or nasal congestion. This tiredness leads to extra crankiness.

Usually kids still feel well enough to play and attend school with colds, as long as they well enough to participate. The average length of a cold is 7-10 days although sometimes it takes two weeks or more for all coughing and nasal congestion to resolve.

Important news flash about mucus: the mucus from a cold can be thick, thin, clear, yellow, green, or white, and can change from one to the other, all in the same cold. The color of mucus does NOT tell you if your child needs an antibiotic and will not help you differentiate between a cold and the flu.

The flu, caused by influenza virus, comes on suddenly and makes you feel as if you’ve been hit by a truck. Flu always causes fever of 101°F or higher and some respiratory symptoms such as runny nose, cough, or sore throat (many times, all three). Children, more often than adults, sometimes will vomit and have diarrhea along with their respiratory symptoms, but contrary to popular belief, there is no such thing as “stomach flu.” In addition to the usual respiratory symptoms, the flu causes body aches, headaches, and often the sensation of your eyes burning. The fever usually lasts 5-7 days. All symptoms come on at once; there is nothing gradual about coming down with the flu.

So, if your child has a runny nose and cough, but is drinking well, playing well, sleeping well and does not have a fever and the symptoms have been around for a few days, the illness is unlikely to “turn into the flu.”

Remember: colds = gradual and annoying. Flu = sudden and miserable.

Fortunately, a vaccine against the flu is available for all kids over 6 months old (unfortunately, the vaccine isn’t effective in younger babies) that can prevent the misery of the flu. In addition, vaccines against influenza save lives by preventing flu-related complications that can be fatal such as pneumonia, encephalitis (brain infection), and severe dehydration.  Even though we are starting to see a lot of flu, it is not too late to get the flu vaccine for your child, so please schedule a flu vaccine ASAP if your child has not yet received one for this season. Parents and caregivers should also immunize themselves- we all know how well a household functions when Mom or Dad have the flu… not very well!

Be sure to read our guest article on ways to prevent colds and flu and our thoughts on over the counter cold medicines.  Now excuse us while we go out to buy yummy-smelling hand soap to entice our kids to wash germs off their hands. After that you’ll find us cooking up a pot of good old-fashioned chicken soup, just in case…

Julie Kardos, MD and Naline Lai, MD
revised from our 2009 and 2015 posts

©2017 Two Peds in a Pod®

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Nearly seven years ago, on the swimming pool bleachers at the local Y, I happened to sit next to Lexi Logan. Above the echoing din of kids splashing, I discovered that although she was trained as a painter, Lexi was interested in branching out into photography. Coincidentally, Dr Kardos and I were interested in branching medicine out into a new media called the internet and were dismayed at the lack of publicly available photos to accompany our blog posts. Lexi and I intersected in the right place at the right time. Since that chance meeting, Lexi has generosity shared dozens of photos with Two Peds in a Pod.

The woman in the photo below, between your Two Peds (Dr. Kardos with the curly hair, Dr. Lai with the straight hair), is our photographer extraordinaire, Lexi Logan. Her work, which you can check out at www.lexilogan.com,  speaks for itself.  Local peeps may want to contact her to take their own family photos.

This Thanksgiving we say thanks to all those parents we’ve ever sat next to on bleachers. All the kid-related information we have learned, from navigating chorus uniforms, bus stop times, best teachers, fun summer camps, and even starting up blogs, has been invaluable.

In particular- thank you, Lexi!

We wish all of our readers a very healthy and happy Thanksgiving,

Dr. Naline  Lai with Dr. Julie Kardos

©2016 Two Peds in a Pod®

two-peds-and-lexi

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stomach-painThis week Two Peds joined Kelley on her blog Happy Health Kids as she talked about the dreaded phrase, “My belly hurts.”

 

If I crunched the numbers on how often my kids have uttered certain phrases, “my belly hurts,” ranks pretty darn high. So common is this refrain, and typically uneventful the outcome, that there’s a cry-wolf quality to it; I typically point my child towards the pantry or bathroom and go about my day. But sometimes, a stomachache persists, and then figuring out the cause can be like falling into a rabbit hole (and equally unpleasant)….click here to continue

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texting collegeToday , Dr. Lai shares with us the texting guidelines she will be giving to her daughter as she goes away for college (wasn’t kindergarten just yesterday?). We can all learn from this list.

–Dr. Kardos

Text me to share a funny meme.

Text me to wish me a happy birthday and then follow it with a call.

Text me if you are about to go over our shared data plan.

Text me if you are deciding whether to study abroad.

Text me sooner than the day before spring break about your spring break plans.

Text me if you are unhappy about a break-up…even if you forgot to tell me you were going out in the first place.

Text me if you have a cold. I know you know what to do, but it will make us both feel better if I tell you to get good rest and hydrate well.

Text me if you are changing majors…but not before you have a plan for a new major

Text me if you find the essentials of life: “eat, sleep, drink, pee, poop,” difficult. Especially the poop—no one will ever obsess about your bowels like a mother (except maybe a grandmother).

Text me when you are not in class (because I know you will be paying rapt attention to your professors and sucking every last bit of paid knowledge out of their craniums).

Text me sometimes at 1am with the understanding that I will be texting you sometimes at 7 am.

Text me to ask for the phone number of your dentist, but do not ask me to schedule the appointment for you.

Text me if you are feeling 😬 or 😞 or like 💩.

Do not text and ask me to email your professors.

Do not text me to ask about your clothing choices for the day…unless you just want me to say you look beautiful.

Do not text me asking for college housing deadline information; you have the same access to the internet as I do. Plus, you are actually on campus!

Do text me to complain about the 4 loads of laundry you did all Saturday afternoon -it makes me happy to see you can survive on your own- and I promise not to lecture you on how you allowed the laundry to pile up.

And of course, text me out of the blue just to say ❤️

mom

aka Naline Lai, MD

©2016 Two Peds in a Pod®

 

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These lucky fish don't have to worry about swimmer's ear... they don't have any ears!

These lucky fish don’t have to worry about swimmer’s ear… they don’t have any ears! –Photo by Dirk Peterson, MD

Its the type of ear pain that usually creeps up on a school aged summer camper. One night he may notice discomfort when his ear is against his  pillow. The next night, the pain gets worse. Eventually, even touching the ear is painful. The ear is probably infected, but infected with “the other kind” of ear infection—swimmer’s ear.

Ear infections are divided into two main types: swimmer’s ear (otitis externa) and middle ear infections (otitis media). An understanding of the anatomy of the ear is important to understanding the differences between the two types of infection.  Imagine you are walking into someone’s ear. When you first enter, you will be in a long tunnel. Keep walking and you will be faced with a closed door. The tunnel is called the external ear canal and the door is called the ear drum.

Swimmer’s ear occurs in the ear canal. Dampness from water, and it can be water from any source- not just the pool, sits in the ear canal and promotes bacterial infection.  

Next, open the door. You will find yourself in a room with a set of three bones. Another closed door lies at the far end.  Look down.  In the floor of the room there is an opening to a drainage pipe. This room is called the middle ear. This is where middle ear infections occur.

During a middle ear infection, fluid, such as during a cold, can collect in the room and promote bacterial infection.  Think of the sensation of clogged ears when you have a cold. Usually the drainage pipe called the eustachian tube,  drains the fluid.  But, if the drain is not working well, or is overwhelmed, fluid gets stuck in the middle ear and become infected. 

Because a swimmer’s ear infection occurs in the external canal, the hallmark symptom of swimmer’s ear is pain produced by pulling the outside of the ear.  Since middle ear infections occur farther down in the ear, pain is not reproduced by pulling on the outer ear.

Swimmer’s ear is treated topically by your doctor with antibiotic drops.  To avoid dizziness and discomfort when putting drops in, first bring the ear drop medicine up to body temp by holding the bottle in your hand.

Home remedies to prevent swimmer’s ear:

  • After immersion in the water, tilt your child’s head to the side and towel dry what leaks out.
  • Mix rubbing alcohol and vinegar in equal parts. After swimming, place a couple drops in the ear.  Do not put these drops in if there is a hole in your child’s eardrum. 
  • Prior to swimming put a drop of mineral oil or olive oil in each ear. This serves as a barrier protection against the water as well an ear wax softener. Do not put in if there is a hole in your child’s eardrum

Although it’s tough to remind children to dry their ears well, take heart.  Dr. Lai once spent two hours trying to get a cockroach out of a child’s ear canal.   We  suspect those parents would have been happier if instead, water had gotten into their child’s ear.

Naline Lai, MD and Julie Kardos, MD

2016 Two Peds in a Pod® 
originally posted August 9, 2009, 2011

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