How can you tell if your child’s scrape is infected if his skin is already bright red?

I heaved a sigh of relief. My children greeted my husband and me at the door. The children had just baby-sat themselves. I thought everyone was unscathed until I saw one of my children covered in bandages. Cuts and scrapes? Apparently, although I had admonished them not to ride anything with wheels and not to climb on anything above the ground, the child with the bandages had tripped over her own feet during a benign game of four square.

“Did you wash the scrapes?” I asked.

“Yes,” the kids said, proudly nodding. They knew the first line of defense against a wound infection is to wash out cuts and scrapes. But as it turns out, they had only dabbed the cuts with wet paper towels. Aghast, I propelled the injured child off to the bathroom and hosed down the cuts. Too many times I have seen a minor scrape turn into a major skin infection.

When a wound is not thoroughly cleansed, the bacteria which normally live on intact skin (Staphylococcus or Streptococcus) find an opportunity to enter the body through the wound and cause infections. Even a mosquito bite can turn into a raging, puss-filled mess if scratched often and not cleansed enough. These days, some children carry on their skin a type of Staphylococcus called MRSA (Methicillin Resistant Staphylococcus Aureus). Since this germ can be tough to treat when it causes an infection, a thorough cleansing is more important than ever.

While infection is rarely introduced from the actual object that cuts the child, exceptions include cuts caused by animal or human bites (the human mouth is particularly filthy) and cuts caused by old, dirty or rusty metal. Tetanus lives in non-oxygenated places such as soil. So for deep or very dirty wounds, make sure your child’s tetanus vaccine is up to date.

Despite what many believe, wiping the surface of a cut with a wipe is not adequate to cleanse a wound. “Irrigate, irrigate, irrigate,” a wise Emergency Department physician explained to me when I was a resident in training. “I have never had someone return with a wound infection,” she said proudly. In the emergency room, saline is usually used. At home, soap and running water are effective. Stay away from hydrogen peroxide and rubbing alcohol because they can irritate rather than help the skin.

After washing your child’s cuts and scrapes, you can use bandages to help prevent further exposure to germs and to avoid irritation from clothes or from your child’s scratching, probing fingers. Infections, if they occur, can set in 2-3 days after your child gets her wound. Remove the bandage daily and check the wound for signs of infection such as pus, increased redness, warmth and pain. Wash the wound again, and then replace the bandage. You could also apply topical antibiotic such as Bacitracin to further help prevent wound infection.

So, even if your child just took a shower, wash him again if he scrapes himself. The sooner you irrigate even the tiniest of wounds, the better.

An ounce of prevention is worth a pound of antibiotics.

Naline Lai, MD and Julie Kardos, MD
© 2018 Two Peds in a Pod®

ick, a tick

I was grumpy all morning after realizing that my dog was out of tick repellent. Really grumpy. I did not like the thought of having to remove a tick from my dog.

After all, on the East Coast of the United States, we are seeing ticks galore. All month long, parents who have had to remove a tick have been bringing us presents such as the one pictured here. Yes, that is a tick you see nicely trapped in tape. Sometimes when parents bring us a tick, it’s still clinging to the child and they ask us to remove it. To save you a trip to the doctor’s office, here is a quick refresher on how to pluck the bugs off:

How to remove a tick:

1. Take a deep breath and pretend that it’s just a speck of lint—not an ugly critter with a bloated stomach and writhing legs.
2. Use tweezers and firmly clasp the head. If the tick is tiny, you will end up grabbing the entire body.
3. Pull the tick straight up and off. Hint: Press down on the skin on either side of the tick so that the skin doesn’t pull up when you pull the tick off. This lessens any pinching sensation your child may feel.

How NOT to remove a tick:

Please do not try to burn a tick off—you’ll just burn your child’s skin.
Avoid suffocation techniques such as covering a tick with petroleum jelly (Vaseline) or nail polish. These techniques are not very effective, they allow the tick to stay on for a longer period of time, and also they may cause the tick to become slippery and difficult to grasp.

What to do after you have removed the tick:

After removal, if the tick’s head is left behind, don’t go digging for it. Just like a tiny splinter, your skin will naturally try to expel it. Soaking the area in warm water will help the process along. Don’t worry about disease transmission: there is not any disease stuck in a tick’s head.

Wash the skin where the tick was using soap and water as you would any cut to prevent a skin infection. A small, minimally tender, pimple-like bump is a common reaction which may linger for a few days. This bump is an irritation response of the skin. If the tick was a deer tick (typically the size of a poppy or sesame seed), watch for the rash of Lyme disease that appears as a flat, pink, round patch about a week later. The patch may clear in the center and grows to at least 2 1/2 inches across.

My daughter told me that once, a girl at her lunch table had a tick on her. None of the kids could pick it off and the girl sat screaming until the lunch lady came over to help her. Maybe you’ll be the lucky adult called over to help next time.

Just remember…pretend it’s a speck of lint.

Naline Lai, MD and Julie Kardos, MD
©2018 Two Peds in a Pod®

Teach your child to recognize poison ivy: “leaves of three, let’em be!”

Recently we’ve had a parade of itchy children troop through our office.  The culprit: poison ivy.

Myth buster: Fortunately, the rash of poison ivy is NOT contagious. You can “catch” a poison ivy rash ONLY from the plant, not from another person.

Another myth buster: You can not spread the rash of poison ivy on yourself through scratching.  However, where  the poison (oil) has touched  your skin, your skin can show a delayed reaction- sometimes up to two weeks later.  Different  areas of skin can react at different times, thus giving the illusion of a spreading rash.

Some home remedies for the itch:

Hopping into the shower and rinsing off within fifteen minutes of exposure can curtail the reaction.  Warning, a bath immediately after exposure may cause the oils to simply swirl around the bathtub and touch new places on your child.

Hydrocortisone 1%-  This is a mild topical steroid which decreases inflammation.  We suggest the ointment- more staying power and unlike the cream will not sting on open areas, use up to four times a day

Calamine lotion – a.k.a. the pink stuff- This is an active ingredient in many of the combination creams.  Apply as many times as you like.

Diphenhydramine (brand name Benadryl)- take orally up to every six hours. If this makes your child too sleepy, once a day Cetirizine (brand name Zyrtec) also has very good anti-itch properties. Some doctors recommend giving it twice a day- ask your pediatrician.

Oatmeal baths – Crush oatmeal, place in old hosiery, tie it off and float in the bathtub- this will prevent oat meal from clogging up your bath tub. Alternatively buy the commercial ones (e.g. Aveeno)

Do not use alcohol or bleach– these items will irritate the rash more than help

The biggest worry with poison ivy rashes is the chance of infection.  Just like with an itchy insect bite, with each scratch, your child is possibly introducing  infection into an open wound.  At night, turn up the air conditioning and put your child into pajamas that cover up the poison ivy. Kids who don’t scratch in the day often scratch subconsciously at night. Unfortunately, it is sometimes difficult to tell the difference between an allergic reaction to poison ivy and an infection.  Both are red, both can be warm, both can be swollen.

However, infections cause pain – if there is pain associated with a poison ivy rash, think infection.  Allergic reactions cause itchiness- if there is itchiness associated with a rash, think allergic reaction.  Because it usually takes time for an infection to “settle in,” an infection will not occur immediately after an exposure to poison ivy.  Infection usually occurs on the 2nd or 3rd day of scratching.  If you have any concerns take your child to her doctor.

Generally, any poison ivy rash which is in the area of the eye or genitals (difficult to apply topical remedies), appears infected, or is just plain making your child miserable needs medical attention.

When all else fails, comfort yourself with this statistic: up to 85% of people are allergic to poison ivy.  If misery loves company, your child certainly has company.

Naline Lai, MD and Julie Kardos, MD
©2018 Two Peds in a Pod®

In the wake of chef Anthony Bourdain and designer Kate Spade’s deaths from suicide, you may be wondering how to address the topic of suicide with your child.  We bring back psychotherapist Dina Ricciardo’s post  for guidance:

“Hi, it’s me, Hannah.  Hannah Baker.” So begins the first episode of 13 Reasons Why, a thirteen installment Netflix series that focuses on the aftermath of the suicide of a 17-year-old high school student.  Based on the novel by Jay Asher, the series has sparked quite a bit of debate and concern among parents and mental health professionals.  At its best, the series has served as a conversation starter; at its worst, it has glamorized suicide and the fantasy of revenge.  At the end of the day, however, an important question remains:  How do we talk with our kids about suicide?  While many difficult topics have become increasingly safer to discuss, suicide is one that is still shrouded in secrecy and shame. In fact, it is so difficult to talk about that I had a hard time writing this post.  Finding the right words about something that often remains unspoken is not an easy task.  So if circumstances require it, how are we to explain suicide to our children?

According to the American Foundation for Suicide Prevention, research has shown that over 90% of people who died by suicide had a diagnosable, though not always identified, brain illness at the time of their death.  Most often this illness was depression, bipolar disorder, or schizophrenia, and was complicated by substance use and abuse.  Just as people die from physical illnesses, they can die as the result of emotional ones.  If we can change the narrative about suicide from talking about it as a weakness or character flaw to the unfortunate outcome of a serious, diagnosable, and treatable illness, then it will become easier for us to speak with honesty and compassion.

Telling the truth about any death is important. While it is natural for us adults to want to protect our children from pain, shielding them from the truth or outright lying will undermine their trust and can create a culture of secrecy and shame that can transcend generations.  We can protect our children best by offering comfort, reassurance, and simple, honest answers to their questions. It is important to recognize that we adults typically offer more information than our children require.  We should start by offering basic information, then let them take the lead on how much they actually want to know.

For young children, your statements may look something like this: “You have seen me crying, that is because I am sad because Uncle Joe has died.”  They may not even ask how the death occurred, but if they do, you can say “He died by suicide. That means he killed himself.”  The rest of the conversation will depend on the child’s response.  With older children, the narrative can follow a similar theme yet use more sophisticated language.  The older the child, the more likely they are to ask direct questions.  Some examples of honest answers are “Do you know how people have illness in their bodies, like when Grandma had a heart attack and our neighbor had cancer?  People can get illness in their brains too, and when that happens, they feel confused, hopeless, and make bad decisions. Uncle Joe didn’t know how to get himself help to stop the pain.”  If they ask how the suicide occurred, you can say “With a gun” or “She cut herself.”  Sometimes you will have to say “I don’t know. I wish I knew the answer.”  Whatever the age of your child, do your best to use simple, truthful language.

Regardless of age, children converse about and process death differently than adults.  If you tell your child about a suicide, it is likely that he/she will want to talk about multiple times over the course of days, weeks, or even years.  Keep the dialogue open, and check in with them periodically if they have questions.  If you find that you or your family is in need of the support of a professional, you might want to consider a bereavement group or a trained professional who specializes in grief.  These resources are available through online directories, local hospitals, and the Psychology Today therapist finder.  Overall, be aware that providing truthful information, encouraging questions, and offering loving reassurance to your children can allow your family to find the strength to cope with terrible loss.

(Excerpts taken from The American Foundation for Suicide Prevention’s “Talking to Children about Suicide”, www.afsp.org.)

Links:

Sesame Sreet Workshop’s When Families Grieve
The Dougy Center for Grieving Children and Families
The American Foundation for Suicide Prevention
Hands Holding Hearts (Bucks County, PA)
The Jed Foundation

Dina Ricciardi, LSW, ACSW

©2017 Two Peds in a Pod®

Guest blogger Dina Ricciardi is a psychotherapist in private practice treating children, adolescents, and adults in Doylestown, PA. She specializes in disordered eating and pediatric and adult anxiety, and is also trained in Sandtray Therapy. Ricciardi is a Licensed Social Worker and a member of the Academy of Certified Social Workers. She can be reached at dina@nourishcounseling.com.

Raw chicken left out overnight—Dr. Lai’s recipe for Salmonella

These days it seems that the bacteria Salmonella is lurking everywhere. Last month’s egg recall for possible Salmonella contamination affected over 200 million eggs, but Salmonella is not just in eggs. In the last few months, dried coconuts and even guinea pigs (as pets, not as food!) have caused people gastroentestinal misery.

Nontyphoidal Salmonella usually causes fever and crampy diarrhea. Sometimes the stools contain blood. This stomach bug mainly lurks in raw poultry, raw eggs, raw beef, and unpasturized dairy products. Luckily, Salmonella does not jump up and attack humans. In general, people are safe from disease as long as they do not eat salmonella-infested food. But children below the age of five often put their hands in their mouths and can acquire Salmonella after touching a  contaminated source.

Reptiles such as  lizards and turtles can carry Salmonella in their stool and are not recommended as pets for young children. Turtles that are four inches or smaller (about the size of a deck of playing cards) are most likely to harbor the bacteria. As a preschooler, Dr. Kardos remembers that her tiny pet turtle suddenly disappeared. Her parents told her that “Her pet would be happier if it went outside to the stream to swim with the other turtles.” In retrospect, Dr. Kardos thinks her pediatrician dad was worried about Salmonella and made the turtle magically disappear.

Even cute little chicks can be problematic. Salmonella carried in the gut of a chick can contaminate the entire surface of a chick. So, although kissing and cuddling a chick makes for a good Instagram post, discourage your children from doing so.

Unfortunately, you cannot depend on a warning stench arising from your lunch to warn you that it is inedible. Salmonella often hides in food and it is difficult to tell what is or is not contaminated. So how can you prevent your kids from catching Salmonella?

Luckily Salmonella is killed by heat and bleach. Even if an otherwise fine-looking and odorless raw egg has Salmonella, adequate cooking will destroy the bacteria. Gone are the days when parents can feed kids soft boiled eggs in a silver cup, have kids wipe up with toast the yolk from a sunny-side up egg, add a raw egg to a milkshake, or let their kids lick the left-over cake batter from the mixing bowl. Instead, cook hardboiled eggs until the yolks are green and crumble, and make sure your scrambled eggs aren’t runny. Wash all utensils well. The disinfecting solution used in childcare centers of ¼ cup bleach to 1 gallon water works well to sanitize counters. Do not keep perishable food, even if it is cooked, out at room temperature for more than two hours. And wash, wash, wash your hands.

A mom once called us frantic because her child had just happily eaten a half-cooked chicken nugget. What if this happens to your child? Don’t panic. Watch for symptoms — the onset of diarrhea from Salmonella is usually between 12 to 36 hours after exposure but can occur up to three days later. The diarrhea can last up to 5-7 days. If symptoms occur, the general recommendation is to ride it out. Prevent dehydration by giving plenty of fluids. My simple rule to prevent dehydration is that more must go in than comes out.

Although of unproven benefit, antibiotic treatment may be considered if your child is at risk for overwhelming infection, including infants younger than three months old and those with abnormal immune systems (cancer, HIV, Sickle Cell disease, kids taking daily steroids for other illnesses) or those with chronic gastrointestinal tract diseases*. Using antibiotics to treat a typical case of salmonella not only promotes general antibiotic resistance, but also does not shorten the time frame for the illness. In fact, the medication can prolong how long your child carries the germ in his stool.

Pictured above is a pot of chicken Dr. Lai accidentally left out overnight one warm summer night. Yuck.

Naline Lai, MD and Julie Kardos, MD

©2018 Two Peds in a Pod®

*Red Book, 2015 Report of the Committee on Infectious Diseases, American Academy of Pediatrics

Gepetto always said his son had allergies, but the villagers knew better

It’s not your imagination. This is a particularly bad spring allergy season. We didn’t need media outlets to tell us that there are more itchy, sneezy, swollen eyed kids out there this year.

It is worth treating your child’s allergy symptoms- less itching leads to improved sleep, better ability to pay attention in school, improved overall mood, and can prevent asthma symptoms in kids who have asthma in addition to their nose and eye allergies.

Luckily, nearly every allergy medication that we wrote prescriptions for a decade ago is now available over-the-counter. As you and your child peer around the pharmacy through itchy blurry eyes, the displays for allergy medications for kids can be overwhelming. Should you chose the medication whose ads feature a bubbly seven-year-old girl kicking a soccer ball in a field of grass, or the medication whose ads feature a bubbly ten-year-old boy roller blading? Its it better to buy a “fast” acting medication or medication that promises your child “relief?”

Here is a guide to sorting out your medication choices:

Oral antihistamines: Oral antihistamines differ mostly by how long they last, how well they help itchiness, and their side effect profile. During an allergic reaction, antihistamines block one of the agents responsible for producing swelling and secretions in your child’s body, called histamine. Prescription antihistamines are not necessarily “stronger.” In fact, at this point there are very few prescription antihistamines. The “best” choice is the one that alleviates your child’s symptoms the best. As a good first choice, if another family member has had success with one antihistamine, then genetics suggest that your child may respond as well to the same medicine. Be sure to check the label for age range and proper dosing.

First generation antihistamines work well at drying up nasal secretions and stopping itchiness but don’t tend to last as long and often make kids very sleepy. Diphenhydramine (brand name Benadryl) is the best known medicine in this category. It lasts only about six hours and can make people so tired that it is the main ingredient for many over-the-counter adult sleep aids. Occasionally, kids become “hyper” and are unable to sleep after taking this medicine. Opinion from Dr. Lai: dye-free formulations of diphenhydramine are poor tasting. Other first generation antihistamines include Brompheniramine (eg. brand names Bromfed and Dimetapp) and Clemastine (eg. brand name Tavist).

Second and third generation antihistamines cause less sedation and are conveniently dosed only once a day. Cetirizine (eg. brand Zyrtec) causes less sleepiness and it helps itching fairly well. Give the dose to your child at bedtime to further decrease the chance of sleepiness during the day. Loratadine (brand name Alavert, Claritin) causes less sleepiness than cetirizine. Fexofenadine (brand name Allegra) causes the least amount of sedation. The liquid formulations in this category tend to be rather sticky, the chewables and dissolvables are favorites among kids. For older children, the pills are a reasonable size for easy swallowing.

Allergy eye drops: Your choices for over-the-counter antihistamine drops include ketotifen fumarate (eg. Zatidor and Alaway). For eyes, drops tend to work better than oral medication. Avoid products that contain vasoconstrictors (look on the label or ask the pharmacist) because these can cause rebound redness after 2-3 days and do not treat the actual cause of the allergy symptoms. Contact lenses can be worn with some allergy eye drops- check the package insert, and avoid wearing contacts when the eyes look red. Artificial tears can help soothe dry itchy eyes as well.

Allergy nose sprays: Simple nasal saline helps flush out allergens and relieves nasal congestion from allergies. Flonase, which used to be available by prescription only, is a steroid allergy nose spray that is quite effective at eliminating symptoms. It takes about a week until your child will notice the benefits of this medicine. Even though this medicine is over-the-counter, check with your child’s pediatrician if you find that your child needs to continue with this spray for more than one allergy season of the year. Day in and day out use can lead to thinning of the nasal septum. Avoid the use of nasal decongestants (e.g., Afrin, Neo-Synephrine) for more than 2-3 days because a rebound runny nose called rhinitis medicamentosa may occur.

Oral Decongestants such as phenylephrine or pseudoephedrine can help decrease nasal stuffiness. This is the “D” in “Claritin D” or “Allegra D.” However, their use is not recommended in children under age 6 years because of potential side effects such as rapid heart rate, increased blood pressure, and sleep disturbances.

Some of the above mentioned medicines can be taken together and some cannot. Read labels carefully for the active ingredient. Do not give more than one oral antihistamine at a time. In contrast, most antihistamine eye drops and nose sprays can be given together along with an oral antihistamine.

If you are still lost, call your child’s pediatrician to tailor an allergy plan specific to her needs.

The best medication for kids? Get the irritating pollen off your child. Have your allergic child wash her hands and face as soon as she comes in from playing outside so she does not rub pollen into her eyes and nose. know that spring and summer allergens/pollen counts are highest in the evening, vs fall allergies where counts are highest in the mornings. Rinse outdoor particles off your child’s body with nightly showers. Filter the air when driving in the car and at home: run the air conditioner and close the windows to prevent the “great” outdoors from entering your child’s nose. If you are wondering about current pollen counts in your area, scroll down to the bottom of many of the weather apps to find pollen counts or log into the American Academy of Allergy Asthma and Immunology’s website.

Naline Lai MD and Julie Kardos, MD
© 2018 Two Peds in a Pod®

Dr. Kardos, on a visit home from medical school, with her mom and grandmothers, 1991.

A flash of surprise spread across her face. “You mean my mother was right? I can’t believe it!” the mom in our office exclaimed.

Many times as we dispense pediatric advice, the parent in our office realizes that their own mother had already offered the same suggestions.

This Mother’s Day, we’re asking readers for anecdotes about times where maybe, just maybe, your mom or your grandmother was right after all. If you have a photo available of your mom or grandmother with your child that you don’t mind sharing as well, we would love to post them along with your anecdotes this Mother’s Day.

Please send them along to us at twopedsinapod@gmail.com before Mother’s Day weekend.

Naline Lai, MD and Julie Kardos, MD

©2018 Two Peds in a Pod®

According to a 2012 National Center for Health Statistics data brief, about half of all children in the United States with an autistic spectrum disorder are diagnosed at age five or older  However, many parents are suspicious much sooner. As part of autism awareness month, we bring you clues in toddler development that can alert you to a potential issue. This post follows up on our earlier post “How can I tell if my baby has autism?“

Pediatricians often use a questionnaire called the M-CHAT (Modified Checklist for Autism in Toddlers) as a screening tool. This test can be downloaded for free. In our office we administer the M-CHAT at the 18-month well child visit and again at the two-year well visit, but the test is valid down to 16 months and in kids as old as 30 months. Not every child who fails this test has autism, but the screening helps us to identify which child needs further evaluation.

At 15-18 months of age, children should show the beginnings of pretend play. For example, if you give your child a toy car, the toddler should pretend to drive the car on a road, make appropriate car noises, or maybe even narrate the action: “Up, up, up, down, down, rrrroooom!” Younger babies mouth the car, spin the wheels, hold it in different positions, or drag a car upside down, but by 18 months, they perceive a car is a car and make it act accordingly. Other examples of pretend play are when a toddler uses an empty spoon and pretends to feed his dad, or takes the T.V. remote and then holds it like a phone and says “hello?” You may also see him take a baby doll, tuck baby into bed, and cover her with a blanket.

Eye contact in American culture is a sign that the child is paying attention and engaged with another person. Lack of eye contact or lack of “checking in” with parents and other caregivers can be a sign of delayed social development.

Kids periodically try to get their parents to pay attention to what they are doing. Lack of enticing a parent into play or lack of interest in what parents or other children are up to by this age is a sign of delayed social development. Ask yourself, “Does my child bring me things? Does he show me things?” Also, although they may not share or take turns, toddlers should still be interested in other children.

Many typical two-year-olds like to line things up. They will line up cars, stuffed animals, shapes from a shape sorter, or books. The difference between a typically-developing two-year-old and one that might have autism is that the typically-developing child will not line things up the exact same way every time. It’s fine to hand your child car after car as he contently lines them up, but I worry about the toddler who has a tantrum if you switch the blue for the green car in the lineup.

Two-year-olds should speak in 2-3 word sentences or phrases that communicate their needs. Autism is a communication disorder, and since speech is the primary means to communicate, delayed speech may signal autism. Even children with hearing issues who are speech-delayed should still use vocal utterances and gestures or formal sign language to communicate.

Atypically terrible “terrible twos.” Having a sensory threshold above or below what you expect may be a sign of autism. While an over-tired toddler is prone to meltdowns and screaming, parents can often tell what triggered the meltdown. For example, my oldest, at this age, used to have a tantrum every time the butter melted on his still-warm waffle. Yes, it seemed a ridiculous reason to scream, but I could still follow his logic. Autistic children are prone to screaming rages beyond what seems reasonable or logical. Look also for the child who does not startle at loud noises, or withdraws from physical contact because it is overstimulating.

By three years, children make friends with children their own age. They are past the “mine” phase and enjoy playing, negotiating, competing, and sharing with other three-year-olds. Not every three year old has to be a social butterfly but he should have at least one “best buddy.”

Regression of skills at any age is a great concern. Parents should alert their child’s pediatrician if their child stops talking, stops communicating, or stops interacting normally with family or friends.

It’ s okay to compare. Comparing your child to other same-age children may alert you to delays. For example, I had parents of twins raise concerns because one twin developed communication skills at a different pace than the other twin.

Although you may wonder if your child has autism, there are other diagnoses to consider. For instance, children need all of their senses intact in order to communicate well. I had a patient who seemed quite delayed, and it turned out that his vision was terrible. He never complained about not seeing well because he didn’t know any other way of seeing. After my patient was fitted with strong glasses at the age of three, his development accelerated dramatically. The same occurs for children with hearing loss—you can’t learn to talk if you can’t hear the sounds that you need to mimic, and you can’t react properly to others if you can’t hear them.

If you or your pediatrician suspect your child has autism, early, intensive special instruction, even before a diagnosis is finalized, is important. Every state in the United States has Early Intervention services that are parent-prompted and free for kids. The sooner your child starts to works on alternate means of communication, the quicker the frustration in families dissipates and the more likely your child is to ultimately develop language and social skills. Do not be afraid of looking for a diagnosis. He will be the same child you love regardless of a diagnosis. The only difference is that he will receive the interventions he needs.

Julie Kardos, MD and Naline Lai, MD
©2018, 2013 Two Peds in a Pod®

The school nurse calls to say, “I have your child here with me and she has a sore throat. I think you should take her to the doctor to see if it’s strep throat.”

What IS strep throat?

Strep throat is a throat infection caused by Group A streptococcus (Strep pyogenes) bacteria. Symptoms can include sore throat, fever, pain with swallowing, enlarged lymph nodes (glands) in the front of the neck, headache, belly pain, vomiting, and rash. Not all symptoms are present in all kids with strep throat. Some kids look fairly ill and others with strep don’t look too bad.

Kids with strep throat do NOT typically have cough, profuse runny nose, or diarrhea. Only about 15 percent of all kids coming to our offices with a main concern of “sore throat” actually have strep throat. That means that MOST kids with sore throats turn out to have something else, most commonly a virus.

Why do we care about strep throat?

Most children’s immune systems are really good at fighting the strep germ. In fact, most kids would recover even if they were not treated. However, some kids’ immune systems go a little haywire when fighting the strep germ. In addition to making antibodies (germ-fighting cells) to fight the strep, they make antibodies against their own heart valves (immune system gets confused). When antibodies attack the heart valve, kids can get rheumatic fever.

Treating strep throat with antibiotics shortens the duration of the illness by only about one day, but more importantly, treatment prevents the body from making the wrong kind of immune cells, or antibodies, against the heart valves. Fortunately, treating strep is not an emergency: starting antibiotics within NINE DAYS of symptoms is good enough to prevent rheumatic fever.

Strep throat can also lead to other complications such as scarlet fever (strep throat plus sandpaper-like rash on the skin), peritonsilar abscesses (pus pocket in the tonsils) and kidney inflammation (first symptom can be cola-colored urine).

How do we know if your child has it?

To definitively diagnose strep throat , we use a long cotton swab to gently swipe the sore throat and obtain a sample of the germs. This sample goes to the laboratory to culture for Group A strep. In other words, we wait to see if the germ grows from the sample.

Doctors cannot diagnose strep throat over the telephone. Nor can doctors or nurses rely solely on physical exam findings, because while there is a “classic” look to strep throat, some kids with sore throats have normal appearing throats yet the test reveals strep. Others have yucky looking throats but in fact have some other viral infection. We physicians ask questions about your child’s symptoms and perform a thorough physical exam and then do a “strep test” if we suspect strep throat. Even doctors send their own children to the doctor for testing. Dr. Lai’s teen was just sent to her pediatrician’s office last week with a sore throat to check for strep the day before a track meet.

Isn’t there a quick way to know?

Many pediatric offices use rapid strep tests to help make a quick decision about treatment because the strep culture takes 48 hours or more to finalize. These rapid tests are fairly reliable, but sometimes can be negative (shows NO strep) even if strep is present, so most doctors send a culture back-up if the rapid test is negative. The other problem with the quick test is that once your child has strep, the quick test can stay positive for about a month, even if your child no longer has strep disease. So if a child is treated for strep throat and then develops another sore throat within a month of treatment, that child needs a strep culture back up if the office quick test is positive.

To further complicate matters, some kids “carry” the strep germ in their throats but never develop the disease (no sore throat or illness symptoms). These kids will test positive for strep but do not require treatment. This is why we do not routinely check kids for strep throat unless they have the typical symptoms. Antibiotics come with their own risk of side effects so we want use them only when absolutely necessary.

What is the proper treatment for strep throat?

The easiest way to treat strep throat is with the antibiotic amoxicillin, taken once daily, for ten days. Penicillin twice daily for ten days also treats strep throat but the liquid form doesn’t taste as good a amoxicillin so can be a little harder to give your kid. Your child’s pediatrician will prescribe one or the other. If your child is allergic to penicillin, your child’s doctor will prescribe a different antibiotic that is also effective.

My child was treated for strep throat. We finished the antibiotic. Three days later his sore throat is back. Why did this happen?

Most likely, your child contracted a new illness. The illness may or may not be strep again. Often the new sore throat is the viral-cold-of-the-day starting up.  If your pediatrician determines that the sore throat  is from strep, the most common reason for getting two episodes of strep throat close together is that your child contracted the germ again (usually from a classmate). It’s not that the antibiotic did not work. It’s just bad luck that your child got it again. Your child’s doctor can use the same antibiotic to treat the second strep or may opt to use a different one.

Fortunately, strep throat has not shown much, if any, resistance to standard antibiotic therapy. The reason that we treat children (and adults)  for a full course of antibiotic is that this duration helps prevent complications. You should give your child the complete course of antibiotic her health care provider prescribes, even if she feels better part way through the treatment. In addition to treating with antibiotic, be sure to provide pain medicine such as acetaminophen (eg. Tylenol) or ibuprofen (eg. Motrin or Advil). Here are more suggestions to treating sore throat pain. Good news: after 12 to 24 hours after the first dose of antibiotic, your child is no longer contagious. If they feel better, they can return to school after this time.

Contact your child’s doctor during treatment if your child experiences increasing pain, inability to swallow, seems dehydrated, or look worse instead of better.

Julie Kardos, MD and Naline Lai, MD
©2018 Two Peds in a Pod® Updated 10/1/2019

Conversation hearts murmuring

When the Tin Man was a child in Oz, I’m sure his pediatrician never told his parents, “Has anyone ever said your child has a heart murmur? I hear one today.”

I know that when I tell parents about a heart murmur in their child, their hearts skip and jump. But not all heart murmurs are bad.

What is a heart murmur?

A heart murmur is an extra sound that we pediatricians hear when we listen to a child’s heart with a stethoscope. A normal heart beat sounds like this:  “lub, dub.  lub, dub.  lub, dub.”  A heart murmur adds a whooshing sound.  So what we hear instead is “lub, whoosh, dub” or “lub, dub, whoosh.”

The “whoosh” is usually caused by blood flowing through a relatively narrow opening somewhere in or around the heart. Think of your blood vessels and heart like a garden hose.  If you run the water (blood) very hard, or put a kink or cut a hole in the hose, the whoosh of the water grows louder in those locations.

Heart murmurs signal different issues at different ages.

In a newborn, some types of heart murmurs are expected. Normal newborn hearts contain extra holes that close up after the first hours or days of birth. One type of murmur occurs as the infant draws in his first breath and holes in the heart, present inside the womb, begin to seal. As the holes get narrower, we sometimes hear the “whoosh” of blood as it flows through the narrowing opening. Then these holes close completely and the murmur goes away.

However, some murmurs in infancy signal “extra holes” in the heart. As pediatricians, we experience our own heart palpitations when moms want to leave the hospital early with their infants who are less than 48 hours old. We worry because many infants who have abnormal hearts may not develop their abnormal heart murmurs and other signs of heart failure until the day or two after birth.

Preschool and early school-age children often develop “innocent” heart murmurs. “Innocent” implies that extra blood flows through their hearts, but the hearts are structurally normal. These murmurs are fairly common and can run in families. However, there are some significant heart problems which do not surface until this age. For this reason, remember to schedule those yearly well child checkups.

For teens, during the pre-participation sports physical, pediatricians listen carefully for a murmur that may indicate that an over grown heart muscle has developed.

What else can cause a heart murmur?

Holes are not the only culprit behind a murmur. The whoosh sound can also arise when a person is anemic and blood flows faster than normal. In anemic kids, the blood flows faster because it lacks enough oxygen-carrying red blood cells and the heart needs to move blood faster in order to supply oxygen to the body. The most common cause for anemia is a lack of eating enough iron-containing foods. Subsequently, we hear these flow murmurs in children whose diets lack iron, in teenagers who grow rapidly and quickly use up their iron stores, and in girls who bleed too much at each period. Replenishing the iron level makes a heart murmur from anemia go away.

Even a simple fever can cause a heart murmur on physical exam. The murmur goes away when the fever goes away.

Pediatric health care providers can often distinguish between “innocent” heart murmurs and not-so- innocent heart murmurs by the sound of the murmur itself (not all “whooshes” sound alike). If any question exists, your child will be referred for more testing, which could include a chest x-ray, an EKG (electrocardiogram), an ECHO (echocardiogram, or ultrasound of the heart), or evaluation by a pediatric cardiologist.

If your child’s pediatrician tells you that your child has a heart murmur, “take heart.”

Many times a murmur comes and goes or just becomes part of your child’s baseline physical exam. Even if your child has a serious heart problem, most cases respond well to medication, surgery, or both. While not all heart problems cause heart murmurs, and while not all murmurs signal heart problems, the presence of a heart murmur in a child can signal that your child needs further testing.

Unless, of course, your child is the Tin Man. In this case, extra sounds indicate that your child needs more oil!

Julie Kardos, MD and Naline Lai, MD
©2010, 2018 Two Peds in a Pod®