To Tell the Tooth, the Whole Tooth and Nothing but the Tooth

Teething, the eruption of teeth through the gums, usually begins between 4-7 months of age, with 95 % of first teeth erupting between 6-8 months.Children may have eruption of their first tooth as early as 2 months of age. The two front teeth (central incisors), usually the lower two are the first to appear. Most children by age 30 months will have all 20 of their primary “baby” teeth (adults have a total of 32 teeth). As the teeth break through the gum line the area directly over the tooth may become red, swollen or even develop a little blood blister. Certain teeth may be more sensitive breaking through then others; molars have more surface area and less sharpness than other teeth decreasing their ability to “slice” through the gum line. Many children have no or very little problem with teething. The pain with teething is often intermittent, waxing and waning over a few separate periods. Teething may also cause the infant to bring his/her hands to the mouth, increased drooling, restless or decreased sleep secondary to tooth discomfort, rubbing of the cheek or ear as a consequence of referred pain and a desire to chew something hard.

Teething has not been shown to cause:

·         Fever >101 degrees

·         Runny nose, congestion or cough

·         Diarrhea

·         Rash

·         Prolonged fussiness

If your child is experiencing any of these symptoms it is probably not teething and you should call the office to discuss them with your doctor.

To ease your baby’s discomfort, try gently rubbing or massaging the gums with one of your fingers. Teething rings made of firm rubber may be helpful. Freezing teething rings or other objects tend to get too hard and can cause more harm than good. Pain relievers and medications that you rub on the gums are usually ineffective as they wash out of the baby’s mouth within minutes. Some medication you rub on your child’s gums can even be harmful if too much is used and the child swallows an excessive amount.

Now that the teeth have come in how do you care for them? Simply brush them with a soft child’s toothbrush or gently wipe with a damp cloth after each feeding when you first start seeing the teeth. To prevent cavities, never let your baby fall asleep with a bottle, either at nap time or at night As your child gets older transitioning to a regular cup preferably by 12-15 months will reduce the risk of childhood caries as well. The American Academy of Pediatrics recommends children seeing a dentist around 6 months after the first tooth erupts but at least starting to see the dentist by age 3.

Frequent Urination in Young Children

Pollakiuria, derived from pollakis in greek meaning often, is also known as extraordinary daytime urinary frequency. Pollakiruia is a benign condition defined as frequent small voids in a previously toilet trained child without evidence of a urinary tract infection. If your child is urinating frequently it is important to call the office so that we may help you distinguish between pollakiuria and other more serious causes. Urination with pollakiuria may occur every 5-10 minutes with the child urinating as many as 10-30 times per day. An important distinguishing factor between polyuria (going the bathroom at an increased frequency secondary to a pathologic reason such as diabetes) and pollakiuria is that in pollakiuria the amount of urine voided is very small whereas in polyuria the amount is usually consistent with a normal voiding volume. The main concern from parents in pollakiuria is that the frequent urination interrupts school or other daily activities. The key to pollakiuria is that it occurs only during daytime hours and most commonly in kindergarten or pre-school aged children. Peak age is 5-6 years old with a range from 3-14 years old. Also, urine color, stream and odor are normal in pollakiuria. There should be no change in bowel habits, pain with urination, abdominal pain or fever. Pollakiruia is a self limiting condition usually lasting 7-12 months. 

Pollakiuria is often brought on by a psychological stressor such as academic difficulties, bullying, death of a loved one, relocation to new school, addition of a new sibling, or divorce. Other triggers may include heightened bladder sensitivity in the colder months or exposure of the urethra to a chemical irritant (bubble baths, hot tubs, tight underwear). The diagnosis of pollakiuria is usually made based on clinical history, physical exam and a negative urinalysis (study of the urine). Imaging such as an ultrasound is rarely indicated. Treatment includes reassurance as in most cases it will resolve over days to weeks (however it is not unusual to take many months). Bladder spasm medications sometimes used in other conditions have not been found to be of any benefit. The key is to identify the emotional trigger and allow the child to talk with his/her parents about what worries them. It may be noted that the urinary frequency only occurs in the stressful environment and improvement of symptoms following counseling or resolution of the stressful situation has been seen.

References:

1.     Bass, L. Pollakiuria, Extraordinary Daytime Urinary Frequency: Experience in Pediatric Practice. Pediatrics. 1991 May;87(5):735-737

2.     Hellerstein S, Lineharger J. Voiding Dysfunction in Pediatric Patients. Clincial Pediatrics. 2003 (42):43-49

A Journey Down the Nile....West Nile that is

West Nile virus is an “arbovirus (arthropodborne virus)” transmitted back and forth between mosquitoes and birds. Humans get infected when a mosquito decides to have a snack after previously picking up the virus. The culex mosquito is the most common culprit to infect humans.

Approximately, 80% of human West Nile infections are asymptomatic (never know that you are infected).  Of those who do develop symptoms the majority consist of abrupt onset of fever, headache, muscle aches, nausea, vomiting, diarrhea and a transient rash. So in summary, West Nile virus for the most part looks like every other viral infection out there. Symptoms usually begin 2-6 days after being bitten by an infected mosquito. Less than 1% of people infected with West Nile develop neurologic involvement (meningitis, encephalitis, flaccid paralysis). Symptoms involving the brain include high fever, stiff neck, severe headaches, muscle weakness, mental confusion, tremors, vision problems, convulsions, paralysis, and loss of consciousness. These rare manifestations can be dangerous and it is likely these few cases are where the excitement in the media and parental concern comes from. Neurologic disease is more common in those over the age of 50. The majority of those who get neuroinvasive disease will recover.

West Nile first appeared in the United States in New York in 1999 and has subsequently spread across North America. The only place in the world that has not had a reported case of West Nile is Antarctica (so I guess moving there is always an option, however, you would likely miss your pediatricians very much).   As of October 16^th 2012 there have been 41 cases of West Nile in the state of Maryland this year, 6 of which have been in Anne Arundel County (data from CDC website http://www.cdc.gov/ncidod/dvbid/westnile/USGS_frame.html)

Diagnosis of West Nile virus can be confirmed with blood or cerebral spinal fluid (spinal tap/lumbar puncture) usually having to wait at least 10 days post-infection to get an accurate result. Because the majority of patients are asymptomatic and have vague viral symptoms it is not currently recommended to test for West Nile unless neurologic symptoms are present.

There is currently no direct treatment for West Nile virus. Fortunately, mild cases of West Nile do not require treatment. However, children who become severely ill may require hospitalization and supportive care.

The key to West Nile virus is prevention. 

1.       Eliminate mosquito breeding sites – Mosquitoes like standing water. Measures to limit breeding sites include draining or removing receptacles of standing water (old tires, toys, flower pots, buckets and barrels, pretty much anything that can collect rain water).  Keeping pools and bird baths clean. Cleaning clogged rain gutters may also help.

2.       Reduce exposure to mosquitoes – Limit outdoor activity at the height of mosquito activity, dusk and dawn.  Repair or place screens on all windows and doors to prevent mosquito access to your home.  Of note, mosquito traps, bug zappers, and others marketed to prevent mosquitoes from biting people have not been shown to be effective and should not be relied upon as the only source of protection.

3.       Use barriers to protect your skin – Use clothing to protect your skin (ie, long sleeve shirts, pants, hats). Also available are mosquito nets for strollers and nets for other areas where children are likely to play outside.

4.       Discourage the mosquito – Mosquito repellents should be used when outside. There are many different repellents to chose from containing a variety of compounds (diethyltoluamide (DEET), picaridin, 3-[N-Butyl-N-acetyl]-aminopropionic acid, ethyl ester, or the plant-based oil of lemon eucalyptus  and its synthetic equivalent p-menthane-3,8-diol). DEET containing products have been used worldwide since 1957 and has a good safety profile and the concerns of toxicity in children were unfounded.  Adverse effects appear to be related to ingestion, chronic or excessive use not the concentration of DEET. Per the EPA and AAP, concentrations up to 30% may be used in children. Products containing DEET can be used in pregnancy without adverse effects. Children under the age of 2 months should not use insect repellents secondary to the increased permeability of their skin and potential for absorption. The higher the percentage of DEET the longer the protection time provided, however, frequent reapplication is recommended.  The EPA does make certain recommendations on proper application of insect repellents:

a.       Do not apply over cuts, wounds or around the eyes or mouth (do not spray the face apply to the face with your hands)

b.      Do not spray on a child’s hand as they may then inadvertently put their hands into their mouth or eyes

c.       Apply just enough to cover exposed skin (do not apply under clothing)

d.      Wash or bathe after coming inside from using repellents and wash clothes again before wearing again

5.       If you find a dead bird: Don't handle the body with your bare hands. Contact your local health department for instructions on reporting and disposing of the body. They may tell you to dispose of the bird after they log your report.

References

American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases.Pickering LK, ed. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012

American Academy of Pediatrics, Committee on Environmental Health.Pesticides. In: Etzel RA, Balk SJ, eds. Pediatric Environmental Health. 3rd ed.Elk Grove Village, IL: American Academy of Pediatrics; 2012:515–548

http://www.healthychildren.org/English/health-issues/conditions/skin/Pages/Preventing-West-Nile-Virus.aspx

http://www.healthychildren.org/English/health-issues/conditions/skin/Pages/West-Nile-Virus.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

http://www.cdc.gov/ncidod/dvbid/westnile/prevention_info.htm

Leave the Frying in the Pan

Sunburns are a nasty experience that can ruin your fun in the sun. Most people have experienced sunburn at one time or another. Despite these negative experiences, 70 to 85 percent of children and adolescents have reported at least one sunburn in the previous year. Exposure to UVA and UVB light causes DNA mutation and subsequent death of the skin cells (consequently this is also the mechanism that leads to skin cancer). The exposure to UV radiation required to produce sunburn is variable. Those of fair skin, light hair and on certain medications (ex. Aspirin, Motrin, doxycycline, lasix etc) are at higher risk. Sunburn’s range from painless redness to highly painful redness with swelling and blistering. In general, redness is first noted at approximately three to five hours following sun exposure, peaks between 12 to 24 hours, and fades over 72 hours in most cases. Despite these experiences people continue to disregard simple prevention techniques (not our patients thoughJ).

Prevention is key to a fun and healthy summer experience.

Babies under 6 months of age:

• Avoid sun exposure: seek shade, avoid being outside during the peak radiation hours 10:00AM – 04:00PM
• Cloudy days do not substitute for appropriate sunburn precautions; UVB is able to pass through clouds with ease and cause sunburn
• Dress infants in lightweight long pants, long-sleeved shirts, and brimmed hats that shade the neck
• When adequate clothing and shade are not available, parents can apply a minimal amount of sunscreen with at least 15 SPF (sun protection factor) to small areas, such as the infant's face and the back of the hands (sensitive skin or “baby formulas” are recommended). Nutrogena Pure and Free is a sunscreen with only zinc and titanium oxide that are believed to be safe in  infants when you must use a sunscreen.
• If an infant gets sunburn, apply cold compresses to the affected area.

For All other Children:

• The first, and best, line of defense against harmful ultraviolet radiation exposure is covering up. Wear a hat with a three-inch brim or a bill facing forward, sunglasses (look for sunglasses that provide 97% -100% protection against both UVA and UVB rays), and cotton clothing with a tight weave.
• Stay in the shade whenever possible, and limit sun exposure during the peak intensity hours - between 10 a.m. and 4 p.m.
• On both sunny and cloudy days use a sunscreen with an SPF of 15 or greater that protects against UVA and UVB rays.
• Use extra caution near water and sand (and even snow!) as they reflect UV rays and may result in sunburn more quickly

How to choose a sunscreen and How to use it right?

Sunscreen works by absorbing and reflecting UV light. Choosing the right sunscreen is key. Make sure your sunscreen is active against both UVA and UVB radiation (sometimes referred to as “Broad spectrum”). Make sure your sunscreen is not expired or is not more than 3 years old.

Sunscreens should be uniformly applied approximately 15 to 30 minutes before sun exposure. The American Academy of Dermatology recommends a sunscreen of SPF 30 or higher be used in most circumstances. Be sure to apply approximately 1oz (2 tablespoons) per application of sunscreen, reapplying every 2 hours or after swimming or sweating (whether water proof or not).

Once my child gets a sunburn what can I do?

If this unfortunate event were to happen, there are therapies to help with symptoms, however nothing can treat the sunburn and reverse the damage both present and future done by the burn.

• The Key is to avoid further sun exposure until the burn has healed.
• Application of moisturizing lotion or aloe vera gel and use of cold compresses or soaks in cool water may ease discomfort.
• Pain may be relieved by pain relievers (motrin/ibuprofen (if over 6M of age), Tylenol etc).
• Itching may be relieved with oral diphenhydramine (Benadryl). 

A Note on Tanning Beds:

Tanning beds either use UVA or combined UVA and UVB. Both UVA and combined UVA/UVB tanning beds can produce sunburns. Multiple studies have found a 75 percent increase in the risk of skin cancer in individuals who utilized tanning devices before the age of 35. Chronic sun exposure (including tanning beds) eventually causes signs of premature aging - including wrinkles, sagging cheeks and skin discoloration so all that effort put into looking 'good' now will leave you looking a lot worse in the future.

Oh No it's the Flu Monster

Routine annual flu vaccination is recommended for all patients over the age of 6 months. Ideally, all patients should receive the vaccine prior to the onset of flu season (Late November to March).

“The flu” is cause by the influenza virus. Unlike the common cold, influenza can cause severe illness (particularly under the age of 2). Symptoms often come on quickly including fever, cough, sore throat, runny or congested nose, muscle aches, headache and fatigue. Most people recover in days however, symptoms may last up to 2 weeks.

The flu season is unpredictable from year-to-year and the severity each year depends on multiple factors (which virus is spreading, how much and when flu vaccine is available and how many people get vaccinated). People at high risk for severe flu include young children, pregnant women, those with chronic medical conditions (asthma, diabetes etc) and adults over the age of 65.

The flu is spread mainly by droplets made when people with the flu cough. Less often, a person might also get flu by touching a surface or object that has flu virus on it and then touching their own mouth, eyes or  nose. You may be able to spread the flu to someone else before you know you are sick, as well as while you are sick. Most children may be able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick.

A number of flu tests are available to detect influenza viruses. The most common are called “rapid influenza diagnostic tests.” These tests can provide results in 30 minutes or less. Unfortunately, the ability of these tests to detect the flu can vary greatly. Therefore, you could still have the flu, even though your rapid test result is negative. Most people with flu symptoms do not require testing because the test results usually do not change how you are treated.

The best way to treat the flu is to prevent it and the single best way to prevent the flu is to get a flu vaccine each season. There are two types of flu vaccines:

“Flu shots” — inactivated vaccines (containing killed virus) that are given with a needle. There are three flu shots being produced for the United States market now. It has been used for decades and is approved for use in people 6 months of age and older. Some minor side effects that could occur are: Soreness, redness, or swelling where the shot was given, fever (low grade), and aches. If these problems occur, they begin soon after the shot and usually last 1 to 2 days.

The nasal-spray flu vaccine — a vaccine made with live, weakened flu viruses that is given as a nasal spray. The viruses in the nasal spray vaccine do not cause the flu. The intranasal vaccine is approved for use in healthy people 2 to 49 years of age. In children, the most common side effects include runny nose, wheezing, headache, vomiting, muscle aches and fever.

Children 6 months through 8 years of age who did not receive at least one dose of the 2010-2011 vaccine, or whom it is not certain whether the 2010-2011 was received, should receive 2 doses of the 2011-2012 seasonal vaccine.

The first dose should be given as soon as vaccine becomes available, and the second dose should be given 28 more days after the first dose. The first dose “primes” the immune system; the second dose provides immune protection. Children who only get one dose but need two doses can have reduced or no protection from a single dose of flu vaccine.

About two weeks after vaccination, antibodies develop that protect against influenza virus infection. Flu vaccines will not protect against flu-like illnesses caused by non-influenza viruses.

Quick note on Flu vaccine and egg allergy: All licensed and recommended influenza vaccines in the US are made using egg-based manufacturing processes. Only contraindication is prior history of anaphylaxis to egg. Individuals with less severe reactions (hives) may receive the vaccine (shot only) and may be watched for 30 minutes after receiving the vaccine. 

Once you have the flu it can be treated. If you get the flu, antiviral drugs are a treatment option. However, not everyone requires antiviral therapy and the medications do not cure the flu just lessen the symptoms. Therefore, only a select population is recommended to receive therapy (<2yo and those with chronic medical conditions). Antiviral drugs are prescription medicines that fight against the flu in your body. When used for treatment, antiviral drugs can lessen symptoms and shorten the time you are sick by 1 or 2 days. They also may prevent serious flu complications.

Always remember basic illness prevention. Cover your nose and mouth with a tissue when you cough or sneeze. Wash your hands often with soap and water. Avoid touching your eyes, nose and mouth. Try to avoid close contact with sick people. If you are sick with flu-like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care.

At Belliacres Pediatrics we pride ourselves in being up-to-date with the current CDC recommendations and ordering our flu vaccines as soon as they are available. Please contact the office if you have any questions and check our twitter feed often (@belliacrespeds) for updates on flu vaccine availability. 

RSV...That Pesky Winter Time Virus

Respiratory Syncytial Virus (RSV)

RSV may cause illness in any age, however, the course of illness and severity of symptoms varies with age. RSV has a seasonal pattern presenting in Maryland anywhere between November and April and peaking in January or February. Almost all children will have an illness caused by RSV by 2 years of age and re-infection is common. In children under the age of one year RSV is the most common cause of bronchiolitis (a viral infection of the lungs causing wheezing, cough or respiratory distress). Those at higher risk or more severe illness include:

• Children under the age of 6 months
• Infants born prior to 35 weeks gestation (prematurity)
• Infants with underlying heart or lung disease
• Infants exposed to second hand smoke

RSV is spread from hand-to-hand contact. Once on your hands, the virus is introduced to the body through your nose or eyes when you touch your face (therefore the key for prevention is regular washing of hands with soap and warm water). RSV may stay on your hands for several hours.

RSV may cause a variety of symptoms depending on age. Older children (>1yo) and adults symptoms will often be limited to congestion, runny nose, cough and fever. However, in infants , we will often see an increased rate of breathing, decreased appetite, wheezing on exam and a cough that can last up to 2-3 weeks. Symptoms will peak usually on day 3-4 of illness.

So, Why do infants have more severe symptoms than older children?. Infants are small (duh Dr. Schneider we all know that) therefore, their lungs are small. When RSV gets into the airway it causes swelling and increased production of mucus. In older children and adults, coughing may move this mucus up and out of the airway. In young infants, they are not able to produce enough force to remove the mucus and over time as the infection progresses this mucus may plug up some of the smaller airways (bronchioles, thus bronchiolitis) making it harder for the child to breath.

Call 9-1-1 for an ambulance if your child:

·         Stops breathing

·         Starts to turn blue or very pale

Or Call our office or the covering physician if your child:

·         Has a very hard time breathing

·         Starts grunting

·         Looks like he or she is getting tired of having to work so hard to breathe

·         The skin and muscles between your child’s ribs or below your child’s ribcage look like they are caving in

·         Your child’s nostrils flare (get bigger) when he or she takes a breath

·         Your infant younger than 3 months has a fever (temperature greater than 100.4ºF or 38ºC)

·         Your child older than 3 months has a fever (temperature greater than 100.4ºF or 38ºC) for more than 3 days

·         Your infant has fewer wet diapers than normal

Diagnosis of RSV is made by your physician and is usually a clinical diagnosis (made on the presenting symptoms, time of year and overall picture of the patient). However, in some cases a nasal swab may be used to diagnosis RSV in the office. Results can be obtained within 30 minutes. However, the swab is not a 100% accurate and may miss some true infections with RSV.

Is there anything I can do on my own to help my child feel better?.

You can:

·         Make sure your child gets enough fluids

·         Use a cool mist humidifier in your child's bedroom

·         Treat your child's fever with acetaminophen (Tylenol) or Ibuprofen (Advil or Motrin as long as over the age of 6 months). Never give aspirin to a child younger than 18 years old.

·         Suction the mucus from your child’s nose with a suction bulb if it is interfering with sucking or breathing.

·         Do not allow anyone to smoke near your child

If your child is older than 12 months:

·         Feed warm, clear liquids to soothe the throat and to help loosen mucus

·         Prop your child's head up on pillows or with the help of a car seat.

Is there any medicine that my child can get prescribed to treat or prevent RSV?  -- Yes and No

Occasionally, we will try a breathing treatment in the office to help patients with significant breathing difficulty. Not all children require these treatments and most children will have little to no benefit from the treatment.

There is a medicine called Synagis that has been shown when used preventatively  to decrease hospital admission and severity of symptoms in a select group of infants. If your child is under the age of 1 and was born significantly premature, has chronic lung disease or congenital heart disease he or she may qualify for this treatment. Please ask our office staff for further information if you think your child meets these criteria.

In general, treatment is time. Since RSV is a virus your child’s body will fight off the infection. Our role as caretakers is to support your child through this process and allow their bodies the best chance to succeed. 

Welcome

The Schneiders of BelliAcres Pediatrics

At BelliAcres Pediatrics, we have always been proud of our record of continuous, competent and personal care that we provide our patients.  We continue to offer unprecedented access to your pediatric provider for the individual care and development of relationships that promote the health of children.

In that tradition, we are proud to announce the arrival of our new pediatrician:

Zachary Richard Schneider, MD

 Dr Schneider earned his Bachelors of Science Degree from Hobart College and his Medical Degree from George Washington University.   He completed his pediatric residency at the Levine Children’s Hospital in Charlotte, North Carolina.  

Dr Schneider grew up in our community, in fact, just a few steps from our office.   It was there that he developed the interest and passion for pediatric primary care and looks forward to those relationships that make us unique in our practice of pediatrics.  He and his wife, Anne, also a local native of Severna Park, are excited about their return to our community.

Yes, as you may have already guessed, Dr Schneider is the son of Dr Donald Schneider.  While they look forward to re-uniting as a family, it is with even greater excitement that they anticipate their new professional relationship.  They hope to, both, provide many years of outstanding and compassionate care to the families of our community.

Please, welcome Dr Zach to BelliAcres Pediatrics.